Journal Search

Journal Search - issue 1, 2013


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


31 March 2013 Volume 13 Issue 1


RECEIVED: 31 March 2013

ACCEPTED: 31 March 2013


Richmond J.  Journal Search - issue 1, 2013. Rural and Remote Health 2013; 13: 2613.


© Jennifer Richmond 2013 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 2013; 29: issue 1
  • Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine 2013; 18: issue 1
  • Australian Journal of Rural Health 2013; 21: issue 1.


Journal of Rural Health 

Contents: 2013; 29:(1)
Issue includes:

Maternal Obesity and Gestational Weight Gain in Rural Versus Urban Dwelling Women in South Carolina
Alexa Gallagher, Jihong Liu, Janice C. Probst, Amy B. Martin and Jeffrey W. Hall

Purpose: An unhealthy prepregnancy weight and/or gaining an inappropriate amount of weight during pregnancy increase the risk for poor pregnancy and birth outcomes. To our knowledge, no studies to date have examined differences in prepregnancy body mass index (BMI) and gestational weight gain (GWG) patterns by rurality.
Methods: The 2004-2006 South Carolina birth certificate data (n = 132,795) were used. Rurality of residence was determined using Rural-Urban Commuting Area (RUCA) codes. Mothers were categorized as underweight (<18.5 kg/m2), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0) using their prepregnancy BMI and as having inadequate, adequate, or excessive GWG according to the Institute of Medicine's 2009 GWG guidelines. Chi-square tests and adjusted multinomial logistic regression were used in analysis.
Findings: Rural women had higher odds of being overweight and obese compared to urban women. This relationship was found to be partially explained by the higher proportion of minorities living in rural areas. The relationship between GWG and residence type varied by BMI category. Specifically, among normal weight women, rural women had increased odds of inadequate GWG. Among overweight women, rural women had decreased odds of excessive GWG. In obese women, rural women had decreased odds of both inadequate and excessive GWG.
Conclusions: Rural women were more likely to have an unhealthy prepregnancy weight than urban women. However, rural residence was found to be protective against unhealthy GWG in overweight and obese women. Future research exploring reasons for these findings and confirmation of these results in other populations is necessary.

Unintentional Injury, Psychological Distress and Depressive Symptoms: Is There an Association for Rural Australians?
Lyn Fragar, Kerry J. Inder, Brian J. Kelly, Clare Coleman, David Perkins and Terry J. Lewin

Purpose: To investigate the association between unintentional injury and mental health in Australian rural communities.
Methods: Using cross-sectional baseline data for a longitudinal study from randomly selected adults in nonmetropolitan Australia, we fitted logistic regression models for the outcomes of domestic or public setting injury and injury in high-risk settings, using prior depression and demographic factors. OR and 99% CI were reported and also calculated for current mental health including psychological distress, depressive symptoms and risky alcohol consumption, comparing those injured with those not.
Findings: Of 2,639 participants who completed the injury component, 364 (13.8%) reported injury requiring treatment from a doctor or a hospitalization in the previous 12 months. Of those requiring treatment or hospitalization, 147 (40.4%) reported being injured in a domestic or public setting and 207 (56.9%) in a high-risk setting. The most common types and mechanisms of injury were sprains and strains, and falls, trips and slips, respectively. Preinjury depression was independently associated with unintentional injury in a domestic or public setting. Being injured in this setting was associated with double the odds of experiencing current depressive symptoms. The likelihood of a high-risk setting injury was significantly associated with male gender. High-risk setting injury was associated with current psychological distress and higher levels of alcohol usage.
Conclusions: This study supports the hypothesis that pre-existing depression is associated with unintentional injury in a rural sample and indicates the important role of prior depression in management of injury, given the high rate of injury in rural communities. Mechanisms by which prior depression increases likelihood of unintentional injury will be further investigated using longitudinal data.

What We Know About the Effectiveness of Farm Safety Day Programs and What We Need to Know
Debra Moehle McCallum, Shannon Murphy, Deborah B. Reed, Deborah T. Claunch and Susan J. Reynolds

Background: Farm safety day camps are grassroots educational interventions organized and conducted by members of a local community. These events are held in an effort to promote safety knowledge and behavior in children who live on family farms or are exposed to the hazards of the agricultural industry. Since the dramatic increase in farm safety day camps beginning in the 1990s, researchers have been called upon to evaluate their effectiveness.
Purpose: The current paper reviews more than a decade of research, describing what is currently known about the effectiveness of farm safety days and suggesting potential methods for addressing questions regarding gaps in what we know about their effectiveness.
Conclusions: The results of these evaluations indicate that farm safety days have a positive impact on children's safety behavior and knowledge; however, much remains to be investigated regarding the effectiveness and impact of these interventions.

Edentulism in High Poverty Rural Counties
Jordan Mitchell, Kevin Bennett and Amy Brock-Martin

Purpose: To examine the differences in oral health status among residents of high-poverty counties, as compared to residents of other rural or urban counties, specifically on the prevalence of edentulism.
Methods: We used the 2005 Behavioral Risk Factor Surveillance System (BRFSS) and the 2006 Area Resource File (ARF). All analyses were conducted with SAS and SAS-callable SUDAAN, in order to account for weighting and the complex sample design.
Findings: Characteristics significantly related to edentulism include: geographic location, gender, race, age, health status, employment, insurance, not having a usual source of care, education, marital status, presence of chronic disease, having an English interview, not deferring care due to cost, income, and dentist saturation within the county.
Conclusions: Significant associations between high-poverty rural and other rural counties and edentulism were found, and other socioeconomic and health status indicators remain strong predictors of edentulism.

Off-Road Vehicle Ridership and Associated Helmet Use in Canadian Youth: An Equity Analysis
Colleen M. Davison, Wendy Thompson, Michael Torunian, Patricia Walsh, Steven McFaull and William Pickett

Purpose: In North America, the use of off-road vehicles by young people is increasing, as are related injuries and fatalities. We examined the prevalence of off-road ridership and off-road helmet use in different subgroups of Canadian youth in order to better understand possible inequities associated with these health risk behaviors.
Methods: Data came from Cycle 6 (2009-2010) of the WHO Health Behavior in School-Aged Children Study (HBSC). Participants (n = 26,078) were young people from grades 6-10 in 436 Canadian schools. Students were asked, for a 12-mo recall period, how frequently they rode off-road vehicles and how often they wore a helmet while riding. Engagement in off-road ridership and helmet use were estimated by age group, gender, urban-rural geographic location, socioeconomic status, and how long participants had lived in Canada.
Findings: About half of the sample reported riding off-road vehicles (12,750; 52%). Among riders, 5,691 (45%) always wore helmets. Riders were more often older students, male and born in Canada. Students in rural areas and small towns were much more likely to ride off-road vehicles than their urban peers (RR, 95% CI: 1.28 [1.23–1.33]). Helmet use was less common among females, new immigrants, older students, and those in lower socioeconomic groups. There was little reported difference in helmet use by urban-rural location.
Conclusions: Risks associated with the use of off-road vehicles and with nonhelmet use are not equitably distributed across Canadian youth. Factors characterizing off-road ridership (notably urban-rural location) are distinct from factors for helmet use. Preventive interventions should target population subgroups.

Rural Roadway Safety Perceptions Among Rural Teen Drivers Living in and Outside of Towns
Marizen Ramirez, Lisa Roth, Tracy Young and Corinne Peek-Asa

Purpose: To compare perceptions about rural road and general driving behaviors between teens who live in- and out-of-town from rural communities in Iowa.
Methods: A cross-sectional survey was conducted with 160 teens anticipating their Intermediate License within 3 months upon enrollment into this study. Self-administered surveys were used to collect demographics and driving exposures (eg, frequency of driving, age when first drove unsupervised). Two Likert scales were included to measure agreement with safe driving behaviors on rural roads and general safe driving behaviors (eg, speeding, seat belt use). T-tests were calculated comparing mean composite scores between in- and out-of-town teens, and between mean rural road and general driving safety attitude scores. A linear regression multivariable model was constructed to identify predictors of the rural road score.
Results: While the majority of teens endorsed rural road and general safe driving behaviors, up to 40% did not. Thirty-two percent did not believe the dangers of animals on rural roads, and 40% disagreed that exceeding the speed limit is dangerous. In-town teens were less safety conscious about rural road hazards with a significantly lower mean composite score (4.4) than out-of-town teens (4.6); mean scores for general driving behaviors were similar. Living out-of-town and owning one's own car were significant predictors of increased rural road safety scores.
Conclusion: Rural, in-town teens have poorer safety attitudes about rural roadway hazards compared with out-of-town teens. Interventions that involve education, parental supervision, and practice on rural roads are critical for preventing teen crashes on rural roads.

Barriers to Cancer Clinical Trial Participation Among American Indian and Alaska Native Tribal College Students
Debra Sprague, Joan Russo, Donna L. LaVallie and Dedra Buchwald

Purpose: American Indians and Alaska Natives (AIs/ANs) have some of the highest cancer-related mortality rates of all US racial and ethnic groups, but they are underrepresented in clinical trials. We sought to identify factors that influence willingness to participate in cancer clinical trials among AI/AN tribal college students, and to compare attitudes toward clinical trial participation among these students with attitudes among older AI/AN adults.
Methods: Questionnaire data from 489 AI/AN tribal college students were collected and analyzed along with previously collected data from 112 older AI/AN adults. We examined 10 factors that influenced participation in the tribal college sample, and using chi-square analysis and these 10 factors, we compared attitudes toward research participation among 3 groups defined by age: students younger than 40, students 40 and older, and nonstudent adults 40 and older.
Findings: About 80% of students were willing to participate if the study would lead to new treatments or help others with cancer in their community, the study doctor had experience treating AI/AN patients, and they received payment. Older nonstudent adults were less likely to participate on the basis of the doctor's expertise than were students (73% vs 84%, P = .007), or if the study was conducted 50 miles away (24% vs 41%, P= .001).
Conclusions: Finding high rates of willingness to participate is an important first step in increasing participation of AIs/ANs in clinical trials. More information is needed on whether these attitudes influence actual behavior when opportunities to participate become available

Community Outreach and Engagement to Prepare for Household Recruitment of National Children's Study Participants in a Rural Setting
Nancy L. Fahrenwald, Betty Wey, Ann Martin and Bonny L. Specker

Context: The National Children's Study (NCS) is a longitudinal study of environmental influences on children's health. Recruitment of a representative birth cohort that will be followed until 21 years of age requires unique approaches across the nationwide study communities.
Purpose: To describe community outreach and engagement in preparation for household recruitment of women of childbearing age at a rural-classified NCS location that includes 4 adjacent Northern Plains counties spanning 2,500 square miles.
Methods: Outreach and engagement methods focused on rural community characteristics. The team established an advisory council, conducted outreach meetings with agencies and groups, participated in local events, and collaborated with stakeholders. Study awareness was raised using radio announcements, local television stories, and widespread distribution of print materials through churches, businesses, and child care centers. Impact evaluation examined the number of stakeholder events by type. Outcome evaluation examined the number of households contacted for recruitment, numbers of age-eligible women who completed the screening, and exploration of whether women had heard about the study.
Findings: Over 300 outreach events occurred, ranging from tribal council meetings to parade entries. Recruitment outcomes were as follows: (1) 80% of 14,700 non-vacant households were reached for potential recruitment; (2) screening interviews were conducted with 89% of the 5,800 age-eligible women identified; and (3) 53% of women who completed the screening had heard about the study.
Conclusions: Outreach targeted to rural communities facilitated strong recruitment outcomes. Collaboration with the cooperative extension service was a unique rural asset that facilitated relevant activities. Participant retention is an ongoing priority.

Recruiting Rural Participants for a Telehealth Intervention on Diabetes Self-Management
Sheridan Miyamoto, Stuart Henderson, Heather Young, Deborah Ward and Vanessa Santillan

Purpose: Recruiting rural and underserved participants in behavioral health interventions is challenging. Community-based recruitment approaches are effective, but they are not always feasible in multisite, diverse community interventions. This study evaluates the feasibility of a rapid, multisite approach that uses rural clinic site coordinators to recruit study participants. The approach allows for rural recruitment in areas where researchers may not have developed long-term collaborative relationships.
Methods: Adults with diabetes were recruited from rural Federally Qualified Health Center (FQHC) clinics. Recruitment feasibility was assessed by analyzing field notes by the project manager and health coaches, and 8 in-depth, semistructured interviews with clinic site coordinators and champions, followed by thematic analysis of field notes and interviews.
Findings: Forty-seven rural sites were contacted to obtain the 6 sites that participated in the study. On average, sites took 14 days to commit to study participation. One hundred and twenty-one participants were acquired from letters mailed to eligible participants and, in some sites, by follow-up phone calls from site coordinators. Facilitators and deterrents affecting study recruitment fell into 4 broad categories—study design, site, site coordinator, and participant factors.
Conclusion: The rapid multisite approach led to quick and efficient recruitment of clinic sites and participants. Recruitment success was achieved in some, but not all, rural sites. The study highlights the opportunities and challenges of recruiting rural clinics and rural, underserved participants in multisite research. Suggestions are provided for improving recruitment for future interventions

'Fault-line of an Earthquake': A Qualitative Examination of Barriers and Facilitators to Colorectal Cancer Screening in Rural, Eastern North Carolina
Stephanie B. Jilcott Pitts, C. Suzanne Lea, Carrie L. May, Chelsea Stowe, Dana J. Hamill, Kelcy T. Walker and Timothy L. Fitzgerald

Purpose: Colorectal cancer (CRC) is a leading cause of cancer mortality and disparately affects rural, low-income and minority individuals. Thus, to inform effective interventions and policies to increase screening rates and thus ameliorate CRC disparities, this study's purpose was to examine barriers and facilitators to CRC screening among low-income, rural eastern North Carolina residents.
Methods: We conducted 4 focus group discussions in October and November 2011, among a convenience sample of eastern North Carolina residents (n = 45). The focus group discussion guide included open-ended questions about barriers and facilitators to CRC screening. Discussions were audio recorded and then transcribed verbatim. A codebook listing codes and operational definitions was developed by 2 research team members, who then iteratively and independently double-coded all transcripts. Nvivo (version 9, QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to manage data. Themes were extracted based upon depth and frequency of mention.
Findings: Major barriers to CRC screening included the high cost of tests and follow-up care, fear of the test itself (colonoscopy), fear of cancer diagnosis, and fear of burdening family members. Violation (among men) and embarrassment (among women) were also barriers. Facilitators included doctor's recommendation, symptoms, support from family and friends, and the desire to live a long and healthy life. Intervention ideas included free tests with information and resources for follow-up care as needed.
Conclusion: Understanding barriers and facilitators to CRC screening can assist clinicians and public health practitioners in designing effective interventions to reduce CRC disparities

Understanding the Landscape: Promoting Health for Rural Individuals After Tertiary Level Cardiac Revascularization
Barbara Pesut, Carol Laberge, Richard Sawatzky, Julia Mallinson and Kathy Rush

Purpose: The purpose of this pilot study was to describe the needs and experiences of rural individuals commuting to an urban center for percutaneous coronary intervention (PCI).
Methods: Data were analyzed from a 'Patient Adherence and Satisfaction Survey' conducted by telephone as part of a quality improvement focus, and supplemented with in-depth semi-structured interviews with rural patients following PCI.
Findings: Both urban and rural patients after PCI experienced few complications, had made some attempts to reduce tobacco usage, and were highly satisfied with explanations of their treatment and their overall treatment experience. Patients in rural settings were more likely to experience chest pain at least rarely following their surgery than people in urban settings (P < .05). Data on participation in cardiac rehabilitation (CR) showed no significant differences between urban and rural dwellers. Four themes emerged from the interviews: standards of care during treatment; transportation; local resources and community support; and lifestyle changes. Although patients were highly satisfied with standards of care during acute treatment, there were unmet needs in relation to transportation and lifestyle changes.
Conclusion: Transitions between rural communities and urban centers and rural adaptations of secondary prevention programs require more attention in health service delivery. Further research is required to better understand potential variations in chest pain patterns between urban and rural residents.

Understanding and Addressing Barriers to Implementation of Environmental and Policy Interventions to Support Physical Activity and Healthy Eating in Rural Communities
Ellen K. Barnidge, Catherine Radvanyi, Kathleen Duggan, Freda Motton, Imogene Wiggs, Elizabeth A. Baker and Ross C. Brownson

Purpose: Rural residents are at greater risk of obesity than urban and suburban residents. Failure to meet physical activity and healthy eating recommendations play a role. Emerging evidence shows the effectiveness of environmental and policy interventions to promote physical activity and healthy eating. Yet most of the evidence comes from urban and suburban communities. The objectives of this study were to (1) identify types of environmental and policy interventions being implemented in rural communities to promote physical activity or healthy eating, (2) identify barriers to the implementation of environmental or policy interventions, and (3) identify strategies rural communities have employed to overcome these barriers.
Methods: Key informant interviews with public health professionals working in rural areas in the United States were conducted in 2010. A purposive sample included 15 practitioners engaged in planning, implementing, or evaluating environmental or policy interventions to promote physical activity or healthy eating.
Findings: Our findings reveal that barriers in rural communities include cultural differences, population size, limited human capital, and difficulty demonstrating the connection between social and economic policy and health outcomes. Key informants identified a number of strategies to overcome these barriers such as developing broad-based partnerships and building on the existing infrastructure.
Conclusion: Recent evidence suggests that environmental and policy interventions have potential to promote physical activity and healthy eating at the population level. To realize positive outcomes, it is important to provide opportunities to implement these types of interventions and document their effectiveness in rural communities.

Ongoing Self-Engagement in Quit Attempts and Cessation Outcomes Among Rural Smokers Who Were Unable to Quit After 2 Years of Repeated Interventions
Siu-kuen Azor Hui, Niaman Nazir, Babalola Faseru and Edward F. Ellerbeck

Purpose: As many smokers experience repeated failures with cessation attempts, it has been postulated that we may create a cadre of highly resistant smokers who are unlikely to engage in treatment or succeed in quitting. Our purpose was to follow a group of recalcitrant rural smokers and examine their ongoing engagement in smoking cessation activities.
Methods: At the end of a 24-month disease management program for rural smokers, we identified participants who reported ongoing daily smoking despite exposure to 4 previous cycles of smoking cessation interventions. At month 36 (1 year after conclusion of the study), we contacted these participants and assessed changes in smoking status and ongoing engagement in cessation activities over the preceding 6 months. We assessed quit attempts and use of pharmacotherapy during the prior 6 months, as well as smoking abstinence at 36 months.
Findings: Among 333 recalcitrant smokers, 49% reported at least one 24-hour quit attempt during the preceding 6 months, 29% tried smoking cessation pharmacotherapy, and 5% quit smoking. Significant predictors of having at least one 24-hour quit attempt were lower numbers of cigarettes smoked per day, being in preparation stage of change, and more pharmacotherapy-assisted quit attempts during the original 24-month trial. Higher motivation to quit and more previous pharmacotherapy-assisted quit attempts significantly predicted cessation medication use. Use of varenicline was strongly associated with cessation.
Conclusions: Many recalcitrant rural smokers continue to engage in treatment and make quit attempts even in the absence of active interventions.

Availability of Emergency Contraception in Rural and Urban Pharmacies in Kansas
Fernand D. Samson, Rebecca Loren, Nicki Downing, Sarah Schroeppel, Patricia J. Kelly and Megha Ramaswamy

Purpose: Determine availability of emergency contraception (EC) at rural and urban pharmacies in Kansas.
Methods: A sample of 201 Kansas pharmacies was selected using a random integer generator. We measured ability to dispense EC within 24 hours and whether it was in stock at the time of the survey call. We examined EC availability based on geographic differences and pharmacy type.
Findings: Of the sample, 186 pharmacists agreed to be interviewed. Of these, 19% (n = 36) were unable to provide EC within 24 hours. There were essentially no differences in availability of EC between rural (75% could dispense in 24 hours) and urban pharmacies (85% could dispense in 24 hours) (P= .105). Corporate pharmacies were more likely to be able to provide EC within 24 hours compared to independent pharmacies (OR = 3.79, CI 1.71-8.43). Thirty-one percent (n = 57) of pharmacists did not carry EC at the time of the survey call. With this sample, urban pharmacies were more than twice as likely to report carrying EC compared to rural pharmacies (OR = 2.47, CI 1.31-4.68), and corporate pharmacies were also more likely to report carrying EC compared to independent pharmacies (OR = 7.77, CI 3.72-16.21).
Conclusions: In a sample of Kansas pharmacies, there were no differences between rural and urban pharmacies in 24-hour EC availability; however, there were differences in those who stocked EC at the time of the survey call. Corporate pharmacies were more likely to dispense EC within 24 hours and have it in stock compared to independent pharmacies, suggesting differences in availability of EC.

Barriers to Electronic Prescribing: Nebraska Pharmacists’ Perspective
Lina Lander, Donald G. Klepser, Gary L. Cochran, Daniel E. Lomelin and Marsha Morien

Purpose: Electronic prescribing (e-prescribing) and its accompanying clinical decision support capabilities have been promoted as means for reducing medication errors and improving efficiency. The objectives of this study were to identify the barriers to adoption of e-prescribing among nonparticipating Nebraska pharmacies and to describe how the lack of pharmacy participation impacts the ability of physicians to meet meaningful use criteria.
Methods: We interviewed pharmacists and/or managers from nonparticipating pharmacies to determine barriers to the adoption of e-prescribing. We used open-ended questions and a structured questionnaire to capture participants’ responses.
Findings: Of the 23 participants, 10 (43%) reported plans to implement e-prescribing sometime in the future but delayed participation due to transaction fees and maintenance costs, as well as lack of demand from customers and prescribers to implement e-prescribing. Nine participants (39%) reported no intention to e-prescribe in the future, citing start-up costs for implementing e-prescribing, transaction fees and maintenance costs, happiness with the current system, and lack of understanding about e-prescribing's benefits and how to implement e-prescribing.
Conclusions: The barriers to e-prescribing identified by both late adopters and those not willing to accept e-prescriptions were similar and were mainly initial costs and transaction fees associated with each new prescription. For some rural pharmacies, not participating in e-prescribing may be a rational business decision. To increase participation, waiving or reimbursing transaction fees, based on demographic or financial characteristics of the pharmacy, may be warranted.


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

Contents: 2013; 18:(1)
Issue includes:

Editorial: A call for rural generalist surgeons
Peter Hutten-Czapski
(No abstract)

Perceptions of medical school among high school students in southwestern Ontario
Kelsey Cassidy, Tamara Foster, ErinMoody, Jane Turner, Shamim Tejpar

Introduction: Canadian medical students are more likely to come from urban and high-income areas and to have well-educated, professional parents. Physicians who grew up in rural areas are more likely to serve in rural and lower-income areas. We identify perceptions held by rural high school students regarding the affordability and attainability of a medical education.
Methods: We distributed a survey to high school students who attended the MedQUEST Health Career Exploration Program in southwestern Ontario. The survey assessed socioeconomic background and perceived barriers to a medical education (including affordability as well as encouragement and discouragement from others).
Results: Of the 119 attendees, 106 (89.1%) completed the survey. Of the students who were interested in becoming physicians, most expected to fund their medical education through scholarships (56 [69.1%]), parental support (50 [61.7%]) or student employment (45 [55.6%]). However, less than half of all respondents (48 [45.3%]) provided reasonably correct estimates for annual medical tuition fees. If at least 1 parent had a postsecondary education, respondents were less likely to cite affordability as a barrier to attending medical school (p = 0.05).
Conclusion: Although students interested in obtaining a medical education cited affordability as a potential barrier, many were not aware of the actual cost of attending medical school. We found an association between perceived affordability of medical school and parents’ level of education. To define this relation further, research is needed to collect more accurate data on family income. Students may benefit from more information about funding opportunities for medical school.

Recruitment and retention of general practitioners in rural Canada and Australia: a review of the literature
Marco Viscomi, Sarah Larkins, Tarun Sen Gupta

Introduction: Both Canada and Australia are facing severe shortages of primary health workers, and these shortages are exacerbated in rural and remote communities. This literature review highlights similarities and explores the factors that serve to attract and retain family practitioners in underserved regions of Canada and Australia.
Methods: We used MEDLINE on OvidSP to review the literature between Jan. 1, 2000, and June 30, 2012. We excluded sources if the primary objective did not consider recruitment or retention of general practitioners.
Results: We found a total of 114 sources, 28 of which were excluded, leaving 86 sources for review. We organized results according to 5 life stages of family physicians in rural practice and graded the literature according to the strength of the methodology and the relevance of the findings. We chronologically categorized Canadian and Australian literature that discussed recruitment and retention of family practitioners into rural practice.
Conclusion: Various factors that pertain to each life stage of a family physician have been shown to positively correlate with the eventual decision to commence and remain practising in rural areas. Training programs should be better structured to attract candidates who are more likely to enter rural practice. Policy-makers should be mindful of these findings, because improvements in retention will deliver large financial savings.


Australian Journal of Rural Health

2013; 21:(1)
Issue includes:

Male farmers with mental health disorders: A scoping review
Philippe Roy, Gilles Tremblay, John L. Oliffe, Jalila Jbilou and Steve Robertson

The issue of male farmers' mental health raises many concerns including high rates of psychological distress and suicide amid the poor uptake of health services among this subgroup. Gender is an important social determinant of health, and this paper provides an overview of connections between farming and masculinities in the context of men's mental health disorders. This scoping review summarises findings drawn from 46 studies to discuss male farmers' mental health disorders, psychosocial interventions and barriers to help-seeking. In providing the review, recommendations are made including the need for an array of study and intervention approaches to advance the mental health and well-being of male farmers and their families.

A hub and spokes approach to building community capacity for eating disorders in rural Western Australia
Julie McCormack, Hunna J. Watson, Chris Harris, Julie Potts and David Forbes

Objective:  To determine whether an outreach community-based training program on eating disorders enhances perceived capacity of rural health and education professionals to respond to and manage eating disorders.
Design:  Survey conducted upon completion of outreach training.
Setting:  Rural Western Australia.
Participants:  Health and education professionals working in rural Western Australia.
Main outcome measures:  Questionnaire responses analysed via descriptive statistics and inferential tests.
Results:  There was a significant increase in perceived ability to identify, support and/or treat people with eating disorders among health and education professionals.
Conclusions:  Outreach training up-skilled rural gatekeepers and introduced systemic health system benefits of increased consultation and liaison, a fine-tuning of referral processes, a reduction in hospital admissions and better uptake of local services by patients discharged from hospital.

The influence of social support, lifestyle and functional disability on psychological distress in rural China: Structural equation modelling
Danjun Feng, Linqin Ji and Lingzhong Xu

Objective:  To describe the prevalence of psychological distress in rural China and examine the associated influence of social support, lifestyle and functional disability.
Design:  Cross-sectional survey with two-stage stratified random sampling.
Setting:  Twenty-seven villages in Dongying City of Shandong Province.
Participants:  A total of 2541 rural residents aged 15–91 years.
Main outcome measures:  Psychological distress was assessed by the Kessler 10, social support was assessed by the Social Support Rating Scale and lifestyle and functional disability was assessed with self-developed questionnaires.
Results:  Of the rural residents assessed, 32.9% had K10 scores of 16 or greater. Women scored significantly higher than men did on the K10 (t (2539)= 7.23, P < 0.001). Functional disability was found to have a direct positive effect on psychological distress. Lifestyle had a direct negative effect on psychological distress and an indirect negative effect on psychological distress by reducing functional disability. Social support had an indirect negative effect on psychological distress by reducing functional disability and enhancing healthy lifestyles.
Conclusions:  A third of the rural population in China reported psychological distress, with the highest prevalence observed in women. Functional disability had a significant direct effect, social support had significant indirect effects and lifestyle had both significant direct and indirect effects on psychological distress.

Understanding Autism and understanding my child with Autism: An evaluation of a group parent education program in rural Australia
Judy Farmer and Andrea Reupert

Objective:  To describe and evaluate a six-session program provided to parents of children with Autism in rural Australia. The program was designed to improve parent's knowledge and understanding of Autism, improve their confidence in managing their child and decrease parental anxiety.
Design:  A self-constructed questionnaire administered pre- and post-intervention.
Setting:  An early intervention centre in a large town in rural Victoria.
Participants:  Ninety-eight parents (or family members) of young children primarily aged 2–6 years of age, diagnosed with Autism.
Interventions:  A ‘multi-stranded content’ program was offered over six evenings. Ten programs were conducted over six years.
Results:  The pre- versus post-session analysis using a paired t-test on matched person-to-person parental responses (n = 92) showed significant increases in parental understanding of Autism and understanding of their own child (P < 0.001), and in understanding the communication, sensory, social, learning and behavioural features of Autism (P < 0.001). Significant increases in parental confidence and a significant reduction in parental anxiety were also shown (P < 0.001). Qualitative data indicated that parents valued learning about the general nature of Autism and sensory processing, and reported feeling less alone.
Conclusions:  The six-week program was successful in terms of its aims. Parent feedback indicated that ongoing parent education sessions at regular intervals would enhance the impact of the program.

Utilisation of multidisciplinary services for diabetes care in the rural setting
Jessica Madden, Amanda Barnard and Cathy Owen

Objective:  To quantify utilisation of allied health care services by diabetics in rural NSW and explore reasons for any underutilisation.
Design:  Self-administered mail survey of 268 patients with diagnosed diabetes identified from practice registers.
Setting:  Two rural general practices.
Participants:  One hundred seventeen respondents with diabetes.
Main outcome measure:  Annual frequency of visits to allied health practitioners.
Results:  In the last year, 40.2% of patients had seen a diabetes educator (DE), 21.4% a dietitian and 47% a podiatrist. However, 25–40% of patients had never used each of the services. Reasons for nonutilisation were non-referral (35.9–68.0%) and lack of perceived need (40.6–59.0%). One third of patients who had not seen a DE in the last year thought their ‘general practitioner (GP) provides a similar service’. However, mean annual GP visits (5.6) were significantly lower than urban and rural comparisons. Patients with formal management plans were, in the last year, twice as likely to have seen a DE and podiatrist, and reported two extra visits to their GP compared to those without.
Conclusions:  Rates of allied health service utilisation were not significantly lower than urban rates; however, there is room for increased uptake of multidisciplinary services. Patients who do not access these services may expect their GP to fulfil multiple roles within a limited number of visits and may not understand the role of other practitioners. Where allied health services are available locally, utilisation may be improved by increasing use of management plans and fostering awareness of the role of allied health practitioners in diabetes management.

Community understanding of the preventability of major health conditions as a measure of health literacy
Karen Moore, Ben J. Smith and Karen Reilly

Objective:  To examine health literacy in a rural community by measuring the understanding of the preventable nature of six major health conditions.
Design:  Cross-sectional population survey.
Setting:  New housing areas of Strathfieldsaye, Victoria.
Participants:  A total of 197 adults aged 18 years or older.
Main outcome measures:  Perceived preventability of skin cancer, lung cancer, cervical cancer, high blood pressure, heart attack and diabetes.
Results:  Skin cancer was the only condition which most people perceived as being all or mostly preventable (50.3%). Lung cancer was perceived to be all or mostly preventable by 35.5% of respondents, high blood pressure by 34.0%, cervical cancer by 27.4%, diabetes by 25.4% and heart attack by only 14.7%.
Conclusions:  This study shows that there is a lack of understanding of the preventability of these health conditions. Efforts need to be directed towards improving the public's knowledge of disease prevention and to ensure that health promotion programs reach populations with the most need.

Supporting GP advanced rural skills training
Andrew McKenzie, Neil Beaton, Jane Hollins, Clare Jukka and Aaron Hollins

Objective:  The aim of this study was to: investigate doctors' experiences of support during GP advanced rural skills training, and identify strategies to improve support.
Design:  The qualitative responses from a cross-sectional, postal survey are reported.
Setting:  Rural vocational training sector.
Participants:  Sixty-one doctors who had completed GP advanced rural skills training (procedural or non-procedural) in Queensland between 1995 and June 2009 participated in the study.
Main outcome measure:  Advanced trained doctors' experiences of support and their strategy recommendations to improve support.
Results:  Experiences and strategies to improve support were developed into a framework of support, consisting of three theme areas. Strategies included: provision of training and career advice to allow immediate use of advanced skills; introduction of rural attachments and rural case studies during training to ensure rural orientation; development of GP mentor and peer networks for clinical and non-clinical support; advocacy to improve understanding and recognition of advanced rural skills training.
Conclusions:  Expanded support is required across the pre-enrolment, training, early practice continuum. A holistic approach to support is required. Training providers, professional bodies, health departments, universities and workforce agencies need to work together to address and resource the support needs of advanced, rural GP trainees before, during and after training.

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