Journal Search

Journal Search - issue 4, 2012


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


18 December 2012 Volume 12 Issue 4


RECEIVED: 18 December 2012

ACCEPTED: 18 December 2012


Richmond J.  Journal Search - issue 4, 2012. Rural and Remote Health 2012; 12: 2467.


© 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 4
  • Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine 2012; 17: issue 4
  • Australian Journal of Rural Health 2012; 20: issue 3.

full article:


Journal of Rural Health 

Contents: 2012; 28:(4)
Issue includes:

The Relationship Between Rural Status, Individual Characteristics, and Self-Rated Health in the Behavioral Risk Factor Surveillance System
Traci N. Bethea, Russell P. Lopez, Yvette C. Cozier, Laura F. White and Michael D. McClean

Purpose: To examine rural status and social factors as predictors of self-rated health in community-dwelling adults in the United States.
Methods: This study uses multinomial logistic and cumulative logistic models to evaluate the associations of interest in the 2006 US Behavioral Risk Factor Surveillance System, a cross-sectional survey of 347,709 noninstitutionalized adults.
Findings: Self-rated health was poorer among rural residents, compared to urban residents (OR = 1.77, 95% CI: 1.54, 1.90). However, underlying risk factors such as obesity, low income, and low educational attainment were found to vary by rural status and account for the observed increased risk (OR = 1.03, 95% CI: 0.94, 1.12). There was little evidence of effect modification by rural status, though the association between obesity and self-rated health was stronger among urban residents (OR = 2.50, 95% CI: 2.38, 2.64) than among rural residents (OR = 2.18, 95% CI: 2.03, 2.34).
Conclusions: Our findings suggest that differences in self-rated health by rural status were attributable to differential distributions of participant characteristics and not due to differential effects of those characteristics.

Quality of Life in Rural and Urban Adults 65 Years and Older: Findings From the National Health and Nutrition Examination Survey
Marianne Baernholdt, Guofen Yan, Ivora Hinton, Karen Rose and Meghan Mattos

Purpose: The proportion of people over 65 years of age is higher in rural areas than in urban areas, and their numbers are expected to increase in the next decade. This study used Andersen's behavioral model to examine quality of life (QOL) in a nationally representative sample of community-dwelling adults 65 years and older according to geographic location. Specifically, associations between 3 dimensions of QOL (health-related QOL [HQOL], social functioning, and emotional well-being) and needs and health behaviors were examined.
Methods: The 2005-2006 National Health and Nutrition Examination survey was linked with the 2007 Area Resources File via the National Center for Health Statistics’ remote access system. Frequencies and distribution patterns were assessed according to rural, adjacent, and urban locations.
Findings: Older adults reported high levels of QOL; however, rural older adults had lower social functioning than their urban counterparts. Older blacks and Hispanics had lower scores than whites on 2 dimensions of QOL. Associations between QOL and needs and health behaviors varied. Although activities of daily living were associated with all 3 dimensions, others were associated with 1 or 2 dimensions.
Conclusions: The lower scores on social functioning in rural areas suggest that rural older adults may be socially isolated. Older rural adults may need interventions to maintain physical and mental health, strengthen social relationships and support, and increase their participation in the community to promote QOL. In addition, older blacks and Hispanics seem more vulnerable than whites and may need more assistance.

Psychological Traumas of War: Training School Counselors as Home-Front Responders
Angie Waliski, JoAnn E. Kirchner, Valorie M. Shue and Patti A. Bokony

Purpose: With nearly 3 million US troops having deployed for Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) since the conflicts began, an estimated 2 million children have been separated from a parent. This manuscript describes a collaborative project between a state's Veterans Healthcare System, a branch of the American Counseling Association, and a medical university on the OEF/OIF/OND deployment experience.
Methods: The project sought to educate school counselors about experiences of OEF/OIF/OND families and learn from their observations as home-front responders in public schools during a 2-day summer workshop. This manuscript describes the framework of the workshop, pre/post evaluation results, and implications for counselors, educators, and supervisors.
Findings: School counselors identified childcare and parenting, emotions and behaviors, finances, and barriers to counseling services as challenges for military children and families. Following the workshop, school counselors reported a greater knowledge concerning understanding aspects of outreach for schools and communities in working with veterans and their families. They also reported a better understanding of the impact of war on military families and knowledge of local and state resources for this population. Specifically, attendees felt they could better identify issues and needs of OEF/OIF/OND families with young children, recommend parenting skills to assist these families, and recognize their psychiatric or medical issues.
Conclusion: In addressing the mental health disparities of military children experiencing combat-related parental separation, it is important to identify protective environments that could provide prevention interventions for this population. Collaboration between the Department of Defense, Department of Veterans Affairs (VA), and Department of Education could help support military families and a society facing continued conflicts abroad.

The Impact of Living in Rural and Urban Areas: Vitamin D and Medical Costs in Veterans
Beth A. Bailey, Todd Manning and Alan N. Peiris

Purpose: Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural-urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization.
Methods: Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural.
Findings: The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization.
Conclusions: Vitamin D deficiency may be an additional health disparity experienced by both rural and inner-city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.

Quality of Diabetes Mellitus Care by Rural Primary Care Physicians
Stephen A. Tonks, Sohil Makwana, Amanda H. Salanitro, Monika M. Safford, Thomas K. Houston, Jeroan J. Allison, William Curry and Carlos A. Estrada

Purpose: To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes.
Methods: Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients’ residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction).
Findings: Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P= .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P= .16). We observed no differences between degree of rural and reasonable BP or LDL control (P= .42, P= .23, respectively) or optimal A1c or BP control (P= .52, P= .65, respectively). Optimal and mean LDL values worsened as rurality increased (P= .08, P= .029, respectively).
Conclusions: In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients’ residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted.

At What Age Should Children Engage in Agricultural Tasks?
Jingzhen Yang, Erin O’Gara, Gang Cheng, Kevin M. Kelly, Marizen Ramirez, Leon F. Burmeister and James A. Merchant

Purpose: We compared parents’ perceived-as-appropriate ages with actual-performance ages for their children engaging in selected agricultural tasks or practices, and we examined the factors associated with age discrepancy.
Methods: We analyzed data from the Keokuk County Rural Health Study collected among parents of children age 17 or younger. Parents were interviewed separately regarding the age of their children's involvement in 14 selected agricultural tasks and their opinions about appropriate age of involvement.
Findings: Of the 264 families included, 86.5% with a son and 69.8% with a daughter reported having children involved in at least 1 of 14 selected agricultural tasks. The average actual-performance ages for children to be involved in any of the tasks were younger than those that parents perceived appropriate. Furthermore, in 6 of the 9 North American Guidelines for Children's Agricultural Tasks (NAGCAT) that we assessed, parents’ perceived-as-appropriate ages were younger than minimum ages recommended by the NAGCAT. Driving an all-terrain vehicle (ATV) was the most common task with actual-performance age younger than the NAGCAT-recommended age; 53.0% of boys (n = 106) and 36.1% of girls (n = 61) did so under the recommended age. Boys and children who live on a farm, or whose parents have been or are farmers, were significantly more likely to perform agricultural tasks at earlier ages.
Conclusions: Our results suggest farm parents and other rural stakeholders need to be better educated and encouraged to follow the NAGCAT guidelines, and that multilevel interventions need to be developed to ensure protection of children from agricultural injury and death.

Child Nutritional Status by Rural/Urban Residence: A Cross-National Analysis
Kiira Fox and Tim B. Heaton

Purpose: Rural children in developing countries have poor health outcomes in comparison with urban children. This paper considers 4 questions regarding the rural/urban difference, namely: (1) do individual-level characteristics account for rural/urban differences in child nutritional status; (2) do community-level characteristics account for rural/urban differences net of individual-level characteristics; (3) does type of residence alter the influence of individual characteristics; and (4) does the rural/urban difference vary across national contexts?
Method: Analysis is based on Demographic and Health Survey data from 35 developing countries. Multilevel regression is used to examine rural/urban differences in nutritional status net of individual, community and national determinants of health status.
Findings: Rural children have a substantially higher risk of poor nutrition. Much of this disadvantage is because of socioeconomic disadvantage, reproductive norms favoring early and more rapid childbearing, and lack of access to modern medicine. Rural residence also structures the nature of the relationships between socioeconomic status, access to medical care, and nutrition. Finally, the rural/urban gap declines as countries develop.
Conclusion: Rural/urban differences in child nutritional status are substantial, and some—but not all—of the differences are attributable to socioeconomic status, access to medical care, and reproductive norms.

Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005-2008)
Christie A. Befort, Niaman Nazir and Michael G. Perri

Purpose: Rural residents have higher rates of chronic diseases compared to their urban counterparts, and obesity may be a major contributor to this disparity. This study is the first analysis of obesity prevalence in rural and urban adults using body mass index classification with measured height and weight. In addition, demographic, diet, and physical activity correlates of obesity across rural and urban residence are examined.
Methods: Analysis of body mass index (BMI), diet, and physical activity from 7,325 urban and 1,490 rural adults in the 2005-2008 National Health and Nutrition Examination Survey (NHANES).
Findings: The obesity prevalence was 39.6% (SE = 1.5) among rural adults compared to 33.4% (SE = 1.1) among urban adults (P= .006). Prevalence of obesity remained significantly higher among rural compared to urban adults controlling for demographic, diet, and physical activity variables (odds ratio = 1.18, P= .03). Race/ethnicity and percent kcal from fat were significant correlates of obesity among both rural and urban adults. Being married was associated with obesity only among rural residents, whereas older age, less education, and being inactive was associated with obesity only among urban residents.
Conclusions: Obesity is markedly higher among adults from rural versus urban areas of the United States, with estimates that are much higher than the rates suggested by studies with self-reported data. Obesity deserves greater attention in rural America.

Natural Environments, Obesity, and Physical Activity in Nonmetropolitan Areas of the United States
Akihiko Michimi and Michael C. Wimberly

Purpose: To assess the associations of the natural environment with obesity and physical activity in nonmetropolitan areas of the United States among representative samples by using 2 indices of outdoor activity potential (OAP) at the county level.
Methods: We used the data from 457,820 and 473,296 noninstitutionalized adults aged over 18 years for obesity and physical activity, respectively, from the 2000-2006 Behavioral Risk Factor Surveillance System. The OAP indices were (1) a recreational opportunity index based on 24 variables related to outdoor physical activity, such as the number of facilities available for walking, biking, hiking, and swimming derived from the 1997 National Outdoor Recreation Supply Information System; and (2) a natural amenities index which was based on physical and social environmental characteristics, such as climate, topographic relief, land cover, and tourism. We fitted logistic regression models using generalized estimating equations to control for county level intracorrelation and tested each index separately to assess its relationship with obesity and physical activity.
Findings: Recreational opportunities were higher in areas with greater natural amenities. After controlling for individual-level socioeconomic and demographic characteristics, the prevalence of obesity decreased and propensity for physical activity increased with increasing levels of both recreational opportunities and natural amenities.
Conclusions: Multiple indices of OAP based on characteristics of the built, natural and social environments were associated with decreased obesity and increased physical activity in nonmetropolitan areas. Public health interventions should consider the opportunities and limitations offered by the natural environment for promoting physical activity and reducing obesity in rural areas.

States’ Experiences With Loan Repayment Programs for Health Care Professionals in a Time of State Budget Cuts and NHSC Expansion
Donald E. Pathman, Jennifer Craft Morgan, Thomas R. Konrad and Lynda Goldberg

Purpose: The landscape of education loan repayment programs for health care professionals has been turbulent in recent years, with doubling of the funding for the National Health Service Corps (NHSC) and cuts in funding for some states’ programs. We sought to understand how this turbulence is being felt within the state offices involved in recruiting clinicians to rural and urban underserved communities.
Methods: We conducted key informant telephone interviews with staff of state offices of rural health, primary care organizations, and/or related organizations within 28 diverse states to answer questions about perceived changes and interplay among solely state-funded loan repayment programs, joint state-federal programs, and the NHSC federal program. Interviews were transcribed, formally analyzed, and key issues summarized.
Findings: Informants reported that solely state-funded and joint state-federal loan repayment programs are greatly valued for their ability to target a state's particular needs and to complement the NHSC federal program. However, budgets for state programs have been threatened, reduced, or eliminated entirely in many cases. All informants positively perceived the NHSC's recent growth and changes, which they feel are helping fill important workforce needs for their states. Nevertheless, the much larger NHSC federal program now competes with some states’ programs for clinicians and service sites; states’ programs are pushed to adjust their operations to maintain a unique 'niche.'
Conclusions: States’ key recruiters lament reductions in funding for states’ loan repayment programs, and welcome the NHSC's recent growth and changes. Better coordination is needed to minimize competition and maximize complementarity between state and federal programs.

A Comparative Study of Financial Data Sources for Critical Access Hospitals: Audited Financial Statements, the Medicare Cost Report, and the Internal Revenue Service Form 990
Alisha Bhadelia Ozmeral, Kristin L. Reiter, George M. Holmes and George H. Pink

Purpose: Medicare Cost Reports (MCR), Internal Revenue Service Form 990s (IRS 990), and Audited Financial Statements (AFS) vary in their content, detail, purpose, timeliness, and certification. The purpose of this study was to compare selected financial data elements and characterize the extent of differences in financial data and ratios across the MCR, IRS 990, and AFS for a sample of nonprofit Critical Access Hospitals (CAHs).
Methods: Line items from AFS of 47 CAHs were compared to data reported in the hospitals’ MCR and IRS 990s. Line items were based on 9 financial indicators commonly used to assess hospital financial performance.
Findings: Of the indicators examined, the equity financing ratio most frequently matched between the 3 reports, while salaries and benefits to total expenses and debt service coverage were often different. Variances were driven by differences in individual account balances used to construct the ratios. Relative to AFS, cash was frequently lower on the IRS 990 while marketable securities and unrestricted investments were often higher. Other revenue and net income were consistently lower on the MCR and IRS 990, and depreciation was often higher on the MCR. The majority of total assets and fund balance (equity) values matched across the 3 reports, suggesting differences in classification among detailed accounts were more common than variances between the component totals (total assets, total liabilities, and fund balance).
Conclusions: Health policy researchers should consider the impact of these variances on study results and consider ways to improve the availability and quality of financial accounting information.

Redefining the Role of the Pharmacist: Medication Therapy Management
Peter Hilsenrath, Joseph Woelfel, Allen Shek and Katrina Ordanza

Purpose: The purpose of this paper is to explore better use of pharmacists in rural communities as a partial solution to scarcity of physicians and other health care providers. It discusses expected reduction in public subsidies for rural health care and the changing market for pharmacists. The paper emphasizes the use of pharmacists as a backdrop for description of Medication Therapy Management (MTM). A pilot study of MTM is also reported.
Methods: This article explores rural health access, the market for pharmacists and MTM using the literature, and economic concepts to provide historical context for this new form of health care delivery. A small case study from a university-based clinic provided primary data to demonstrate viability.
Findings: MTM can augment rural health by providing care for patients who receive increasing numbers of complex medications. It helps better integrate pharmacists into primary care and holds promise as a cost-effective, if not cost-saving alternative.
Conclusion: More constrained fiscal conditions are a virtual certainty going forward. The rural health community needs cost-effective health care alternatives that can prosper with lower levels of public financial support. MTM is one such option.


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

Contents: 2012; 17:(4)
Issue includes:

Epidural steroid injections for low back pain in rural practice: a 5-year retrospective study
Azad Mashar; Robert Minty, Lauren Minty; Wilma M. Hopman, Len Kelly

Introduction: Epidural steroid injections (ESIs) are a safe and accessible therapy for chronic low back pain, one of the most common and challenging chronic conditions seen in primary care. However, the indications for and effectiveness of ESI remain controversial. In rural settings with limited public transportation infrastructure, such a mobility-limiting condition can have even more negative effects on quality of life and function. Furthermore, diagnostic and specialist services are often limited. A paucity of safe, effective and accessible treatments leads to heavy reliance on oral analgesics, especially opioids, which have well-known complications.
Methods: We reviewed the use of ESI for the 2 most common types of chronic low back pain in those with neurologic symptoms: lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS). We did a retrospective chart review of all patients who underwent ESI between Jan. 1, 2005, and Feb. 25, 2010, at our rural hospital in northwestern Ontario.
Results: During the study period, 123 ESIs were administered to 65 patients. After the first injection, 40 patients (62%) reported improvement, 10 (15%) reported worsening or no change, and 15 (23%) had no follow-up documented.
Conclusion: Some patients with neurologic compromise from LDH or LSS have improvement in symptoms after ESI. A prospective study is underway to more rigorously assess the effectiveness of this treatment.

Joint position paper on rural maternity care
Joint Position Paper Working Group

A review of the current literature on issues of maternity care relevant to rural populations underpins 14 recommendations prepared and approved by 5 national physician, midwifery and nursing organizations. This review and these recommendations are intended to help rural obstetric care providers to continue to provide quality care for women in their communities.


Australian Journal of Rural Health

2012; 20:(3)
Issue includes:

Northern Territory Emergency Response: Criticism, support and redesign
Brendon W. Evans

The recent Federal Government Report and Media release, Stronger Futures in the Northern Territory: Report on Consultations and its claim of ‘widespread Indigenous Support’ has brought the topic of the Northern Territory Emergency Response (the Intervention) back into the public mind. This article provides a synthesis of four years of debate around the Northern Territory Emergency Response, at a time when the program is nearing the end of its time frame. It outlines the main arguments supporting the Intervention, the central criticisms and the government's response to these evaluations, with the aim of providing a primer or summary for health professionals to the discussion around this important public issue.

Food scarcity, not economic constraint limits consumption in a rural Aboriginal community
Brooke A. Scelza

Objective: To determine whether food scarcity or economic constraint is more strongly associated with purchasing patterns in a rural Aboriginal community.
Design: Store receipts were collected to determine money spent in the community shop across a four-month period from January to April 2006. Variability in expenditures is then studied using measures of food scarcity (days since shop loading) and economic constraint (days since payday).
Setting: Parnngurr Outstation in the Western Desert of Australia.
Main outcome measures: Daily gross and per-household gross expenditures at the community shop.
Results: There is a significant association between food scarcity and money spent in the shop (−42.89, confidence interval −62.62 to −23.18, P < 0.001). There is no association between economic constraint and money spent in the shop.
Conclusion: In rural and remote communities, reliable access to food is critical to food security. Circumstantial constraints such as seasonal flooding and political insecurity can augment food access problems and put Aboriginal people at risk of malnutrition and other dietary harms.

The benefits of a tailor-made pilot primary health-care course for Indigenous high school students in remote Queensland
Xiuzhi Pham, Priscilla Page, Sundram Sivamalai and Torres Woolley

Objective:  This study highlights the benefits of a tailor-made course for an Indigenous high school in a remote North Queensland community.
Design:  Qualitative research study using a Grounded Theory approach to allow thematic analysis of participant's responses to a researcher-administered, pre-defined, semistructured questionnaire.
Setting:  Remote community college in Abergowrie, North Queensland.
Participants:  Four male high school students and eight key stakeholders were interviewed over the telephone (n = 12).
Results:  Thematic analyses of the feedback from students and stakeholders showed a variety of benefits from the course for Indigenous students: increased knowledge of health issues, greater awareness and interest in health career pathways, increased pride, self-esteem and self-confidence, positive role-modelling and leadership behaviour in the students, and hope for future career development. Weaknesses identified were mainly associated with a lack of resources and support for the course.
Conclusions:  This study demonstrates that a tailor-made primary health-care education course can create opportunities for Indigenous people to pursue health careers, promote health knowledge and leadership skills, inspire pride and self-esteem, and strengthen links within the community.

In the wake of the 2009 Gippsland fires: Young adults' perceptions of post-disaster social supports
Rouve Jan Forbes, Rebecca Jones and Andrea Reupert

Objective: To explore young (18–27 years) rural adults' experience of both formal and informal social support networks post-bushfire. To inform delivery of social support services for young adults post-bushfire.
Design: Qualitative: semi-structured, face-to-face interviews with transcripts analysed using thematic content analysis.
Setting: Gippsland 2009 flame-impacted regions: Boolarra and Central Gippsland Black Saturday fire complexes.
Participants: Ten bushfire impacted young adults (18–27 years): six female and four male.
Results: The central theme was the importance of acknowledgement and validation of participants' experience as autonomous individuals. Participants' experience of social supports and networks as either helpful or unhelpful depended on the degree to which the supports delivered enhanced sense of acknowledgement, entitlement, affiliation, informational links, engagement in the recovery process and amelioration of displacement in relation to family, friends, community and environment.
Conclusion: Participants believed that how an individual, community or service provider framed loss had a significant impact on entitlement and how needs were met. Importantly, how society, policy and service providers framed young adults as either adult or adolescent impacts on how their needs were met. This study highlights the need to resituate how loss is viewed and the need for policy and service providers to address the existing nomenclature mismatch and framing of loss so that young adults are not excluded from supports essential to recovery.

Mental health and well-being in resident mine workers: Out of the fly-in fly-out box
Kristy N. Mclean

Objective:  To explore psychosocial issues perceived to impact the mental health and well-being of resident (non-fly-in fly-out) mine workers at a local mine in regional Queensland.
Design:  A descriptive qualitative study using semistructured interviews.
Setting:  The research was conducted on-site at an open-cut coal mine in regional Queensland.
Participants:  Ten miners (nine men) currently employed in workshop, production or supervisory roles.
Main outcome measures:  Self-reported issues affecting psychological well-being.
Results:  Participants' occupation and the surrounding context appeared to have both positive and negative influences on their well-being. Overall findings could be grouped into four key themes: (i) the importance of relationships; (ii) the impact of lifestyle; (iii) work characteristics; and (iv) mental health attitudes. While not without strains on mental health, in general, participants reported that their current situation was superior to their previous mining jobs. This was attributed to close relationships among locally recruited workers, respect for management practices and rosters that allowed adequate sleep recovery and family time between shifts.
Conclusions:  This study is the first to examine mental health and well-being in non-fly-in fly-out mining populations. It suggests that while some issues appear inherent in the mining occupation, personal and organisational support can help workers have a more positive workplace experience. Further work looking at more extensive comparisons over various mining contexts will greatly assist in the development of programs and support structures for rural and regional mine workers.

Cardiovascular risk factors and psychological distress in Australian farming communities
Susan Brumby, Ananda Chandrasekara, Scott McCoombe, Peter Kremer and Paul Lewandowski

Objective:  To examine the prevalence of cardiovascular disease (CVD) risk factors, psychological distress and associations between physical and mental health parameters within a cohort of the Australian farming community.
Design:  Cross-sectional descriptive study.
Setting:  Farming communities across Australia.
Participants:  Data of men (n = 957) and women (n = 835) farmers from 97 locations across Australia were stratified into categories based on National Cholesterol Education Program guidelines.
Main outcome measure(s):  Prevalence of and interrelationship between overweight, obesity, dyslipidaemia, hypertension, diabetes risk and psychological distress.
Results:  There was a higher prevalence of overweight (42.5%, 95% confidence interval (CI), 34.2–50.8), obesity (21.8%, 95% CI, 18.3–25.3), abdominal adiposity (38.4% 95% CI, 24.5–52.5), hypertension (54.0%, 95% CI, 34.4–73.5) and diabetes risk (25.3%, 95% CI, 17.7–36.7) in the farming cohort compared with national data. There was also a positive significant association between the prevalence of psychological distress and obesity, abdominal adiposity, body fat percentage and metabolic syndrome in older (age ≥ 50 years) participants.
Conclusions:  This study group of farming men and women exhibited an increased prevalence of CVD risk factors and co-morbidities. The findings indicate a positive association between psychological distress and risk for developing CVD, particularly in the older farmers. If the younger cohort were to maintain elevated rates of psychological distress, then it is foreseeable that the next generation of farmers could experience poorer physical health than their predecessors.

Issues with medication supply and management in a rural community in Queensland
Amy C.W. Tan, Lynne M. Emmerton and H. Laetitia Hattingh

Objective:  To identify the key issues reported by rural health-care providers in their provision of medication supply and related cognitive services, and in order to advise health workforce and role development and thus improve the quality use of medicines in rural communities.
Design:  Exploratory semistructured interview research.
Setting:  A rural community comprising four towns in a rural health service district in Queensland, Australia.
Participants:  Forty-nine health-care providers (medical practitioners, pharmacists, nurses and others) with medication-related roles who serviced the study community, identified through databases and local contacts.
Main outcome measures:  Medication-related roles undertaken by the health-care providers, focusing on medication supply and cognitive services; challenges in undertaking these roles.
Results:  Medical and nursing providers reported challenges in ensuring continuity in supply of medications due to their existing medical workload demands. Local pharmacists were largely involved in medication supply, with limited capacity for extended cognitive roles. Participants identified a lack of support for their medication roles and the potential value of clinically focused pharmacists in medication management services.
Conclusions:  Medication supply may become more efficient with extended roles for certain health-care providers. The need for cognitive medication management services suggests potential for clinical pharmacists' role development in rural areas.

Trade-off between local access and safety considerations in childbirth: Rural Tasmanian women's perspectives
Ha Hoang and Quynh Le

Objectives:  This study investigates: (i) Tasmanian rural women's preferences for different models of intrapartum care; (ii) their preferences for travel time to safe delivery; and (iii) factors which influence these preferences.
Design:  Mixed-methods study using a survey questionnaire and semistructured interviews was adopted. A questionnaire explored women's preferences for different models of care and preferred travel time. Interviews were conducted to validate the survey results and provide insightful information on their preferences on the models of care. Women who have had rural childbirth experiences from six Tasmanian rural communities were invited to participate in the study.
Results:  Two hundred and ten women completed the questionnaire with a response rate of 35%. Twenty-two follow-up interviews were conducted. The survey found that women preferred to give birth in a hospital setting to homebirth despite having to travel for two hours. Midwifery-led care with one hour travel time was the second preferred model of care. Women were willing to travel to access the regional hospital but within limit. Their preferences suggest that women have to trade-off between local access and safety considerations. The interviews validate the survey results. Three main themes emerged from the interview data namely (i) safety; (ii) distance from hospital; and (iii) type of delivery. Their preferences were associated with their maternal care experiences in the past.
Conclusion:  In order to achieve the maternity services that are woman centred and respond to the needs and preferences of women, the service design and provision should take into account these women's preferences.

Who brings dengue into North Queensland? A descriptive, exploratory study
Caroline Mannestål Johansson, William J.H. McBride, Kajsa Engström and Jane Mills

Objective:  To describe the demographics, patterns of assessment and treatment of people visiting a regional emergency department with potential diagnoses of malaria or dengue fever.
Design:  To identify potential dengue fever cases, we used an indicator of recent overseas travel and fever that is a request for malaria testing. A chart audit of 301 medical records of people between 2008 and 2010 was conducted to describe patient characteristics, diagnostic tests performed and treatment.
Setting:  A regional hospital located in the wet tropics.
Results:  Malaria testing was most often performed on Australian citizens (64.1%), medical evacuees (20.3%) and tourists (18.6%). Overall, 49.8% of patients tested for malaria did not also have a dengue test, despite being indicated in 54% of this group. People tested for malaria usually lived in a residential house or unit (69.7%). Only 9% were staying in hotels and hostels. Oceania was the most commonly visited region in the two weeks prior to presentation. Malaria was diagnosed in 17.3% and dengue fever in 12% of patients tested. Patients with dengue fever were more likely than patients with malaria to self-refer to hospital, be staying in commercial accommodation and to have recently travelled to Southeast Asia.
Conclusion:  Both dengue fever and malaria occur predominantly in residents who reside in non-commercial accommodation. Efforts to identify imported dengue fever cases should focus on both tourists and local residents returning from overseas countries.

Celebrating another decade of progress in rural health: What is the current state of play?
John S. Humphreys and Gordon Gregory

The Australian Journal of Rural Health is currently celebrating its 20th anniversary. Following a review of the first decade of rural health published by the authors in 2002, this article outlines and reviews the range of policies that have impacted upon rural health in Australia since then. During the past decade there has been a raft of new policies and programs designed to bring about improved rural health outcomes, and some progress has been made. However, a number of significant barriers to overcoming the rural-urban health differential remain. Special consideration will continue to be needed to rural affairs generally and to health system reform and rural health in particular.

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