Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Contents, 2003; 9: (1) Hiver 2004 / Winter 2004
Health impact on caregivers of providing informal care to a cognitively impaired older adult: rural versus urban settings
Michel Bédard, Amanda Koivuranta, Amber Stuckey
Introduction: Rural caregivers, compared to urban caregivers, may experience a heavier burden, which could result in poorer health status for these caregivers. Furthermore, caregiving demands may prevent rural caregivers from engaging in healthy behaviours. We investigated potential differences between rural and urban caregivers in the health impact on these caregivers of caring for cognitively impaired individuals.
Methods: Two convenience samples of caregivers of older adults with cognitive impairment were obtained from Northern Ontario. The rural sample (n = 20) was taken from a community of < 15 000 inhabitants, the urban sample (n = 17) from a community of 125 000. We obtained demographical information for caregivers and care recipients, and information regarding the level of independence in activities of daily living and frequency of behaviour problems of care recipients, the type and quantity of supports available and used by caregivers, global health indices and a measure of healthy behaviours from caregivers.
Results: A greater proportion of rural caregivers was non-spousal and employed. Care recipients' characteristics from the 2 groups were similar, except for higher frequencies of behaviour problems among the rural sample. Rural caregivers had access to fewer formal supports but did not report greater burden, poorer health status, or fewer healthy behaviours than urban caregivers. However, for rural caregivers, higher reports of burden were associated with fewer healthy behaviours (r = 0.79, p = 0.001); we found no such association for urban caregivers (r = 0.04, p = 0.861).
Conclusion: Rural caregivers may have special needs regarding the management of behaviour problems in care recipients and in the promotion of healthy behaviours for themselves. Primary health care providers have an important role in ensuring that these needs are met.
Case study on priority setting in rural Southern Alberta: keeping the house from blowing in
Lisa Halma, Craig Mitton, Cam Donaldson, Bruce West
Objective: This case study describes the priority-setting process undertaken by health care providers in the Municipal District of Taber, Alta., to improve and integrate chronic disease services within a fixed budget.
Methods: Providers first reviewed the current chronic disease management system, then considered alternatives based on program priorities and costs and benefits of potential changes.
Results: Despite reaching consensus that a chronic disease clinic was the top priority for funding, providers were unable to redesign services accordingly. Redesign efforts were hampered by the groups' difficulty in identifying services that should receive fewer resources in order to fund priority areas, inexperience with priority-setting frameworks, group composition, the belief that many programs were already at "bare bone" funding levels, and perceptions of limited budget control. In the end, recommendations were made to use attrition to release resources, establish multi-disciplinary teams and group visits, where appropriate, and relocate providers to a centralized location. Upon review of study outcomes, Taber providers were granted more decision-making authority.
Conclusion: Overall, the use of a systematic priority-setting process, culminating in recommendations for action, has moved Taber providers closer to an integrated model of service delivery. It is recommended that formal priority-setting frameworks continue to be used in Taber for primary care renewal or at any level where consideration of existing evidence and projected costs is require.
Salud Rural: Revista de formación y actualización en la labor diaria del médico de atención primaria
Contents, 2003; 20: 17
Contents: 2003; 20 1: Winter
Improving Rural Cancer Patients' Outcomes: A Group-Randomized Trial
Thomas E Elliott, Barbara A Elliott, Ronald R Regal, Colleen M Renier, Irina V Haller, Byron J Crouse, Martha T Witrak, Patricia B Jensen
Context: Significant barriers exist in the delivery of state-of-the-art cancer care to rural populations. Rural providers' knowledge and practices, their rural health care delivery systems, and linkages to cancer specialists are not optimal; therefore, rural cancer patient outcomes are less than achievable.
Purpose: To test the effects of a strategy targeting rural providers and their practice environment on patient travel for care, satisfaction, economic barriers, and health-related quality of life.
Methods: A group-randomized trial was conducted with 18 rural communities in the north-central United States. Twelve of these communities were included and defined as the unit of analysis for the patient outcomes portion of the study. The intervention targeted rural providers and their practice environment. The subjects were patients with breast, colorectal, lung, and prostate cancers from the rural communities. The main outcomes were patients' travel to obtain health care, satisfaction with care, perceptions of economic barriers to care, and health related quality of life. In total, 881 patients were included. Results: Group randomization was balanced. Travel for health care was significantly reduced in the community group exposed to the intervention during months 13 to 24 following cancer diagnosis. The mean miles traveled per patient were 1,326 (SE = 306) for the experimental group and 2,186 (SE = 347) for the control group (P=0.03). No significant differences in satisfaction with care, economic barriers to care, or health-related quality of life were found.
Conclusions: The intervention significantly reduced cancer patient travel for health care, which suggests that access to care improved in the experimental group. The results of this study do not allow conclusion that there was no effect on other patient outcomes. The results supported the study's conceptual framework and many of its hypotheses.
Arguing For Rural Health in Medicare: A Progressive Rhetoric for Rural America
Thomas C Ricketts
Rural health policy is the laws, regulations, rules, and interpretations that benefit or affect health and health care for rural populations. This paper examines how rural health policy is viewed in the broader field of public policy, discusses the role of advocacy in developing rural health policy, and suggests ways to make that advocacy more effective. This paper critically reviews policy statements and policy positions taken by key opinion leaders and the leading stakeholders in rural health policy to determine how advocacy for rural communities is expressed. It is not clear how the rural health advocacy coalition is viewed by the professional policy world or the public: as an issues network pressing for fair and equal treatment or as an interest group seeking special advantages. This paper also explores the types of claims that rural advocates make in the specific context of Medicare policy to determine to what extent those claims reflect a central theme of fairness and inclusiveness in national policies versus claims that benefit special interests. The paper suggests that the rhetoric of rural advocates can be better structured to advocate for policies on the basis of a progressive sense of fairness.
The Role of International Medical Graduates in America's Small Rural Critical Access Hospitals
Amy Hagopian, Matthew J Thompson, Emily Kaltenbach, L Gary Hart
Context: Critical access hospitals (CAHs) are a federal Medicare category for isolated rural facilities with 15 or fewer acute care beds that receive cost-based reimbursement from Medicare. Purpose: This study examines the role of foreign-born international medical graduates (IMGs) in the staffing of CAHs.
Methods: Chief executive officers (CEOs) of CAH facilities answered a telephone survey on their use of IMGs and the characteristics of those IMGs in winter 2002 (388 responded, for a 96% response rate). This descriptive report presents roles and characteristics of IMGs in CAH facilities and the opinions of the CEOs about these practitioners.
Findings: Overall, 1 (24%) in 4 admitting physicians in CAHs are graduates of non-US medical schools (compared with 23% of physicians nationally), although the rates are higher for CAHs in persistent poverty counties, CAHs that report recruitment problems, and CAHs with smaller medical staffs. Hospitals east of the Mississippi River are more heavily reliant on IMGs than hospitals in the west. Most IMGs are internists (59%) and most (61%) come from India, the Philippines, or Pakistan. Hospital administrators rate the clinical skills of their IMGs highly and their interpersonal skills only slightly lower. Almost half of CAH administrators said their communities recruited their first IMGs during or after 1994, the year of pro-IMG legislative changes.
Conclusion: IMG physicians play a significant and possibly growing role in staffing CAHs.
A Sense of Place: Rural Training at a Regional Medical School Campus
William J Crump, Darel Barnett, Steve Fricker
ABSTRACT: Context: Traditionally, rural students experience urban disruption during the many years of education and training in urban environments before choosing a practice site. Regional rural campuses that allow students to live and work in small towns during the last 2 years of medical school are one strategy to address this issue.
Purpose: To report the results of the first 10 years of a rural campus in western Kentucky, including response to difficulties filling openings for third- and fourth-year medical students at the campus.
Methods: A survey was sent to all 76 students who had shown interest in the rural campus, asking them to prioritize the important issues in their campus choice.
Findings: Students not choosing the rural campus placed a higher
priority on large-city amenities, better opportunities for their spouse, and proximity to family in eastern and central Kentucky. Students who chose the rural campus placed a higher piority on one-on-one clinical training and interest in small town life.
Conclusions: For the rural clinical campus to reach its potential, more rural students from the western part of the state must be admitted to medical school and then choose this campus. Strategies to reinforce the sense of place among rural
students focus on experiential programs in rural areas. Initial results suggest that medical educators should consider geography more carefully when designing approaches to address physician maldistribution.
2003; 21 (3)
Literacy Assessment of Patients in Rural Florida
Kimberly Harper, Melva Thompson-Robinson, Marisa Lewis
The purpose of this study was to gain a greater understanding of the health literacy needs of a rural minority population in Gadsden County, Florida. The Short Test of Functional Health Literacy in Adults (STOFHLA) was used to assess health literacy levels among participants. Twenty-nine participants out of 30 (93%) had adequate functional health literacy. The STOFHLA is a reliable and valid instrument for measuring functional health literacy. Limitations of this study are as follows: the population from which the participants were recruited was biased, the number of participants recruited was small, and the recruited participants may not have represented the larger populations.
Using Outreach Endeavors to Determine Hispanic Diabetics
Supporting the Hispanic population with the management of diabetes mellitus is escalating into an overriding challenge for health care providers. Developing an effective outreach undertaking is one mechanism for addressing barriers that restrict access to health services for Hispanic clients. This discussion of one clinically focused outreach endeavor is presented to provide a framework for considering the implications for practice when working toward the successful management of key risk factors related to the disease process.
Telemedicine Burn Project at the Texas Tech University Health Sciences Center
Many people, whether young or old, will be affected by a burn injury at some point in their lives. This article discusses the telemedicine burn project at the Texas Tech University Health Sciences Center (TTUHSC). It addresses some of the challenges that rural patients face when seeking treatment and discusses solutions through telemedicine.
Ophthalmologic Care Among Diabetic Mexician-American Adults Residing in a Colonia
Mark Gallardo, Arthur Islas, Darryl M Williams
Ocular damage with possible progression to blindness is a common complication of diabetes mellitus. These changes can be diminished by early detection through regularly scheduled eye examinations and by intervention that includes better control of hyperglycemia. In Mexican-American populations, both type 2 diabetes and the ophthalmologic complications appear to be more prevalent and perhaps more severe than in the general population. Using a survey of diabetic patients enrolled in community clinics as well as a sponsored screening program, this study shows that access to eye care is inadequate within a small survey population drawn from residents of colonias along the Texas-Mexico border. These individuals are exclusively Mexican-American and also possess many of the characteristics of low socio-economic status that impede access to health care. At the same time, the reservoir of ophthalmologic disorders appears to be high, based upon the findings of a comprehensive screening program. Taken together, these findings strongly suggest the need for new strategies employing provider and patient education as well as modified referral methods in order to improve the access to recommended health care services for this rural population.
Using Partnerships in Developing a Diverse RN Workforce on the South Plains of Texas
Elizabeth Amos, Alexia Green, Mike McMurry
In an attempt to address the nursing shortage on the South Plains of West Texas, a unique partnership was formed between the Texas Tech University Health Sciences Center School of Nursing (TTUHSC SON) and the South Plains WorkSource (SPWS). The goal of this union was to increase rural and minority community awareness of nursing as a profession and to enhance university efforts to recruit, retain, and graduate disadvantaged and rural students (DARS). The project used a simple model (Bessent, 1997) to guide enhanced efforts and strategies developed to meet DARS program objectives. The model emphasizes the strategy of community awareness and partnerships to enhance the overall process of recruitment, retention, and graduation of DARS. This article describes these major project strategies and evaluates their effectiveness in enhancing recruitment and retention of disadvantaged and rural students.
Australian Journal of Rural Health
2003; 12 (1)
Rural nurse practitioners in South Australia: recognition for registered nurses already fulfilling the role
The introduction of the nurse practitioner role is hailed as a new initiative in the South Australian public health system. In reality, some registered nurses working in rural public health care facilities have been practicing in the role for many years. The role of the rural registered nurse, the pathway towards achieving rural nurse practitioner status and the anticipated advantages of implementing the rural nurse practitioner role will be presented.
Epidemiological study of gambling in the non-metropolitan region of central Queensland
Grant Schofield, Kerry Mummery, Wei Wang, Geoff Dickson
Design: The South Oaks Gambling Screen (SOGS), a clinical diagnostic tool for identifying problem and pathological gamblers was utilised.
Setting: Central Queensland extends from Bundaberg to Mackay and west to the Queensland - Northern Territory border. The region incorporates a number of rural and regional centres and the major centres of Rockhampton, Gladstone, Mackay and Bundaberg.
Subjects: Computer-aided telephone interviews were conducted with a random sample of 1029 adults.
Main outcome measures: a comparison of CQ gambling rates with national averages.
Results: Over 90% of the population had engaged in some form of gambling activity in the past month. One point eight percent of the sample fulfilled criteria for 'problem gambling'. The prevalence of 'probable pathological gambling', was 0.8%. An additional 1% of the population were identified as being 'problem gamblers'. These rates are slightly lower than the Australian average identified by the Productivity Commission in 1999. Nonetheless, they indicate the presence of a large number of individuals affected by problem gambling.
Conclusions: Comparisons of these data with treatment statistics available from the regional counselling service for problem gamblers indicate that the majority of these gamblers do not seek treatment. It is clear that many gamblers with serious pathology go undetected and untreated. General practitioners are suggested as one appropriate point for screening and further referral. A whole-of-government approach to problem and pathological gambling is also advocated.
What is already known: Gambling is increasingly recognised as a health determinant for individuals, families and communities throughout metropolitan and non-metropolitan Australia. Previous research has not yet identified the prevalence rate of problem gambling in non-metropolitan communities within Australia.
What this study adds: The prevalence of problem gambling in Central Queensland identified by this study does not exceed national rates. Central Queensland's gambling problem is likely to be at least the equal as the rest of Australia.
Post operative pain experiences of central Australian Aboriginal women. What do we understand?
Clare Fenwick, John Stevens
Objective: The aim of this study was to explore the postoperative pain experiences of Central Australian Aboriginal women and the subsequent interpretation of that pain experience by non-Aboriginal female nurses.
Design: Qualitative study using grounded theory methodology.
Setting: Postoperative surgical setting of a Central Australian regional hospital.
Subjects: Five Aboriginal female clients who had undergone a surgical procedure, eight non-Aboriginal female nurses and four Aboriginal female health workers employed by a Central Australian regional hospital.
Results: Aboriginal women have culturally appropriate ways of expressing and managing pain that are not well understood by non-Aboriginal female nurses. In addition, the Aboriginal women inappropriately endow non-Aboriginal nurses with the same powers and skills expected of healers from their culture. This phenomenon resulted in the non-Aboriginal nurses lacking the cultural insight and the appropriate knowledge and tools required to assess and manage the postoperative pain of Central Australian Aboriginal women effectively or efficiently.
Conclusions: Non-Aboriginal nurses have a profound knowledge deficit about the postoperative pain experiences of Central Australian Aboriginal women. This deficit is evident through the use of culturally inappropriate and unreliable pain assessment strategies and tools and the misinterpretation of traditional pain relief strategies, such as the use of pituri, rubbing and centreing. The findings of this study suggested that nurse/client interactions related to language and role interpretation were in cultural conflict. The nurses expected the Aboriginal women to adopt pain behaviours as understood from the nurses' culture. The nurses anticipated that the client would contribute to their own care by communicating pain experiences in ways that are familiar and are believed to be universal. The Aboriginal women expected the nurses to conduct business similar to that of their own traditional tribal healers, 'to see within' and to 'just know'.
What is known on this subject: The National Health and Medical Research Council claim there is a dearth in systematic studies of pain issues for Aboriginal and Torres Strait Islander people. Previous studies conducted suggest that Aboriginal people do not feel pain and have an extraordinary high pain tolerance. However, no significant studies exist in the area of pain management that address the cultural needs of Aboriginal people.
What this paper adds: Statistical evidence gathered from the informal Acute Pain Service operational within a Central Australian regional hospital, revealed that although the hospital clientele were predominately of Aboriginal descent, the service catered for a greater proportion of non-Aboriginal people. The misconception that Aboriginal people have a high pain tolerance requiring less pain relief is outdated and erroneous, as this paper will reveal.
Implementing computerised workload data collection in rural primary health care
Christina West, Jane Farmer, Bruce Whyte
Objective: Describes the implementation of a computerised information system to collect workload data and discusses feedback from staff evaluation of use and value.
Design: Feedback interviews following service implementation.
Setting: Remote rural primary health care, Scotland.
Subjects: Thirty-three primary health care staff.
Main outcome measures: Not relevant, as the study was service development with qualitative evaluation.
Results: Findings of evaluation interviews indicate a number of themes common to remote rural practice that make implementing a computerised information system problematical. These include: logistical problems caused by small practice teams and wide areas covered; inadequate allowance for recording of blurred roles and the wide range of non-clinical duties carried out; lack of local contextual and cultural information, which is necessary to make sense of data collected. Remote rural health professionals found reports from the system of limited value as they felt they already had good knowledge of local activities and had few opportunities, due to small teams, to use data for service redesign.
Conclusion: Remote rural primary care is underpinned by a number of organisational and philosophical features that require understanding when considering the implementation of initiatives developed in an urban working environment.
What is already known on the subject: A small number of studies have evaluated the implementation of information systems in primary health care, but there is little information about the feasibility and value of routinely gathering data in rural areas. This work was required to assess the extent to which information systems developed in urban practice can be implemented and are applicable to rural practice.
What does this study add: This evaluation shows that certain features of rural practice may mean that data gathering has to be adapted and that, in any case, rural practices may find less value in the outputs of information systems compared with urban counterparts. Those considering the dissemination of national initiatives should consider the need to adapt their policies for implementation in rural settings.
[Norwegian medical journal for general practice and public health] [in Norwegian]