Journal Search

Journal Search - issue 1, 2012


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Jennifer Richmond1
PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


31 March 2012 Volume 12 Issue 1


RECEIVED: 31 March 2012

ACCEPTED: 31 March 2012


Richmond J.  Journal Search - issue 1, 2012. Rural and Remote Health 2012; 12: 2172.


© Jennifer Richmond 2012 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 2012; 28: issue 1
  • Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine 2012; 17: issue 1
  • Australian Journal of Rural Health 2011; 19: issue 6.


Journal of Rural Health 

Contents: 2012; 28:(1)
Issue includes:

Differencesin Readiness Between Rural Hospitals and Primary Care Providers for Telemedicine Adoption and Implementation: Findings From a Statewide Telemedicine Survey

Amy Brock Martin, Janice C. Probst, Kyle Shah, Zhimin Chen and David Garr

Purpose:Published advantages of and challenges with telemedicine led us to examine the scope of telemedicine adoption, implementation readiness, and barriers in a southern state where adoption has been historically low. We hypothesized that rural hospitals and primary care providers (RPCPs) differ on adoption, readiness, and implementation barriers. We examined the degree to which they differ on (a) telemedicine adoption or readiness; (b) telemedicine training needs; (c) current use of technology for patient care; and (d) environmental concerns in facilities for telemedicine.
Methods: Paper surveys were sent to rural hospitals and RPCPs with response rates of 50% (n = 38) and 25.9% (n = 339), respectively. Three of 4 hospitals were represented. Chi-square analyses were used to test for differences between rural hospitals and RPCPs.
Findings: Compared to RPCPs, rural hospitals were significantly more likely to report higher rates of telemedicine knowledge (P= .0007); planning for or implementing telemedicine (P < .0001); and reporting their disaster recovery data systems (P= .0002) and availability and location of outlets and connections (P= .03) as adequate for telemedicine. Rural hospitals were less likely to report having no telemedicine education needs (P= .04).
Conclusions: Telemedicine continues to be a viable solution for bridging geographic access gaps to a variety of specialty care. Users need assistance in understanding legal implications, care coordination, billing for services, and disaster data recovery. In rural areas, hospitals appear to best embody characteristics of facilities that successfully implement telemedicine and have the greatest degree of readiness.

The Adoption and Use of Health Information Technology in Rural Areas: Results of a National Survey

Ranjit Singh, Michael I. Lichter, Andrew Danzo, John Taylor and Thomas Rosenthal

Context:Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural-urban differences in HIT adoption at the national level.
Purpose: To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption.
Methods: A national mail survey of 5,200 primary care offices, stratified by rurality using Rural-Urban Commuting Area categories, was conducted in 2007-2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans.
Results: A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02).
Conclusions: HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.

Factors Influencing Electronic Clinical Information Exchange in Small Medical Group Practices

John E. Kralewski, Therese Zink and Raymond Boyle

Purpose:The purpose of this study was to identify the organizational factors that influence electronic health information exchange (HIE) by medical group practices in rural areas.
Methods: A purposive sample of 8 small medical group practices in 3 experimental HIE regions were interviewed to determine the extent of clinical information exchange with other health care providers and to identify the factors influencing those patterns.
Findings: HIE was found to be largely limited to exchanging immunization data through the state health department and exchanging clinical information within owned provider systems. None of the clinics directly exchange clinical information with non-owned clinics or hospitals.
Conclusions: While regional HIE networks may be a laudable goal, progress is slow and significant technical, political, and financial obstacles remain. Limiting factors include data protection concerns, competition among providers, costs, and lack of compatible electronic health record (EHR) systems.

EMRs and Clinical IS Implementation in Hospitals: A Statewide Survey

Mirou Jaana, Marcia M. Ward and James A. Bahensky

Purpose:Present an overview of clinical information systems (IS) in hospitals and analyze the level of electronic medical records (EMR) implementation in relation to clinical IS capabilities and organizational characteristics.
Methods: We developed a survey instrument measuring clinical IS implementation and classified clinical IS across 5 EMR levels. The survey was administered to hospitals in a state with a large number of rural hospitals (84% response rate).
Findings: Clinical IS were classified across 5 EMR levels, a useful approach for understanding the gaps in clinical IS in hospitals. Almost half (43%) of hospitals in Iowa were at EMR Level 0, with at least 1 of the ancillary systems still absent; 12% were at Level 1 with all 3 ancillary systems in place; 16% were at Level 2 corresponding to an early EMR system; 18% were at Level 3 corresponding to an intermediate EMR system; and 10% were at Level 4 corresponding to an advanced EMR system. In contrast, 22% had no plans for EMR implementation at all. EMR level was lower in critical access hospitals and positively associated with more slack resources and staffed beds. Over a 3-year period, there were increases in ancillary systems and clinical documentation implementation.
Conclusions: The survey performed well. There was agreement with published estimates of EMR penetration, sensitivity to change over time, and association with known organizational factors. It is well designed and can be used to map onto a comprehensive classification scheme capturing the EMR level and evaluating progress toward meaningful use.

Development and Testing of Emergency Department Patient Transfer Communication Measures

Jill Klingner and Ira Moscovice

Purpose:Communication problems are a major contributing factor to adverse events in hospitals.1 The contextual environment in small rural hospitals increases the importance of emergency department (ED) patient transfer communication quality. This study addresses the communication problems through the development and testing of ED quality measurement of interfacility patient transfer communication.
Methods: Input from existing measures, measurement and health care delivery experts, as well as hospital frontline staff was used to design and modify ED quality measures. Three field tests were conducted to determine the feasibility of data collection and the effectiveness of different training methods and types of partnerships. Measures were evaluated based on their prevalence, ease of data collection, and usefulness for internal and external improvement.
Findings: It is feasible to collect ED quality measure data. Different data sources, data collection, and data entry methods, training and partners can be used to examine hospital ED quality. There is significant room for improvement in the communication of patient information between health care facilities.
Conclusion: Current health care reform efforts highlight the importance of clear communication between organizations held accountable for patient safety and outcomes. The patient transfer communication measures have been tested in a wide range of rural settings and have been vetted nationally. They have been endorsed by the National Quality Forum, are included in the National Quality Measurement Clearinghouse supported by the Agency for Health Care Research and Quality (AHRQ), and are under consideration by the Centers for Medicare and Medicaid Services for future payment determinations beginning in calendar year 2013.

Is Distance to Provider a Barrier to Care for Medicaid Patients With Breast, Colorectal, or Lung Cancer?

John F. Scoggins, Catherine R. Fedorenko, Sara M. A. Donahue, Dedra Buchwald, David K. Blough and Scott D. Ramsey

Purpose:Distance to provider might be an important barrier to timely diagnosis and treatment for cancer patients who qualify for Medicaid coverage. Whether driving time or driving distance is a better indicator of travel burden is also of interest.
Methods: Driving distances and times from patient residence to primary care provider were calculated for 3,917 breast, colorectal (CRC) and lung cancer Medicaid patients in Washington State from 1997 to 2003 using We fitted regression models of stage at diagnosis and time-to-treatment (number of days between diagnosis and surgery) to test the hypothesis that travel burden is associated with timely diagnosis and treatment of cancer.
Findings: Later stage at diagnosis for breast cancer Medicaid patients is associated with travel burden (OR = 1.488 per 100 driving miles, P= .037 and OR = 1.270 per driving hour, P= .016). Time-to-treatment after diagnosis of CRC is also associated with travel burden (14.57 days per 100 driving miles, P= .002 and 5.86 days per driving hour, P= .018).
Conclusions: Although travel burden is associated with timely diagnosis and treatment for some types of cancer, we did not find evidence that driving time was, in general, better at predicting timeliness of cancer diagnosis and treatment than driving distance. More intensive efforts at early detection of breast cancer and early treatment of CRC for Medicaid patients who live in remote areas may be needed.

Receipt of Cancer Screening Services: Surprising Results for Some Rural Minorities

Kevin J. Bennett, Janice C. Probst and Jessica D. Bellinger

Background:Evidence suggests that rural minority populations experience disparities in cancer screening, treatment, and outcomes. It is unknown how race/ethnicity and rurality intersect in these disparities. The purpose of this analysis is to examine the cancer screening rates among minorities in rural areas.
Methods: We utilized the 2008 Behavioral Risk Factor Surveillance System (BRFSS) to examine rates of screening for breast, cervical, and colorectal cancer. Bivariate analysis estimated screening rates by rurality and sociodemographics. Multivariate analysis estimated the factors that contributed to the odds of screening.
Results: Rural residents were less likely to obtain screenings than urban residents. African Americans were more likely to be screened than whites or Hispanics. Race/ethnicity and rurality interacted, showing that African American women continued to be more likely than whites to be screened for breast or cervical cancer, but the odds decreased with rurality.
Conclusions: This analysis confirmed previous research which found that rural residents were less likely to obtain cancer screenings than other residents. We further found that the pattern of disparity differed according to race/ethnicity, with African Americans having favorable odds of receipt of service regardless of rurality. These results have the potential to create better targeted interventions to those groups that continue to be underserved.

Prevalence Estimates of Health Risk Behaviors of Immigrant Latino Men Who Have Sex With Men

Scott D. Rhodes, Thomas P. McCoy, Kenneth C. Hergenrather, Aaron T. Vissman, Mark Wolfson, Jorge Alonzo, Fred R. Bloom, Jose Alegría-Ortega and Eugenia Eng

Purpose:Little is known about the health status of rural immigrant Latino men who have sex with men (MSM). These MSM comprise a subpopulation that tends to remain 'hidden' from both researchers and practitioners. This study was designed to estimate the prevalence of tobacco, alcohol, and drug use, and sexual risk behaviors of Latino MSM living in rural North Carolina.
Methods: A community-based participatory research (CBPR) partnership used respondent-driven sampling (RDS) to identify, recruit, and enroll Latino MSM to participate in an interviewer-administered behavioral assessment. RDS-weighted prevalence of risk behaviors was estimated using the RDS Analysis Tool. Data collection occurred in 2008.
Results: A total of 190 Latino MSM was reached; the average age was 25.5 years and nearly 80% reported being from Mexico. Prevalence estimates of smoking everyday and past 30-day heavy episodic drinking were 6.5% and 35.0%, respectively. Prevalence estimates of past 12-month marijuana and cocaine use were 56.0% and 27.1%, respectively. Past 3-month prevalence estimates of sex with at least one woman, multiple male partners, and inconsistent condom use were 21.2%, 88.9%, and 54.1%, respectively.
Conclusions: Respondents had low rates of tobacco use and club drug use, and high rates of sexual risk behaviors. Although this study represents an initial step in documenting the health risk behaviors of immigrant Latino MSM who are part of a new trend in Latino immigration to the southeastern United States, a need exists for further research, including longitudinal studies to understand the trajectory of risk behavior among immigrant Latino MSM.

Does the Universal Health Insurance Program Affect Urban-Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

Pei-An Liao, Hung-Hao Chang and Fang-An Yang

Purpose:To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban-rural inequality in health service utilization among the elderly.
Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference-in-differences model was employed and estimated by the random-effect probit method.
Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents.
Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.

Adoption and Perceived Effectiveness of Financial Improvement Strategies in Critical Access Hospitals

George M. Holmes and George H. Pink

Methods:Information about the use and perceived effectiveness of 44 specific strategies to improve financial performance was collected from an online survey of 291 CAH Chief Executive Officers and Chief Financial Officers. Responses were merged with financial and operational characteristics of the respondents’ hospitals obtained from Medicare cost reports. Use rates and perceived success and failure were calculated for each strategy. A cluster analysis was applied to classify strategies based on their use and success. Finally, CAH characteristics were examined to predict the use of individual strategies.
Findings: Financial improvement strategies are pervasive among CAHs. The administrators who responded to the survey in this study reported using an average of 17.0 of the maximum 44 strategies listed in the survey questionnaire. Revenue/cost, human resource, and capital strategies were more frequently used than service expansion and reduction strategies. Overall, CAH characteristics did not explain the use or perceived success of specific strategies, but they did partially predict the number of strategies attempted.
Conclusions: CAH administrators have used multiple strategies to improve financial performance with a wide variety of reported success. More research into the effectiveness of specific interventions is needed to help administrators select evidence-based strategies.

Complementary and Alternative Medicine in Rural Communities: Current Research and Future Directions

Jon Wardle, Chi-Wai Lui and Jon Adams

Contexts:The consumption of complementary and alternative medicine (CAM) in rural areas is a significant contemporary health care issue. An understanding of CAM use in rural health can provide a new perspective on health beliefs and practice as well as on some of the core service delivery issues facing rural health care generally.
Purpose: This article presents the first review and synthesis of research findings on CAM use and practice in rural communities.
Methods: A comprehensive search of literature from 1998 to 2010 in CINAHL, MEDLINE, AMED, and CSA Illumina (social sciences) was conducted. The search was confined to peer-reviewed articles published in English reporting empirical research findings on the use or practice of CAM in rural settings.
Findings: Research findings are grouped and examined according to 3 key themes: 'prevalence of CAM use and practice,''user profile and trends of CAM consumption,' and 'potential drivers and barriers to CAM use and practice.'
Conclusions: Evidence from recent research illustrates the substantial prevalence and complexity of CAM use in rural regions. A number of potential gaps in our understanding of CAM use and practice in rural settings are also identified.


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

Contents: 2012; 17:(1)
Issue includes:

Health views and metabolic syndrome in a Finnish rural community: a cross-sectional population study

Juhani Miettola, Irma Nykanen, Esko Kumpusalo

Introduction:Metabolic syndrome (MetS) can be prevented through the promotion of healthy lifestyles. In rural areas, MetS is associated with unhealthy lifestyles and socioeconomic and demographic changes. However, there is scarce evidence on how health views contribute to the unhealthy lifestyles that result in MetS.
Methods: The study involved adults in 8 birth cohorts between 30 and 65 years of age living in the rural community of Lapinlahti in eastern Finland. We assessed participants' demographic and lifestyle factors and health views. For assessment of health views, we applied factor analysis. For MetS classification, we used the 2005 criteria of the National Cholesterol Education Program.
Results: The prevalence of MetS among the participants was 38%. In a backward logistic regression analysis adjusted for other variables, there was a significant association between MetS and older age (odds ratio [OR] 2.91) as well as low level of physical activity (OR 1.99). In a factor analysis, 4 principal factors of lay health views were identified, of which blame-shifting (OR 1.36, 95% confidence interval [CI] 1.21–1.49) and social alienation (OR 1.23, 95% CI 1.24–1.40) were significantly associated with MetS in an unadjusted logistic regression analysis.
Conclusion: It is important, particularly in primary health care, to recognize health views behind MetS and to empower communities in the prevention of MetS.

Diagnostic approach to pulmonary embolism in a rural emergency department

Mike Ballantine, Munsif Bhimani, W. Ken Milne

Introduction:Pulmonary embolism (PE) is a serious condition with mortality estimates of up to 10%. We sought to investigate the diagnosis of PE, time to access imaging and diagnostic utility of each modality in a rural emergency department (ED).
Methods: We completed a retrospective chart review to determine the investigations performed and treatments initiated in the management of suspected PE in a rural hospital.
Results: A total of 47 charts from a 5-year period were reviewed. Of these, 83.0% indicated a D-dimer test was ordered, and 31.9% and 40.4% indicated either ventilation–perfusion (V/Q) or computed tomography (CT) were ordered during the ED visit. Computed tomography diagnosed 11 of the 12 instances of confirmed PE. Mean time to patients undergoing V/Q or CT was 1.58 and 1.59 days, respectively. Low-molecular-weight heparin was started in 83.0% of patients.
Conclusion: In this ED there may be overreliance on the D-dimer test, irrespective of Wells score. Access to V/Q and CT were similar to that of an urban centre. Empiric anticoagulation was started in most patients.


 Australian Journal of Rural Health

2011; 19:(6)
Issue includes:

Urban–rural influences on suicidality: Gaps in the existing literature and recommendations for future research

Tonelle E. Handley, Kerry J. Inder, Brian J. Kelly, John R. Attia and Frances J. Kay-Lambkin

Suicide is a major public health issue of particular concern among rural populations, which experience a consistently higher suicide rate than urban areas. Although extensive research efforts have been directed towards understanding suicidality and related factors, there is a continued lack of clinically useful factors to target preventive measures, particularly among some regional and demographic groups. This suggests limitations in the conceptualisation of this important construct. A review of the literature was undertaken, using a snowballing and saturation approach. Literature was considered relevant if it addressed the research question ‘what are the current limitations in research on urban/rural influences on suicidality?’ Findings were used to develop a set of guidelines to inform future research. A number of gaps in existing research relevant to limitations in rural suicide research were identified: inconsistencies in terminology; a focus on high-end suicidal behaviours; a disproportionate focus on urban populations; a dominance of cross-sectional research; and a high use of clinical samples. These limitations are discussed in terms of their implications for rural suicidality, and are used to support the development of recommendations for future research, with a focus on encouraging consistency and standardisation. A number of limitations can be identified in existing research on suicide. Targeting these specific areas can be an important step in addressing the current gaps in knowledge relating to rural suicide prevention.

Performance pressure: Simulated patients and high-stakes examinations in a regional clinical school

Pam Harvey and Natalie Radomski

Objective: To investigate the effects and challenges of being a simulated patient (SP) in a high-stakes clinical examination context in a regional setting.
Design: Mixed methods, using a written survey, focus groups, and a retrospective postal survey.
Setting: A university clinical school in a Victorian regional city.
Participants: Nineteen SP volunteers (from an existing database of 55 people) who had been involved in mid-year, summative Objective Structured Clinical Examination (OSCE) role-play performances.
Main outcome measures: Challenges of the OSCE role-play experience and the reported effects on SPs. The implications of these factors have an impact on the sustainability of SP programs in regional settings.
Results: Physical and emotional effects like exhaustion were reported, as well as empathy and concern for the medical students. The retrospective postal survey indicated that the SPs had no long-term negative effects from their high-stakes examination experiences. Participants also reported that a level of decision making and improvisation was needed in the performance of their OSCE role plays.
Conclusions: Our study reveals the complexity and demands on SPs in performing in high-stakes clinical examinations. The results highlight that SP roles involve more than the transfer of scripted information. SPs should be considered as members of the examination team when preparing and implementing high-stakes examinations to assist in maintaining standardised performance during and across OSCE role plays. Relationships between SPs and educational institutes need to be nurtured to ensure that the ability to continue high-stakes OSCEs in a regional setting is maintained.

Factors influencing the selection of rural practice locations for early career pharmacists in Victoria

Cristen A. Fleming and M. Joy Spark

Objective: To identify factors influencing the choice of practice location for early career pharmacists working and living in Victoria.
Design: Survey.
Setting: Victorian pharmacies.
Participants: Pharmacists living in Victoria in April 2009, who had registered with the Pharmacy Board of Victoria after 1 October 2004, stratified into major city and rural areas.
Main outcome measures: Questionnaire responses analysed via descriptive statistics, chi-square and direct logistic regression.
Results: Early career pharmacists were more likely to practice in a rural location if they had undertaken a rural internship, had a spouse or partner with a non-metropolitan background and were not practicing in a hospital pharmacy. Pharmacists who had lived in a rural area during their childhood and had studied pharmacy at a rural university were four times more likely to have undertaken a rural internship than those that studied at a major city university.
Conclusions: The strongest indicator for future practice location was a pharmacist's internship location. Childhood location and pharmacy education location were indicators of internship location. Pharmacists with a rural childhood location, especially those who study at rural universities, are more likely to work in rural areas.

Travelling all over the countryside: Travel-related burden and financial difficulties reported by cancer patients in New South Wales and Victoria

Alison Zucca, Allison Boyes, Graham Newling, Alix Hall and Afaf Girgis

Objective: To describe travel burden and travel-related financial burden experienced by cancer patients over the first year after diagnosis.
Design, setting, participants: Population-based longitudinal cohort of recent adult cancer patients diagnosed with the eight most incident cancers recruited from New South Wales and Victorian Cancer Registries. Self-report survey data were collected at 6 and 12 months after diagnosis from 1410 participants (city: n = 890; regional/remote: n = 520).
Main outcome measures: Travel time to cancer treatment, living away from home for treatment, travel-related treatment decisions, extent of financial issues, unmet need for financial help.
Results: During the first 12 months after diagnosis, outer regional/remote residents had the greatest travel burden; 61% (n = 79) travelled at least 2 hours one way to receive treatment, and 49% (n = 66) lived away from home to receive treatment. Strongest associates of travel burden were living in regional/remote areas (odds ratio (OR) = 18.9–135.7), having received surgery (OR = 6.7) or radiotherapy (OR = 3.6). Between 6 and 12 months after diagnosis, 2% (n = 24) of patients declined cancer treatment because of the time it would take to get to treatment. Patients who travelled more than 2 hours or lived away for treatment reported significantly greater financial difficulties (38%; 40%) than those who did not (12%; 14%), even after adjusting for covariates.
Conclusions: Travel burden is greatest for rural patients, and is associated with greater financial burden. Appropriate and adequate provision of travel and accommodation assistance schemes remains paramount to achieving equitable delivery of cancer services.

Rural maternity care and health policy: Parents' experiences

Rebecca Evans, Craig Veitch, Richard Hays, Michele Clark and Sarah Larkins

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context.
Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study.
Setting: Four north Queensland rural towns.
Participants: Thirty-three parents living in one of the four rural towns.
Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care.
Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns.
Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re-evaluated in order to improve rural Australians' access to vital health services such as maternity care.

Young mothers' lived experiences prior to becoming pregnant in rural Victoria: A phenomenological study

Sarah Roberts, Melissa Graham and Sarah Barter-Godfrey

Objective: To explore the lived experiences and social context prior to becoming pregnant, of women who became mothers during adolescence in rural Victoria.
Design: Qualitative interpretive phenomenological study using semistructured interviews.
Setting: Rural community in North East Victoria, Australia.
Participants: Four rural women who gave birth to a child between the ages of 15 and 19.
Results: Five themes emerged from the data as being essential to the participants' experiences prior to pregnancy. These included feeling isolated; life change: transition into adulthood; support and understanding in sexual relationships; feeling dissatisfied; and overcoming adversity. Participants' provided practical recommendations to improve life for young people in rural areas through reflecting on their own experiences.
Conclusion: These findings highlight the complex nature of rural young women's experiences leading up to pregnancy and suggest that early motherhood might be largely reflective of the social environment in which one lives prior to pregnancy. Providing somewhere safe to go, organised and appropriate social activities and increasing access to health services were identified as being pertinent to improving experiences for rural young people prior to pregnancy. Health professionals should consider the importance of supporting young women through non-judgemental, approachable and accessible services

Asian migrants' lived experience and acculturation to Western health care in rural Tasmania

Daniel Terry, Mohammed Ali and Quynh Lê

Objectives: The study was designed to explore the lived experience of Asian migrants' health care-seeking behaviour in Tasmania, to discern the acculturation process by which Asian migrants are enabled to use the health system and to identify strategies, which assist migrants to understand and use the health system better.
Methods: Qualitative research was adopted. Semistructured interviews were conducted with 36 Asian migrants residing in North, South and North West Tasmania, which were recruited through purposive sampling.
Results: Six main themes emerged from the interviews: the acculturation process, interactions with the health care system, access issues, culturally appropriate health care, positive health care in Tasmania and suggestions for improving health care.
Conclusions: The findings indicated that Asian migrants' views affected their health care-seeking behaviours because of the lack of information, poor communication, limited access and choices in Tasmania. Interestingly, those married to local Tasmanians had the shortest trajectory to health system acculturation. The study recommended developing health and well-being for Asian migrants by increasing access to information regarding navigating the health system and improving access to and awareness of language services. In addition, ensuring adequate, appropriately written, culturally specific and congruent information should be available to assist migrants' transition into a new health care system. Lastly, greater cultural awareness within the health profession to meet the needs of culturally specific individuals and communities is required when they seek care.

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