Journal Search

Journal Search - June 2003


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Paul Worley1
-, Editor-in-Chief


* Jennifer Richmond


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30 June 2003 Volume 3 Issue 2


RECEIVED: 30 June 2003

ACCEPTED: 30 June 2003


Worley P.  Journal Search - June 2003. Rural and Remote Health 2003; 3: 226.


© Paul Worley 2003 A licence to publish this material has been given to Deakin University,

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Journal Search brings Rural and Remote Health users a selection of relevant recent abstracts from MEDLINE. This month's themes are rural: medical workforce and training; nutrition in maternal and child health, obstetrics, public health.

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Can Fam Physician 2003; 49: 320-7
Rural women family physicians. Are they unique?
Incitti F, Rourke J, Rourke LL, Kennard M
University of Western Ontario, London

OBJECTIVE: To compare the scope of practice and degree of personal and professional satisfaction of rural women family physicians with their rural male, urban female, and urban male counterparts. DESIGN: Cross-sectional mailed survey.
SETTING: Rural and urban Ontario family practices.
PARTICIPANTS: A total of 442 rural and urban family physicians.
MAIN OUTCOME MEASURES: Personal and professional characteristics, scope of practice, and degree of personal and professional satisfaction.
RESULTS: Rural women family physicians' scope of practice is as broad as that of rural men, and the women are more likely to attend births. They work many more hours on average than their urban counterparts. Rural women incorporate more professional activities into their practices than both male and female urban family physicians do, but they are less satisfied, both personally and professionally.
CONCLUSION: Rural family practice provides a broad scope of practice for both women and men, but initiatives are needed to make rural practice more professionally and personally satisfying for both women and men.

Can Fam Physician 2003; 49: 312-7
Improving on-line skills and knowledge. A randomized trial of teaching rural physicians to use on-line medical information
Kronick J, Blake C, Munoz E, Heilbrunn L, Dunikowski L, Milne WK
Office of Professional and Educational Development, Faculty of Medicine and Dentistry, The University of Western Ontario, London.

OBJECTIVE: To assess the change in frequency and methods with which a pilot group of rural physicians consulted on-line medical resources before and after an educational intervention.
DESIGN: Physicians were randomly assigned to an educational intervention or control group. Self-administered questionnaires were completed before and 3 months after the intervention.
SETTING: Rural practices in southwestern Ontario.
PARTICIPANTS: Eighty rural (defined as a population of 15000 or less) physicians in southwestern Ontario, with a computer with Internet access.
INTERVENTIONS: Individualized 3-hour training session on using the World Wide Web to research patient-related questions.
MAIN OUTCOME MEASURES: Frequency of access and comfort with on-line medical information were compared after intervention with baseline data using the Wilcoxon two-sample test.
RESULTS: At follow up, the intervention group showed a significant improvement over the control group in their frequency of accessing the World Wide Web to address patient-related questions (P = .009), in their comfort level in using on-line databases (P = .032), and in their frequency of accessing on-line databases (P = .044).
CONCLUSION: Rural physicians' comfort and competence in using computers to address patient problems can be improved by an individualized 3-hour training session.

Health Aff (Millwood) 2003; 22: 255-62
International medical graduates and the primary care workforce for rural underserved areas
Fink KS, Phillips RL Jr, Fryer GE, Koehn N
Department of Family Medicine, University of North Carolina at Chapel Hill, USA

The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.

J Allied Health 2003; 32: 46-51
Assistive technology education needs of allied health professionals in a rural state
Gitlow L, Sanford T
Department of Occupational Therapy, Husson College, Bangor, Maine 04496, USA

A nonexperimental design using a mailed questionnaire was used to answer five questions regarding allied health practitioners: What (1) present skills, (2) knowledge and (3) assistive technology (AT) competence do allied health practitioners have; what are (4) the AT skills and knowledge that allied health practitioners would like to obtain; and (5) how would these practitioners like to have AT education provided. More than two thirds of the subjects reported having nonexistent or foundational knowledge in most of the AT areas. Additionally, more than 50% of the respondents had a moderate or significant need for information in most areas of AT. No clear preferences regarding training options were revealed, other than a traditional classroom approach being the least attractive option. Most respondents are not willing to travel more than 1 hour from their home for AT education. This study revealed useful information for developing the content and format of AT education for allied health practitioners in Maine. We will expand this pilot study to investigate the AT educational needs of a wider variety of practitioners and consumers.

J Am Board Fam Pract 2003; 16: 124-30
An accelerated rural training program
Stageman JH, Bowman RC, Harrison JD
Department of Family Medicine, University of Nebraska Medical Center, Omaha 68198-3075, USA

BACKGROUND: Several authors have pointed out the need for enhanced training for those residents contemplating rural practices. Most students and policy makers are reluctant to commit to primary care training beyond the required 3 years.
METHODS: The University of Nebraska Medical Center received approval for an accelerated family practice training program in 1993, and developed a 4-year program that requires a 1-year rural procedures fellowship and a commitment to practice in rural Nebraska.
RESULTS: The Nebraska accelerated rural training program has recruited 10 classes to this program and has placed more than 50% of the graduates in communities with a population of less than 8,000.
CONCLUSION: The requirements of this program are unique. Special consideration must address the issues of recruitment of students, integration into the basic program, licensure issues, determination of fellowship training needs, and faculty recruitment.

Public Health Nutr 2003; 6: 217-224
A qualitative exploration of rural feeding and weaning practices, knowledge and attitudes on nutrition
Kruger R, Gericke G
Department Consumer Science, University of Pretoria, Pretoria 0002, South Africa

AIM: An exploratory qualitative investigation was done to determine the feeding and weaning practices, knowledge and attitudes towards nutrition of mothers/caregivers of children up to 3 years old attending baby clinics in the Moretele district (South Africa). METHODOLOGY: Qualitative data collection on six relevant nutrition topics was done using focus group interviews. Trained moderators, using a pre-tested, structured interview schedule, interviewed participants in six age groups. Focus group interviews were taped, transcribed and translated. Content analysis produced systematic data descriptions and ethnography provided descriptive data.
RESULTS: Breast-feeding was the choice feed and bottle-feeding was only given when breast-feeding was impossible. Solid food was introduced early (at 2-3 months) and a mixed family diet at 7-9 months. Milk feeds were stopped completely from 18-24 months. Weaning diets were compromised due to poor food choices, preparation practices and limited variety. The participant's nutrition knowledge regarding specific foods, their functions and recommended quantities was poor. The women adhered to their cultural beliefs regarding food choices and preparation practices.
CONCLUSION: The data analysis revealed that inadequate nutrition knowledge and adherence to cultural practices lead to poor-quality feeding practices. Cultural factors and taboos have a powerful influence on feeding practices and eating patterns. Young mothers often find it impossible to ignore their ill-informed elders or peer group. Nutrition knowledge needs to be changed in a first step towards implementing improved feeding practices. Facilitated group discussions could focus on possible solutions for the identified nutrition-related problems.

Public Health Nutr 2003; 6: 131-7
Food and nutrient intakes among pregnant women in rural Tamil Nadu, South India
Andersen LT, Thilsted SH, Nielsen BB, Rangasamy S
Research Department of Human Nutrition, The Royal Veterinary and Agricultural University, Rolighedsvej 30, 1958 Frederiksberg C, Denmark

OBJECTIVES: To study pregnant women's diet at food and nutrient levels and how these match recommendations; to describe how factors such as education level, economy and folk dietetics influence the women's food choice; and to give suggestions for the improvement of nutrition education in the existing antenatal care systems.
DESIGN AND SUBJECTS: Thirty pregnant women in the last trimester were interviewed three times using a 24-hour dietary recall with weighing of foods and recipes of dishes. Interviews regarding health, nutrition and socio-economic status, and measurements of weight and height of the women, were conducted.
SETTING: Rural parts of Salem District, Tamil Nadu, South India.
RESULTS AND CONCLUSION: The women's diet (without supplements) was insufficient in energy and all nutrients except fat, compared with the Indian recommendations. Aggravating low intakes of micronutrients were found which were reflected in low intakes of foods other than rice. Eating customs and economy appeared to influence the women's food choice negatively in relation to recommendations while factors such as education level, family type, pregnancy number and folk dietetics did not seem to have a negative effect. The amounts of foods recommended, especially green leafy vegetables, must be shown to the women. The nutrition advice given by all levels of health providers must be the same and based on cheap, local, commonly consumed foods.

J Nutr 2003; 133: 1064-9.

Factors associated with stunting in infants aged 5-11 months in the dodota-sire district, rural Ethiopia
Umeta M, West CE, Verhoef H, Haidar J, Hautvast JG
Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia. Division of Human Nutrition and Epidemiology, Wageningen University, The Netherlands Department of Gastroenterology, University Medical Centre Nijmegen, The Netherlands

The contribution of various factors to malnutrition, particularly stunting, may differ among areas and communities. This cross-sectional study aimed to estimate the level of malnutrition and identify factors associated with the high level of stunting in breast-fed infants aged 5-11 mo living in Dodota-Sire District, Ethiopia. Infants (n = 305) and their mothers were examined physically, and anthropometric and demographic data were collected. The content of zinc, calcium and copper in breast milk was measured, and data collected on the type, frequency of consumption, and time of introduction of supplementary feeding. Overall, 36% were stunted, 41% underweight and 13% wasted. The highest prevalence of malnutrition was seen in infants aged 9-11 mo. Among mothers, 27% had chronic energy deficiency (body mass index, <18.5 kg/m(2)) and 20% were night blind, indicating that vitamin A deficiency was a serious problem. Infants fed >3 times/d, consuming >600 mL/d or consuming cow's milk in addition to cereals and/or legumes had markedly higher length-for-age Z-scores than their peers fed less frequently, consuming less food or not consuming cow's milk [differences: 0.39, 95% confidence interval (CI): 0.04-0.74; 0.17, 95% CI: 0.02-0.32; 0.40, 95% CI: 0.07-0.72, respectively). Infants of mothers with low concentrations of zinc in their breast milk were more stunted. In conclusion, the quality and quantity of foods consumed by infants is insufficient to prevent stunting. Thus it is necessary to increase the nutrient supply to infants by increasing intake and nutrient concentration of breast milk and of supplementary foods they consume, and by providing supplements to infants where appropriate.

Aust Fam Physician 2003; 32: 127-31
Shared antenatal care for indigenous patients in a rural and remote community
Nel P, Pashen D
Emergency Department, Palliative Care Service, Mount Isa Health Service District, Queensland

BACKGROUND: An increase in perinatal mortality prompted a review of services to pregnant women in remote northern and western Queensland, Australia. In order to address the needs of the indigenous population in particular, a range of service changes was implemented to improve outcomes.
OBJECTIVE: This article aims to highlight the changes made in the delivery of local and regional antenatal services.
DISCUSSION: Mt Isa Hospital is the supplier of obstetric services for the north and west of Queensland. Poor antenatal access rates and other service issues for Indigenous patients were identified as contributing to these poor outcomes. Consultation with Indigenous patients and health service providers prompted changes in modes of delivery of services that in the short term seem to have improved results. The models for delivery of services include primary health care clinics in remote communities. Aboriginal community controlled health services, and flying obstetrician clinics.

Am J Perinatol 2003; 20: 63-8
Vaginal birth after cesarean delivery in a small rural community with a solo practice
Upadhyaya CD, Upadhyaya DM, Carlan SJ
Highlands Regional Medical Center and Florida Hospital Heartland Division, Sebring, Florida

The objective of this study is to review the safety and success of a trial of labor after cesarean in a group of patients managed by a solo practitioner in a rural community. This was a retrospective review of all deliveries performed over an 11-year period by a single practitioner in a rural community. Standard contraindications for attempt at vaginal birth after cesarean were observed. Between January 1, 1989 and December 31, 1999, there were 5015 total deliveries. Women with at least one previous cesarean delivery accounted for 11.8% (593) of all patients. Trial of labor was attempted in 413 (74.5%) of these patients, and resulted in vaginal delivery in 308 (75%). Maternal complications were similar between the groups. There was no incidence of uterine rupture, maternal deaths, or neonatal deaths. Vaginal birth after cesarean can be performed safely in isolated rural hospitals with a high success rate.

Can Fam Physician 2003; 49: 328-33
Appendectomies in rural hospitals. Safe whether performed by specialist or GP surgeons
Iglesias S, Saunders LD, Tracy N, Thangisalam N, Jones L,

OBJECTIVE: To compare outcomes of appendectomies performed in rural hospitals by specialist surgeons and GP surgeons.
DESIGN: Retrospective analysis of the Canadian Institute for Health Information's (CIHI) Discharge Abstract Database (DAD) 1996-1999.
SETTING: Rural hospitals in Ontario, Saskatchewan, Alberta, and British Columbia.
PARTICIPANTS: All surgeons who performed appendectomies in these hospitals during the study period.
MAIN OUTCOME MEASURES: Mortality; diagnostic accuracy, perforation, and repeat laparotomy rates; length of stay; and need for transfer to another acute-care institution. RESULTS: Specialist surgeons performed 3624 appendectomies; GP surgeons performed 963. Rates of comorbidity, diagnostic accuracy, and transfer, and mean lengths of stay were similar for patients of GP and specialist surgeons. Patients operated on by specialists were older and more likely to have perforations and to require second intra-abdominal or pelvic procedures. Triage to a specialist, older age, and comorbidity all independently predicted perforation. Only perforation predicted a second intra-abdominal or pelvic procedure.
CONCLUSION: Appendectomy is a safe procedure in rural hospitals, whether performed by specialist or GP surgeons. Some difficult cases are routinely referred to specialists.

Int J Health Plann Manage 2003; 18: 23-39
Understanding referral from primary care clinics in rural Kenya: using health information systems to prioritize health services
Macintyre K, Lochigan M, Letipila F
1440 Canal St Suite 2200, Tulane University, New Orleans, LA 70112, USA

This study analyses the referral patterns of patients, over time, from primary care to secondary or tertiary level facilities in rural Africa. The data come from a health information system of a non-governmental organization with a decade of experience in health services delivery in Samburu District, Kenya. The differential referral patterns from two communities are examined in some detail to shed more light on the meaning of a 'referral rate' in this context. First, referral rates over time for two clinics are calculated and compared. These quantitative data, obtained from monthly reports from 1989 to 1997, are interpreted in the light of qualitative data obtained from interviews with community health workers, nurses and members of the communities. The main differences in referral between these ostensibly similar communities are for malaria, trauma and anaemia. Social, environmental and specific health services factors are used to explain these differences. We demonstrate that basic information from health information systems, which tell us little on their own because referral in this context is a rare event, can be combined with local knowledge from the community to provide evidence for health managers to set priorities for public health and clinical interventions.

Gerontologist 2003; 43: 151-7
Linkages in the rural continuum: the balanced budget act and beyond
Angelelli J, Fennell ML, Hyatt RR, McKenney J

PURPOSE: This study examined how rural hospitals altered their postacute and long-term care strategies after the Balanced Budget Act of 1997 (BBA97). Design and METHODS: A nationally representative sample of 540 rural hospital discharge planners were interviewed in 1997. In the year 2000, 513 of 540 discharge planners were reinterviewed. The study is a descriptive analysis of how rural hospitals formed new and altered existing organizational strategies during a time of turbulent changes in federal government reimbursement policy. We classify rural hospital strategic behavior in 1997 according to the Miles and Snow typology of Prospectors, Analyzers, Defenders, and Reactors, and then we examine how the various hospital types altered key strategies following BBA97.
RESULTS: Between 1997 and 2000, more than 26% of sampled rural hospitals that did not participate in the swing-bed program in 1997 (44/167) had chosen to do so in 2000, whereas only 3% of those using swing beds in 1997 had eliminated them (12/346). Other strategies such as divestiture of hospital-based nursing homes were related to concurrent swing-bed adoption. Rural hospitals also increased their reliance on formal linkages with external providers of long-term care.
IMPLICATIONS: After the BBA97 reimbursement changes, rural hospitals increased their reliance on swing beds and formal linkages to external providers. We observed changes in overall strategy types, away from the Defender and toward the Prospector and Analyzer strategy types. Our findings illustrate the importance of swing beds as a critical buffer for rural hospitals challenged by the uncertainty of the post-BBA97 environment.

Qual Health Res 2003; 13: 435-43
Health diaries in a rural Australian study
Keleher HM, Verrinder GK
School of Health Sciences, Deakin University, Burwood, Victoria, Australia

The authors designed a study around the use of health diaries comprising both open- and closed-ended questions and kept over a 16-week period by 118 rural and remote-dwelling families in Victoria, Australia. Participants documented their use of health services, episodes of illness, actions taken to keep healthy, and reflections on services and programs. In this article, the authors report on the health diary method. They discuss the qualitative ways in which the participants used their study involvement to enrich their lives: accessing health information and advice, furthering their concerns about rural health, and using the research process for social support. The authors discuss issues surrounding the rural and remote context of the study and the length of time over which the diaries were kept.

Trop Med Int Health 2003; 8: 310-315
The effect on haemoglobin of the use of iron cooking pots in rural Malawian households in an area with high malaria prevalence: a randomized trial
Geerligs PP, Brabin B, Mkumbwa A, Broadhead R, Cuevas LE
Tropical Child Health Group, Division of Tropical Medicine, Liverpool School of Tropical Medicine, Liverpool, UK Department of Paediatrics, Medical College, Blantyre, Malawi Emma Kinderziekenhuis, Academic Medical Centre, University of Amsterdam, The Netherlands

BACKGROUND: Innovative low-cost sustainable strategies are required to reduce the high prevalence of iron-deficiency anaemia in developing countries.
METHODS: We undertook a community-based randomized controlled intervention trial to assess the effects of cooking in iron or aluminium cooking pots in Malawian households in an area with high malaria prevalence. Analysis was by intention to treat and consistency of use. The primary outcomes were change in haemoglobin and iron status.
FINDINGS: The study population comprised 164 participants eating from aluminium cooking pots and 158 from iron cooking pots. The mean haemoglobin change was significantly increased after 6 weeks in adults who consistently ate from an iron cooking pot (+3.6 g/l compared to -3.2 g/l, mean difference between groups 6.8 g/l, 95% CI +0.86, +12.74). In children, no significant haemoglobin change was observed in consistent pot users, although they showed a significant reduction in iron deficiency (iron 8.6 ZP/g and aluminium 10.8 ZP/g, mean difference 2.2 ZP/g, 95% CI +1.08, +3.32). INTERPRETATION: Rural Malawian adults in a high malaria transmission area who consistently consume food prepared in iron cooking pots show a significant rise in haemoglobin after 6 weeks use. Children showed a reduction in iron deficiency, but no significant improvement in haemoglobin, possibly because of their high malaria parasite prevalence. Using iron cooking pots in developing countries could provide an innovative way to prevent iron deficiency and anaemia in malarious areas where regular iron supplementation is problematic.

Aust Fam Physician 2003; 32: 186-8
Enhanced primary care. A rural perspective
Lewis P, White A, Misan G, Harvey P, Connolly J, Noone J
Adelaide University, South Australia, Australia

BACKGROUND: The Enhanced Primary Care (EPC) program is designed to promote better management of and improved health outcomes for people with chronic illness. Specific Medicare item numbers provide government funding to encourage general practitioners to take up health assessments, care plans and case conferences. AIM: We investigated elements of the EPC program from a rural general practice perspective. METHOD: Questionnaires summarising experience of EPC for patients and health care providers, undertaken over four weeks at three rural general practices, and observation. RESULTS: The EPC program assisted the management and coordination of care for patients with multidisciplinary care needs. General practitioners were generally positive about the EPC program. The main barrier was the extra time required. The main concern of allied health workers was the lack of appropriate remuneration for their participation. Patients were positive in their responses, but many appeared to lack the motivation and self management skills to take full advantage of the program.
DISCUSSION: Strategies seeking to increase the uptake of EPC items need to address efficiency and accessibility, and funding for participating health professionals.

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