Journal Search

Journal Search - issue 2, 2012


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


28 June 2012 Volume 12 Issue 2


RECEIVED: 28 June 2012

ACCEPTED: 28 June 2012


Richmond J.  Journal Search - issue 2, 2012. Rural and Remote Health 2012; 12: 2275.


© 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 2
  • Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine 2012; 17: issue 2
  • Australian Journal of Rural Health 2012; 20: issue 2.


Journal of Rural Health 

Contents: 2012; 28:(2)
Issue includes:

Farmers’ Concerns: A Qualitative Assessment to Plan Rural Medical Education
Brittney T. Anderson, Gwendolyn J. Johnson, John R. Wheat, Amina S. Wofford, O. Sam Wiggins and Laura H. Downey

Abstract Context: Limited research suggests that translational approaches are needed to decrease the distance, physical and cultural, between farmers and health care.
Purpose: This study seeks to identify special concerns of farmers in Alabama and explore the need for a medical education program tailored to prepare physicians to address those concerns.
Methods: We conducted 2 focus groups with 20 farmers from diverse communities, backgrounds, and farming operations. The sessions were audio-recorded, transcribed, coded, and analyzed for determined patterns.
Findings: The following categories were developed as areas of importance to farmers: the need for physicians to understand the culture of farming, occupational exposures in farming, and recommendations for improving the health of farmers.
Conclusion: Findings suggest that to adequately serve farmers, medical students interested in entering practice in rural areas should have or develop a relevant and adequate understanding of farming practices.

Teaching and Learning Resilience: Building Adaptive Capacity for Rural Practice. A Report and Subsequent Analysis of a Workshop Conducted at the Rural Medical Educators Conference, Savannah, Georgia, May 18, 2010
Randall Longenecker, Therese Zink and Joseph Florence

Abstract Purpose: Resilience, the capacity to endure and overcome hardship, has been suggested as a basic competency for rural medical practice. Unfortunately for physician educators, the medical education literature offers only limited guidance for nurturing this adaptive capacity. We describe the process and subsequent analysis of a daylong curriculum development workshop conducted at the annual meeting of Rural Medical Educators in 2010.
Methods: Fifty administrator, faculty and student attendees reflected individually and worked in groups to construct key curricular components and modalities for teaching this competency. Prior to the meeting, participants were asked to submit a personal story about resilience. The 22 narratives received were distributed across 8 groups and provided the grist for the small group discussions, in which each group identified key concepts for teaching and learning about resilience, constructed a concept map, and developed a curriculum that was presented to all session participants. Concept maps, curriculum outlines and notes taken during the presentations were analyzed using content analysis techniques.
Findings: Data highlight the importance of (1) embracing hardship as an opportunity for growth, (2) viewing resilience as both an individual and community property, (3) pursuing adaptability more than hardiness, and (4) setting a lifelong pattern of learning this competency in practice. Specific teaching modalities are suggested including individual reflective time and group activities.
Conclusions: To our knowledge this represents a first effort to define and develop a medical curriculum for teaching resiliency in rural predoctoral and residency education.

Admission Factors Predicting Family Medicine Specialty Choice: A Literature Review and Exploratory Study Among Students in the Rural Medical Scholars Program
Daniel M. Avery, Jr, John R. Wheat, James D. Leeper, Jerry T. McKnight, Brent G. Ballard and Jia Chen

Purpose: The Rural Medical Scholars Program (RMSP) was created to increase production of rural family physicians in Alabama. Literature review reveals reasons medical students choose careers in family medicine, and these reasons can be categorized into domains that medical schools can address through admission, curriculum, and structural interventions. We examine whether admission factors can predict family medicine specialty choice among students recruited from rural Alabama.
Methods: We developed a questionnaire to study the ability of admission factors to predict family medicine specialty choice among Rural Medical Scholars (RMS). Eighty RMS graduates were surveyed by mail and 64 (80%) responded.
Findings: Student characteristics of humanitarian outlook with commitment to rural or underserved populations, family medicine decision or intention made before or at medical school admission, and community influence were positive associations with RMS choosing family medicine residencies; shadowing in an urban hospital was a negative association.
Conclusions: Statements of interest, intentions, plans, and decisions regarding family medicine should be elicited at the time of RMSP admission interview. Strong attachment to home community and commitment to serving and living in a rural area are also important. Students whose introduction to medicine was informed through shadowing or observing in urban hospitals should be considered less likely to become family physicians. Larger sample size studies are needed to assess the role of gender, race, marital status, size of rural town, and MCAT score of candidates in affecting residency choices of students selected for this rural medical education track.

Orthopedic Surgery in Rural American Hospitals: A Survey of Rural Hospital Administrators
Derek Weichel

Rural American residents prefer to receive their medical care locally. Lack of specific medical services in the local community necessitates travel to a larger center which is less favorable. This study was done to identify how rural hospitals choose to provide orthopedic surgical services to their communities.
Methods: All hospitals in 5 states located in communities that met the criteria for a rural town according to the Rural Urban Commuting Area codes were included. A survey with topics including community and hospital demographics, orthopedic surgical workforce and demand, surgical services, and the perceived benefit of orthopedic services was sent to the hospital administrators.
Results: Of the 223 rural hospitals surveyed, 145 completed the survey. Of those completing the survey, 30% had at least one full-time orthopedic surgeon, 25% did not provide any orthopedic surgical services, 65% never had an orthopedic surgeon on ER call, 33% were recruiting an orthopedic surgeon, 52% stated that it is more difficult to recruit an orthopedic surgeon vs a general surgeon, and 71% of the administrators acknowledged a need for additional orthopedic surgical services in their community. For those hospitals that did not have a full-time orthopedic surgeon, members of those communities traveled a mean distance of 55 miles for emergency orthopedic surgical care as reported by the hospital administrators.
Conclusions: There are many rural communities that have limited access to orthopedic surgical services. While many of the rural hospital administrators feel that there is a need for additional orthopedic surgical services in their communities, it is difficult to recruit orthopedic surgeons to these areas.

Cognitive Appraisals of Specialty Mental Health Services and Their Relation to Mental Health Service Utilization in the Rural Population
Tisha L. Deen, Ana J. Bridges, Tara C. McGahan and Arthur R. Andrews III

Abstract Purpose: Rural individuals utilize specialty mental health services (eg, psychiatrists, psychologists, counselors, and social workers) at lower rates than their urban counterparts. This study explores whether cognitive appraisals (ie, individual perceptions of need for services, outcome expectancies, and value of a positive therapeutic outcome) of help-seeking for depression symptoms are related to the utilization of specialty mental health services in a rural sample.
Methods: Demographic and environmental characteristics, cultural barriers, cognitive appraisals, and depression symptoms were assessed in one model predicting specialty mental health service utilization (MHSU) in a rural sample. Three hypotheses were proposed: (1) a higher number of environmental barriers (eg, lack of insurance or transportation) would predict lower specialty mental health service utilization; (2) an increase in cultural barriers (stigma, stoicism, and lack of anonymity) would predict lower specialty mental health utilization; and (3) higher cognitive appraisals of mental health services would predict specialty mental health care utilization beyond the predictive capacities of psychiatric symptoms, demographic variables, environmental barriers, and cultural barriers.
Findings: Current depression symptoms significantly predicted lifetime specialty mental health service utilization. Hypotheses 1 and 2 were not supported: more environmental barriers predicted higher levels of specialty MHSU while cultural barriers did not predict specialty mental health service utilization. Hypothesis 3 was supported: cognitive appraisals significantly predicted specialty mental health service utilization.
Conclusions: It will be important to target perceptions and attitudes about mental health services to reduce disparities in specialty MHSU for the rural population.

Emergency Department Reliance Among Rural Children in Medicaid in New York State
Jane L. Uva, Victoria L. Wagner and Foster C. Gesten

Abstract Purpose: This study examines variation in emergency department reliance (EDR) between rural and metro pediatric Medicaid patients in New York State for noninjury, nonpoisoning primary diagnoses and seeks to determine the relationship between receipt of preventive care and the likelihood of EDR.
Methods: Rural/urban designations were based on Urban Influence Codes established by the United States Department of Agriculture (USDA). Healthcare Effectiveness Data and Information Set (HEDIS®) well-visit measures were calculated using 2008 Medicaid claims and encounter data. Well-child numerator status and location of residence variables were then entered as independent variables in multivariate logistic regression models. Models controlled for the effects of Medicaid financing system (fee-for-service vs managed care), Medicaid aid type, race/ethnicity, gender, and 2008 clinical risk group category.
Findings: The likelihood of EDR was higher in all age categories for rural compared to metro residing Medicaid children in New York State. Meeting HEDIS well-child criteria was protective against emergency department (ED) reliance in the adolescence age group (OR = 0.84).
Conclusion: ED reliance is associated with rural residence. Increased access to primary and specialty care in rural settings could help reduce EDR, particularly among rural adolescents.

Birth Outcomes Across Three Rural-Urban Typologies in the Finger Lakes Region of New York
Kelly L. Strutz, Ann M. Dozier, Edwin van Wijngaarden and J. Christopher Glantz

Purpose: The study is a descriptive, population-based analysis of birth outcomes in the New York State Finger Lakes region designed to determine whether perinatal outcomes differed across 3 rural typologies.
Methods: Hospital birth data for the Finger Lakes region from 2006 to 2007 were used to identify births classified as low birthweight (LBW), small for gestational age (SGA), and preterm delivery (PTD). Maternal residences were defined using 3 existing ZIP code-level rural-urban typologies: Census Bureau ZIP codes, Rural-Urban Commuting Area codes, and Primary Service Areas. Within each typology, rural maternal characteristics and birth outcomes were compared to those in urban areas using multivariable logistic regression models.
Findings: In bivariate analyses, rurality was associated with LBW and SGA for all typologies, whereas PTD was associated with residence in the Census Bureau typology only. After controlling for demographic characteristics, births to mothers in the most rural level of the Census Bureau typology and to all rural mothers in the Rural-Urban Commuting Area (RUCA) and Primary Service Area typologies were more likely to be LBW and PTD. SGA was not consistently associated with residence across typologies.
Conclusions: The typologies produced similar results for these outcomes, although effects were of greater magnitude in the RUCA and Primary Service Area typologies than in the Census Bureau typology. Comparison across typologies can have practical implications for researchers and policy makers interested in understanding the dynamics of rurality and birth outcomes in their regions.

White Infant Mortality in Appalachian States, 1976–1980 and 1996–2000: Changing Patterns and Persistent Disparities
Nengliang Yao, Stephen A. Matthews and Marianne M. Hillemeier

Purpose: Appalachian counties have historically had elevated infant mortality rates. Changes in infant mortality disparities over time in Appalachia are not well-understood. This study explores spatial inequalities in white infant mortality rates over time in the 13 Appalachian states, comparing counties in Appalachia with non-Appalachian counties.
Methods: Data are analyzed for 1,100 counties in 13 Appalachian states that include 420 counties designated as Appalachian by the Appalachian Regional Commission. Area Resource File data for 1976-1980 and 1996-2000 provide county- and city-level infant mortality rates, poverty rates, rural-urban continuum codes, and numbers of physicians per 1,000 residents. Multiple regression analyses evaluate whether Appalachian counties are significantly associated with elevated white infant mortality in each time period, accounting for covariates.
Findings: White infant mortality rates decreased substantially in all sub-regions over the last 2 decades; however, disparities in infant mortality did not diminish in Appalachian counties compared to non-Appalachian counties. After accounting for poverty, rural/urban status, and health care resources, Appalachian counties were significantly associated with comparatively higher infant mortality during the late 1970s but not in the late 1990s. At the more recent time point, higher poverty rates, residence in more rural areas, and lower physician density were associated with greater infant mortality risk.
Conclusion: Appalachian counties continue to experience relatively elevated infant mortality rates. Poverty and rurality remain important dimensions of health service need in Appalachia.

Self-Rated Health and the 'First Move' Around Retirement: A Longitudinal Study of Older Americans
Nan E. Johnson

Purpose: I examine whether less favorable self-rated health raises the risk of outmigration more for young-old adults (aged 53-63 at the start of the 10-year longitudinal study in 1994) in nonmetro than metro counties and increases the odds that both groups of outmigrants will choose metro over nonmetro destinations. Finally, I examine whether nonmetro outmigrants are more likely than metro outmigrants to cite a health concern or a desire to get closer to relatives or friends as a reason for the migration.
Methods: I use the Health and Retirement Study (HRS) to track the main residences of nonmetro and metro older adults from 1994-2003. With a discrete-time Event History Analysis, I assess the joint effects of nonmetro/metro residence in 1994 and self-rated health (updated at each biennial wave) upon the risk of a first migration. Those who migrated were asked to recall why.
Findings: At worse levels of self-rated health, the odds of remaining in a nonmetro county of residence drop in favor of migrating to another nonmetro county. Among migrants, the worse the self-rated health, the higher the odds of within-type migration (nonmetro-nonmetro and metro-metro) over cross-type migration (nonmetro-metro and metro-nonmetro). The percentages of migrants citing a health concern or a desire to live closer to relatives or friends as a reason for migration do not differ by county type of origin.
Conclusions: An implication for rural health policy is that young-old adults with worse self-rated health tend to remain in nonmetro areas, even when they migrate.

The Effect of Increased Travel Reimbursement Rates on Health Care Utilization in the VA
Richard E. Nelson, Bret Hicken, Alan West and Randall Rupper

Purpose: The reimbursement rate that eligible veterans receive for travel to Department of Veterans Affairs (VA) facilities increased from 11 to 28.5 cents per mile on February 1, 2008. We examined the effect of this policy change on utilization of outpatient, inpatient, and pharmacy services, stratifying veterans based on distance from a VA facility.
Methods: We compared health care utilization and costs on a sample of VA patients in the 10.5 months before the reimbursement rate increase and the 10.5 months after the reimbursement rate increase. Using a difference-in-difference technique, we ran multivariable logistic and count regressions for utilization and generalized linear models (GLM) for cost outcomes. Regressions were stratified based on urban and rural residence, as well as by distance thresholds.
Findings: Our cohort contained 250,958 veterans, 76.7% (n = 192,559) of whom were eligible to receive a travel reimbursement. After the reimbursement rate increase, eligible veterans at all distances were 6.8% more likely to have an outpatient encounter and had 2.6% more outpatient encounters in the VA compared to those not eligible for the reimbursement (P < .001). Similar results were found for prescription fills at all distances, but inpatient encounters remained generally unaffected.
Conclusions: Our results suggest that this policy change was successful in increasing access to VA care for patients regardless of location of residence.

Alcohol Consumption Among Urban, Suburban, and Rural Veterans Affairs Outpatients
Emily C. Williams, Lynne V. McFarland and Karin M. Nelson

Purpose: United States rural residents tend toward poorer health than urban residents. Although alcohol use is associated with multiple medical conditions and can be reduced via brief primary care-based interventions, it is unknown whether alcohol consumption differs by rurality among primary care patients. We sought to describe alcohol consumption among urban, suburban, and rural Veterans Affairs (VA) outpatients.
Methods: Outpatients from 7 VA facilities responded to mailed surveys that included the validated Alcohol Use Disorders Identification Test Consumption (AUDIT-C) screening questionnaire. The ZIP code approximation of the US Department of Agriculture's rural-urban commuting area (RUCA) codes classified participants into urban, suburban, and rural areas. For each area, adjusted logistic regression models estimated the prevalence of past-year abstinence among all participants and unhealthy alcohol use (AUDIT-C ≥ 3 for women and ≥ 4 for men) among drinkers.
Findings: Among 33,883 outpatients, 14,967 (44%) reported abstinence. Among 18,916 drinkers, 8,524 (45%) screened positive for unhealthy alcohol use. The adjusted prevalence of abstinence was lowest in urban residents (43%, 95% CI 42%-43%) with significantly higher rates in both suburban and rural residents [45% (44%-46%) and 46% (45%-47%), respectively]. No significant differences were observed in the adjusted prevalence of unhealthy alcohol use among drinkers.
Conclusions: Abstinence is slightly more common among rural and suburban than urban VA outpatients, but unhealthy alcohol use does not vary by rurality. As the VA and other health systems implement evidence-based care for unhealthy alcohol use, more research is needed to identify whether preventive strategies targeted to high-risk areas are needed.

Echocardiogram Utilization Among Rural and Urban Veterans
Kingston Okrah, Mary Vaughan-Sarrazin, Peter Kaboli and Peter Cram

Purpose: To compare echocardiography use among urban and rural veterans and whether differences could be accounted for by distance.
Methods: We used Veterans Administration (VA) administrative data from 1999 to 2007 to identify regular users of the VA Healthcare System (VA users) who did and did not receive echocardiography. Each veteran was categorized as residing in urban, rural or highly rural areas using RUCA codes. Poisson regression was used to compare echocardiography utilization rates among veterans residing in each area after adjusting for demographics, comorbidities, clustering of patients within VA networks and distance to the nearest VA medical center offering echocardiography.
Findings: Our study included 22.7 million veterans of whom 1.3 million (5.7%) received at least 1 echocardiogram. Of echocardiography recipients, 69.2% lived in urban, 22.0% in rural and 8.8% in highly rural areas. In analyses adjusting for patient demographics, comorbidities, and clustering, utilization of echocardiography was modestly lower for highly rural and rural veterans compared with urban veterans (42.0 vs 40.1 vs 43.1 echocardiograms per 1,000 VA users per year for highly rural, rural and urban, respectively; P < .001). After further adjusting for distance, echocardiography utilization was somewhat higher for veterans in highly rural and rural areas than it was for urban areas (44.9 vs 41.8 vs 40.8 for highly rural, rural and urban, respectively; P < .001).
Conclusions: Echocardiography utilization among rural and highly rural veterans was marginally lower than for urban veterans, but these differences can be accounted for by the greater distance of more rural veterans from facilities offering echocardiograms.


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

Contents: 2012; 17:(2)
Issue includes:

Professional, personal and community: 3 domains of physician retention in rural communities
Pamela J. Cameron, PhD; David C. Este, PhD; Catherine A. Worthington

Introduction: We sought to explore the professional, personal and community domains of physician retention in 4 rural communities in Alberta and to develop a preliminary framework for physician retention.
Methods: We used a qualitative, collective case study design to study 4 rural communities (cases) in Alberta that retained family physicians for 4 years or longer. Participants included physicians, staff members, spouses and community members. Data collected from interviews, documents and observations were analyzed individually, and similarities and differences across all cases were assessed.
Results: A range of factors that could influence physicians’ decisions to stay in a particular community were described by participants. Within the professional domain, physician supply, physician dynamics, scope of practice and practice set-up were common across all communities, and innovation, and management and support emerged from some communities. The personal factors, goodness-of-fit, individual choice, and spousal and family support were present in all communities. Four community factors — appreciation, connection, active support, and physical and recreational assets — emerged across all communities, and reciprocity was present in 3 communities. From these data, we developed a preliminary retention framework.
Conclusion: Physicians, policy-makers and community members are encouraged to consider the 3 retention domains of professional, personal and community.

Needs of specialists in rural and remote Canada
Clare Toguri, MSc; Michael Jong, MBBS; Judith Roger

Introduction: Very little literature exists on rural specialists as a unique group and how best to meet their needs. We sought to provide some baseline information on specialists practising in rural and remote Canada to better understand their reasons for working rurally, their workload and how supported they felt, as well as their sources of advice and satisfaction with continuing medical education (CME).
Methods: The Society of Rural Physicians of Canada mailed a survey to specialists working in rural and remote Canada. Specialists were identified based on databases of the Canadian Medical Association (CMA) and the provincial colleges. The survey focused on reason(s) for working in a rural or remote setting, level of support and CME.
Results: The survey was sent to 1500 physicians and yielded a 19% response rate. Although 85% of respondents felt supported overall, less than 20% felt supported by the CMA or by the Royal College of Physicians and Surgeons of Canada (RCPSC). Conversely, most felt supported by immediate colleagues (85%) and their community (78%). Most wished they had access to more training, with close to 90% agreeing that additional training should be available if they had worked for several years in a rural or remote area and a need was demonstrated.
Conclusion: The CMA and the RCPSC may wish to work with rural specialists to foster a more supportive relationship and better meet their needs. Additionally, efforts should be made to provide rural specialists with better access to relevant CME.


Australian Journal of Rural Health

2012; 20:(1)
Issue includes:

Who should receive recruitment and retention incentives? Improved targeting of rural doctors using medical workforce data
John S. Humphreys, Matthew R. McGrail, Catherine M. Joyce, Anthony Scott and Guyonne Kalb

Objective: The objective of this study was to define an improved classification for allocating incentives to support the recruitment and retention of doctors in rural Australia.
Design and setting: Geo-coded data (n = 3636 general practitioners (GPs)) from the national Medicine in Australia: Balancing Employment and Life study were used to examine statistical variation in four professional indicators (total hours worked, public hospital work, on call after-hours and difficulty taking time off) and two non-professional indicators (partner employment and schooling opportunities) which are all known to be related to difficulties with recruitment and retention.
Main outcome measures: The main outcome measure used for the study was an association of six sentinel indicators for GPs with practice location and population size of community.
Results: Four distinct homogeneous population size groups were identified (0–5000, 5001-15 000, 15 001–50 000 and >50 000). Although geographical remoteness (measured using the Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA)) was statistically associated with all six indicators (P < 0.001), population size provided a more sensitive measure in directing where recruitment and retention incentives should be provided. A new six-level rurality classification is proposed, based on a combination of four population size groups and the five ASGC-RA levels. A significant increase in statistical association is measured in four of six indicators (and a slight increase in one indicator) using the new six-level classification versus the existing ASGC-RA classification.
Conclusions: This new six-level geographical classification provides a better basis for equitable resource allocation of recruitment and retention incentives to doctors based on the attractiveness of non-metropolitan communities, both professionally and non-professionally, as places to work and live.

Farming suicides during the Victorian drought: 2001–2007
Robyn Guiney

Objective: The objective of this study was to determine whether farming suicides increased in Victoria during the prolonged drought in south eastern Australia and gain an understanding of Victorian farming suicides during the period.
Method: Intentional self-harm deaths of farmers and primary producers notified to the Victorian State Coroner from 2001 to 2007 were examined to identify characteristics and determine whether the annual number of farming suicides increased.
Results: Farming suicides accounted for just over 3% of Victorian suicides. The total number of farming suicides was 110 for the period and ranged between 11 and 19 deaths per year, rising and falling inconsistently from year to year. Males accounted for nearly 95% of farming suicides, with firearms and hanging the most frequently used methods, and most deaths occurring between 30 and 59 years of age.
Conclusions: The small number of relevant cases and fluctuations in the annual number of deaths provides no evidence of a pattern of increasing farming suicides during the drought years, when there was approximately one suicide every 3 weeks. Given the elevated suicide risk in male farmers and association with multiple psychosocial and environmental factors, it cannot be concluded, however, that suicide risk itself did not increase during this period of heightened uncertainty and stress. Drought should not be dismissed among the many risk factors, and it is possible that increased mental health awareness and community support programs targeting drought-affected areas contributed to improved management of stress and suicide risk in regional and rural Victoria over the past decade.

Design, implementation and initial assessment of the Northern Territory Point-of-Care Testing Program
Mark D.S. Shephard, Brooke Spaeth, Beryl C. Mazzachi, Malcolm Auld, Steven Schatz, John Loudon, Janet Rigby and Vinod Daniel

Objective: The objective of the study was to improve pathology services in selected remote health centres from the Northern Territory (NT) through the implementation of a quality managed point-of-care pathology testing (POCT) service.
Design: Study of the efficacy of the POCT service after 1 year and qualitative survey of POCT device operators.
Setting: The study was set in thirty-three remote health centres in the NT administered by the NT Department of Health.
Participants: Remote health centre staff at participating remote health centres participated in the study.
Interventions: The introduction of the i-STAT device to perform on-site POCT.
Main outcome measures: The main outcome measures used in the study were the number of remote staff trained, volume of testing performed and satisfaction of POCT device operators.
Results: One hundred and sixty-four health professional staff were trained to perform i-STAT POCT during the first year of the program. A total of 2290 POCT tests were performed on the i-STAT. The volume of testing consistently increased across the year. Tests for international normalised ratio were the most frequently performed (averaging 70 tests per month). Stakeholder satisfaction with the i-STAT device was high, with a statistically significant improvement in satisfaction levels with pathology service provision being reported after the introduction of POCT. Greater than 80% of respondents stated POCT was more convenient than the laboratory service and assisted in the stabilisation of acutely ill patients.
Conclusions: The NT POCT Program has been operationally effective and well received by staff working as i-STAT POCT operators in remote health centres. Retention of remote health centre staff is the most significant challenge to ensuring the program's long-term viability.

Communicating about breast cancer: Rural women's experience of interacting with their surgeon
Eli Ristevski, Melanie Regan, David Birks, Nicole Steers, Anny Byrne and Matthew R. McGrail

Objective: This study examined rural women's satisfaction with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Differences in satisfaction were investigated between treatment groups (mastectomy and breast conservation surgery) and demographic variables (age, marital status, education level, employment status and place of residence). Practice was compared with clinical practice guidelines.
Design: The study was designed as a cross-sectional survey.
Setting: The study was set in Eastern regional Victoria, Australia.
Participants: Seventy women diagnosed with early breast cancer participated in the study.
Main outcome measures: The main outcome measures used by the study were satisfaction in three areas of practice: (i) telling a woman she has breast cancer; (ii) providing information and involving the woman in the decision-making; and (iii) preparing the woman for specific management.
Results: No differences in satisfaction were found between treatment groups and demographic variables. Overall, women in this study were highly satisfied (>93%) with the interaction and communication with their surgeon. Women reported that the surgeon created a supportive environment for discussion, that they were provided with adequate information and referrals, and that they were actively involved in the decision-making. Practice could have been improved for women who were alone at diagnosis as women without a partner made a quicker decision about treatment.
Conclusion: Rural women in Victoria Australia were largely satisfied with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Current practice was predominately in line with clinical practice guidelines.

Why does a rural background make medical students more likely to intend to work in rural areas and how consistent is the effect? A study of the rural background effect
Michael Jones, John S. Humphreys and Matthew R. McGrail

Objective: Evidence indicates that medical graduates with a rural background are more likely to become rural doctors than those with an urban background (the rural background effect (RBE)). Exactly why this is so has rarely been studied. This study sought to identify the role of social, environmental and economic factors in addition to isolation characterising rural environments that either explain or modify the association between rural background and becoming a rural doctorrural practice intention.
Design and setting: Secondary analysis of linked databases from the Medical Schools Outcomes Database (MSOD), Australian Bureau of Statistics and other government sources.
Participants: Seven thousand four hundred twenty-two commencing medical students who took part in the MSOD survey and for whom external data could be linked.
Results: No social, environmental or economic factor studied or isolation significantly contributed to explaining the RBE, although there is some evidence that areas of more attractive climate strengthen the RBE. However, even when the RBE is at its weakest, it remains a strong, positive predictor of attraction to rural practice.
Conclusion: Why the RBE occurs remains unexplained. Evidence was found of a reduced RBE under certain climatic conditions and personal circumstances, but further work is required to better understand why rural background is so strongly related with rural medical intention and practice.

Personal–professional boundary issues in the satisfaction of rural clinicians recruited from within the community: Findings from an exploratory study
Judy Gillespie and Rhea Redivo

Objective: The objective of this paper is to highlight, from within a broad study of recruitment/retention, findings that identify personal–professional boundaries as key challenges for rural child and youth mental health clinicians recruited from within the community.
Design: Two mixed methods online questionnaires followed by semistructured telephone interviews with a small subset of respondents were administered to clinicians, team leaders, supervisors and managers whose practice responsibilities encompass rural settings in three regions of British Columbia, Canada.
Participants: Forty-four clinicians and 27 team leaders/managers participated in the survey while eight clinicians and one team leader/manager participated in the semistructured interviews. Half the clinician respondents were recruited from within the community. Of those recruited from outside the community, half had prior experience living or working in a rural community.
Main outcome measures: Levels of satisfaction with lifestyle, practice and preparation for practice were compared across categories of respondents identified earlier. Open-ended comments were coded by theme and also compared across categories of respondents.
Results: While expressing their higher levels of satisfaction with rural lifestyle and professional practice, clinicians recruited from within rural communities report significant initial and ongoing stress related to personal–professional boundaries and dual relationships. They also report lower levels of satisfaction with orientation and preparation for practice relevant to dealing with these stressors.
Conclusion: Prior attachment to rural communities, increasingly viewed as an effective recruitment and retention strategy, requires better preparation and ongoing supports to enable practitioners to deal with dual relationships and the personal–professional boundary issues that are a direct consequence of their attachments.

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