Journal Search

Journal Search - issue 4, 2005


name here
Paul Worley1
PhD, Editor-in-Chief *


* Paul Worley


1 Rural and Remote Health


22 December 2005 Volume 5 Issue 4


RECEIVED: 12 December 2005

ACCEPTED: 22 December 2005


Worley P.  Journal Search - issue 4, 2005. Rural and Remote Health 2005; 5: 532. Available: www.rrh.org.au/journal/article/532


© Paul Worley 2005 A licence to publish this material has been given to ARHEN, arhen.org.au

go to urlCited by

no pdf available, use your browser's print function to create one

full article:

Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in rural health journals worldwide.


Journal Canadien de la M├ędecine Rural/Canadian Journal of Rural Medicine
[in French and English]

Contents, 2005; 10: (4) Fall 2005 / Automne 2005
Issue includes:

Qualitative troponin I estimation in the diagnosis of acute coronary syndromes in three rural hospitals
Hugh Ross Hindle, Sally Katherine Hindle

Objective: To examine the utility of point-of-care qualitative troponin I (TnI) testing in patients with possible acute coronary syndromes (ACS).
Methods: A retrospective chart review of all patients undergoing qualitative TnI testing between September 2001 and February 2002 was conducted at the emergency departments of 3 rural hospitals in Alberta. We looked at the incidence of ACS, the comparison between TnI and creatine kinase (CK) testing and the timing of testing.
Results: Of the 235 patients tested, 8 had ST-elevation myocardial infarctions and 11 non ST-elevation infarctions. One patient had unstable angina with minimal myocardial damage. Qualitative TnI testing was positive in all 14 cases of infarction tested more than 6 hours after symptom onset, and CK elevation occurred in 15/17 cases (TnI sensitivity 1.0 [95% confidence interval (CI) 0.78-1.0], CK sensitivity 0.882 [95% CI 0.66-0.97]). There were 3 positive TnI tests and 33 raised CK levels in patients without evidence for ACS (TnI specificity 0.986 [95% CI 0.96-0.99], likelihood ratio [LR] 72.0 [95% CI 23.4-221.5]); CK specificity 0.847 [95% CI 0.79-0.89], LR 5.8 [95% CI 4.0-8.3]). In 44 patients (20.8%) TnI testing was inappropriately not repeated more than 6 hours after symptom onset.
Conclusion: Qualitative TnI testing appears highly sensitive and more specific than CK estimation in detecting myocardial infarction. Diagnostic algorithms must emphasize the importance of testing 6 or more hours after symptom onset.

Relationship between practice location of Ontario family physicians and their rural background or amount of rural medical education experience
James TB Rourke, Filomena Incitti, Leslie L Rourke, MaryAnn Kennard

Introduction: The present study was designed to determine if there was a difference in rural background and rural medical education experience between practising rural physicians and practising urban physicians in Ontario.
Method: A cross-sectional survey was mailed to 507 strictly defined rural family physicians and 505 urban family physicians practising in Ontario. The main outcome measures were population of the community while growing up, rural medical education and medical school attended.
Results: Responses of 264 rural physicians were compared with 179 urban physician responses. The groups were comparable in years of practice. Rural physicians were significantly more likely to have grown up in a rural community (34.9% v. 14.6%), to have had clinical training in a rural setting during medical school (55.4% v. 35.2%) and to have had clinical training in a rural setting of 8 weeks or more during postgraduate residency training (38.8% v. 20.2%). During residency training, longer duration of rural placements (more than 6 months) was significantly associated with practice in a rural area (15.5% of rural physicians, 1.7% of urban physicians). After controlling for other predictors, each of the following were independent variables: growing up in a community of less than 10 000 people (odds ratio [OR] 3.31), having had some undergraduate rural clinical training (OR 2.46), having had postgraduate rural training of 8 weeks or more (OR 2.17), attending a Canadian medical school outside Ontario (OR 3.80) and being male (OR 2.57).
Conclusion: Practising rural physicians compared with urban physicians were significantly more likely to have come from a rural background, to have had an undergraduate rural medical education, to have had postgraduate rural training, to have graduated from a Canadian medical school outside Ontario, and to be male. Each of these had an independent effect on practice location.

Women's health in northern British Columbia: the role of geography and gender
Beverly D Leipert, Linda Reutter

Introduction: Although research interest in women's health is growing, much of the literature does not sufficiently describe the importance of geography and gender for the health of women. This qualitative study explored factors in the northern Canadian context that influence women's health by interviewing 25 women in northern Canada.
Results: Findings reveal that the importance of the northern context for women's health can be attributed to the north's historical location, and its physical, sociocultural and political environments. The northern context contributes to the marginalization of northern women that is characterized by isolation, limited options, limited power and being silenced.
Conclusion: Health care practice and policy must attend to contextual as well as individual and sociocultural factors if women's health is to be advanced in northern settings.

The occasional removal of an embedded fish hook
Harvey V Thommasen, Amy Thommasen

Fishing is a popular rural recreational activity involving millions of Canadians. Rural physicians can expect to see the occasional patient presenting with penetrating tissue trauma involving fish hooks. Management of an embedded hook includes taking a careful history, doing a physical examination of the hook injury and surrounding tissue and preparing the skin with antiseptic solution before attempting removal. Local anesthetic is probably necessary for all but the most superficially embedded hooks. Radiography may provide additional information with respect to presence of internally embedded barbs, depth of penetration or bony involvement. Complicated wounds, such as those involving the eye and those deeply embedded near tendons, blood vessels and nerves should be referred to more experienced specialists.
Five fish hook techniques are described; namely, the 1) Simple Retrograde technique, 2) String-pull technique, 3) Advance-and-Cut technique, 4) Needle-Cover technique, and 5) Cut-it-Out technique. The technique chosen will depend on a number of variables, including the type of fish hook embedded, the anatomic location of the injury, the depth of tissue penetration and provider experience. The first 2 techniques result in the least amount of tissue trauma, can be performed with local anesthetic and should be attempted first, especially with barbless hooks and superficially embedded barbed hooks.
Wound care following hook removal involves flushing any open wound with saline, applying topical antibiotic ointment and covering the wound with a simple dressing. The patient should be reminded about the risk of infection and told to return if signs of infection arise ?erythema, discharge, pain and swelling. A follow-up appointment is organized as needed. Consideration should be given for the use of prophylaxis antibiotics, but they are generally not indicated. Tetanus status should be addressed before discharge.


Journal of Rural Health

Contents: 2005; 21 4: Fall
Issue includes:

Update: Health Insurance and Utilization of Care Among Rural Adolescents
Janice C Probst, Charity G Moore, Elizabeth G Baxley

Context: Adolescence is critical for the development of adult health habits. Disparities between rural and urban adolescents and between minority and white youth can have life-long consequences. Purpose: To compare health insurance coverage and ambulatory care contacts between rural minority adolescents and white and urban adolescents.
Methods: Cross-sectional design using data from the 1999?000 National Health Interview Survey, a nationally representative sample of US households. Analysis was restricted to white, black, and Hispanic children aged 12 through 17 (8,503 observations). Outcome measures included health insurance, ambulatory visit within past year, usual source of care (USOC), and well visit within past year. Independent variables included race, residence, demographics, facilitating/enabling characteristics, and need.
Results: Across races, rural adolescents were as likely to have insurance (86.8% vs 87.7%) but less likely to report a preventive visit (60.1% vs 65.5%) than urban children; residence did not affect the likelihood of a visit or a USOC. Minority rural adolescents were less likely than whites to be insured, report a visit, or have a USOC. Most race-based differences were not significant in multivariate analysis holding constant living situation, caretaker education, income, and insurance. Low caretaker English fluency, limited almost exclusively to Hispanics, was an impediment to all outcomes.
Conclusions: Most barriers to care among rural and minority youth are attributable to factors originating outside the health care system, such as language, living situation, caretaker education, and income. A combination of outreach activities and programs to enhance rural schools and economic opportunities will be needed to improve coverage and utilization among adolescents.

Psychosocial Work Characteristics Predict Cardiovascular Disease Risk Factors and Health Functioning in Rural Women: The Wisconsin Rural Women's Health Study
Vatsal Chikani, Douglas Reding, Paul Gunderson, Catherine A McCarty

Background: The aim of the present study is to investigate the association between psychosocial work characteristics and health functioning and cardiovascular disease risk factors among rural women of central Wisconsin and compare psychosocial work characteristics between farm and nonfarm women.
Methods: Stratified sampling was used to select a random sample (n=1500) of farm and nonfarm women aged 25 to 71 years from the Central Marshfield Epidemiologic Study Area. The baseline examination included measurements of blood pressure, height, weight, and fasting blood lipids, glucose, and insulin. Psychosocial job condition was measured with the Karasek Job Content Questionnaires (JCQ). Health functioning was assessed by the Short Form-36 Health Survey.
Results: The analysis of JCQ showed that nonfarm residents were more likely to have jobs with high demand and high decision latitude compared to farm residents. Also, the farm residents (40.3%) were more likely to be occupied in passive jobs (jobs with low levels of demand and control) than the nonfarm residents (26.9%). Among farm residents, psychological job demand was associated with HDL level (b = 0.17), triglycerides (b = 0.0), their ratio (b = 0.005), and blood insulin level (b = 0.014), and among nonfarm residents, psychological job demand was associated with diastolic blood pressure (b = 0.17) and total cholesterol level (b = 0.002).
Conclusion: Our results showed that rural farm residents had a higher prevalence of CVD risk factors and were more likely to be occupied in jobs with low levels of demand and control. Job stress predicted more CVD risk factors among farm residents compared to nonfarm residents. Therefore, interventions reducing job strain among rural farm residents are timely and necessary.

The Limited Effect of Screening for Depressive Symptoms With the PHQ-9 in Rural Family Practices
George R Bergus, Arthur J Hartz, Russell Noyes, Marcia M. Ward, Paul A James, Thomas Vaughn, Patricia L Kelley, Suzanne D Sinift, Suzanne Bentler, Eileen Tilman

Context: Previous studies have found that routine screening for depression does not improve patient outcome unless it is combined with case management. However, these studies were conducted before the widespread use of SSRIs or in settings other than traditional primary care. Purpose: This study investigated whether screening for depressive symptoms improves outcomes for depressed patients seen in rural fee-for-service primary care offices.
Methods: Depression screening was conducted at 2 private rural clinics in Iowa using the PHQ-9. Patients with depressive symptoms were randomized to the control group or the intervention group, where providers were given completed PHQ-9 questionnaires at the baseline visit. The outcome PHQ-9 scores were assessed by telephone at 4, 10, and 24 weeks after the index visit.
Findings: A total of 861 patients were screened for depressive symptoms; 51 subjects enrolled in the trial. The intervention and control groups did not significantly differ with respect to changes in PHQ-9 scores at any of the 3 follow-up times. They also did not differ with respect to the proportion of subjects who were actively managed with medication or by referral to a mental health specialist: 46% vs 33% (P =.38) for all subjects and 50% vs 50% (P =.96) for subjects with major depression at baseline.
Conclusions: Screening for depressive symptoms with the PHQ-9 in 2 rural medical clinics did not significantly increase physicians?active management of depression or lead to improved patient outcomes.

Depressive Symptoms in Adolescents Living in Rural America
Ann R Peden, Deborah B Reed, Mary Kay Rayens

Purpose: The purposes of this pilot study were to examine prevalence of depressive symptoms among rural adolescents and identify related social and environmental variables.
Methods: A convenience sample of 299 14- to 18-year-old agriculture class students at 5 rural high schools in Kentucky and Iowa completed a survey that included demographic information, family farm history, experience with suicide, perception of school environment, and indicators of farm injuries and risky behaviors. Participants also completed the Center for Epidemiologic Studies Depression Scale (CES-D) as well as scales to assess the number of major life events in the last year, active coping use, and family closeness.
Findings: The prevalence of a high level of depressive symptoms (CES-D >/=16) in this sample was 34%. Nine percent had seriously considered suicide in the last year. Unlike previous reports, boys reported as many depressive symptoms as girls. Although the literature reports that engaging in risky behavior is associated with depressive symptoms, the only risky behavior linked with depressive symptoms in this sample was operating a 4-wheel all-terrain vehicle. Other predictors of depressive symptoms included poor family relationships and poor active coping.
Conclusions: Interventions to identify and prevent depressive symptoms in rural adolescents are needed. Boosting active coping and improving family function may also prevent the development of clinical depression in rural adolescents.

Home-based Comprehensive Assessment of Rural Elderly Persons: The CARE Project
David D Cravens, David R Mehr, James D Campbell, Jane Armer, Robin L Kruse, Laurence Z Rubenstein

Context: Home-based comprehensive geriatric assessment (CGA) has been effective in urban areas but has had little study in rural areas. CGA involves medical history taking, a physical exam, and evaluation of functional status, mental status, cognitive status, gait and balance, medications, vision, extent of social supports, and home safety. We sought to develop and pilot a model of rural home-based CGA to determine whether successful urban models can be adapted to rural areas.
Methods: This study was a developmental demonstration project with qualitative and quantitative evaluation components of a home-based CGA model using a home health agency and a geriatrician participating from a remote location by teleconference. Findings and recommendations were relayed to patients, caregivers, and primary physicians. The population studied was elderly volunteers (N = 51) aged 75 years and older who did not have a terminal diagnosis or immediate plans to enter a long-term carer facility. Survey instruments and focus groups were used with subjects, family members or caregivers, and physicians to generate refinements and outcome measures for the model.
Findings: Among the 51 patients undergoing CGA, Instrumental Activities of Daily Living dependency and balance and gait problems were highly prevalent. Means of 1.1 major problems and 4.9 nonmajor problems were identified per patient. Recommendations were implemented for 32% of major problems and for 35% of nonmajor problems. Primary physicians found recommendations for vaccination and home safety change helpful but were skeptical of physical examination findings by the nurse. Practitioners noted that this study resulted in several positive outcomes: (1) some subjects initiated regular clinic visits; (2) several visually impaired elders began services for the blind; (3) identification of gait and balance problems resulted in physical therapy treatment; and (4) identification of caregiver stress was addressed by social-work intervention. Potential further refinements of the model for rural home-based CGA were identified.
Conclusions: Home-based CGA identifies important problems of rural older adults. However, modifications are still needed to create a truly effective process.

Challenges and Strategies Related to Hearing Loss Among Dairy Farmers
Louise Hass-Slavin, Mary Ann McColl, William Pickett

Context: Farming is often imagined to be a serene and idyllic business based on historical images of a man, a horse, and a plow. However, machinery and equipment on farms, such as older tractors, grain dryers, and vacuum pumps, can have noise levels, which may be dangerous to hearing with prolonged, unprotected exposure.
Purpose: This qualitative study in Ontario, Canada, explored the challenges and coping strategies experienced by dairy farmers with self-reported hearing loss and communication difficulties. Through in-depth interviews, 13 farmers who experience significant hearing loss were questioned about the challenges they face as a result of hearing loss and the strategies they use to overcome or compensate for problems.
Findings: The 2 major challenges encountered by dairy farmers with a hearing loss were: (1) obtaining information from individuals, within groups, and through electronic media; and (2) working with animals, machinery, and noise. To cope with these challenges, participants used strategies identified as problem and emotion focused.
Conclusions: Four themes arose from analysis of the challenges encountered and strategies used: 1. Hearing loss is experienced as a "familiar,?but "private,?problem for dairy farmers. 2. Communication difficulties can negatively affect the quality of relationships on the farm. 3. Safety and risk management are issues when farming with a hearing loss. 4. The management or control of excessive noise is a complex problem, because there are no completely reliable yet practical solutions.

Rural Medical School Applicants: Do Their Academic Credentials and Admission Decisions Differ From Those of Nonrural Applicants?
Daniel R Longo, Robert J Gorman, Bin Ge

Context and Purpose: Medical schools located in states with sizable rural areas are concerned about preparing physicians for practice in these areas; this is of particular concern for medical schools that are part of a state-owned university with a responsibility to educate physicians for rural areas. Because individuals from rural areas are most likely to return to practice medicine in rural areas at the conclusion of their training, it is important to recruit these individuals to medical schools to educate them for rural practice.
Methods: This study examines 7 years of admission data for students who applied and were accepted to the University of Missouri-Columbia School of Medicine, which has as a specific mandate to prepare physicians for rural practice.
Findings: The study indicates that rural applicants are more likely to be admitted to the medical school, and based on admissions criteria they are at least as academically qualified as nonrural applicants.
Conclusions: The study demonstrates that a medical school can maintain competitive admission criteria while at the same time accepting those students more likely to enter rural practice. This is valuable information that medical schools with a similar mission to prepare physicians for rural practice might consider in their admissions decision-making process.

The Montana Model: Integrated Primary Care and Behavioral Health in a Family Practice Residency Program
Claire Oakley, Douglas Moore, Duncan Burford, Roxanne Fahrenwald, Kathryn Woodward

To address the local health care needs of both patients and primary care providers in Montana, an integrated primary care and behavioral health family practice clinic was developed. In this paper we describe our experience with integrating mental health and substance abuse services into a primary care setting (a community health center) while simultaneously teaching family practice physicians to take the lead in providing these services. The Deering Community Health Center in Billings, Montana, is a Federally Qualified Health Center serving a largely low-income patient population. The medical care at the clinic is provided primarily by the faculty and residents of the Montana Family Medicine Residency. The teaching model was founded on the belief that improved care will result when physicians have increased comfort with, and are able to enjoy the challenges of, patients with mental illnesses. The enhanced longitudinal curriculum incorporates mental health across the 3 years of the family practice residency. Unique characteristics of this model include staffing and the concurrent delivery of a high volume mental health service while teaching family practice resident physicians and the faculty to integrate this competency into their primary care practices.

Modeling the Emergency Ambulance Pass-By of Small Rural Hospitals in Victoria, Australia
Patrick Gleeson; Stephen Duckett

Context: Many small rural hospitals struggle to attract sufficient numbers of suitable patients. Inadequate patient throughput threatens the viability of these hospitals and, consequently, the financial, physical, and social well-being of the whole community. Anecdotal evidence suggests that many emergency ambulance patients are routinely taken past their local small rural hospital to the area's major receiving hospital.
Purpose: To quantify the ambulance pass-by of local small rural hospitals and identify the factors that influence its occurrence. Methods: Data were collected from the ambulance and hospital records of 3 small rural centers in central Victoria, Australia.
Results: Ambulances transport a significant number of patients past their local small rural hospitals to the area's major receiving hospital. This takes less time for paramedics than bringing a patient to the local hospital first if the patient is then redirected by that hospital to the larger hospital. There is an inverse relationship between the rate of cases in which the local hospital redirects ambulances to the regional hospital and the rate of ambulance crew decisions to use the local hospital.
Conclusions: If some patients are being transported directly to the major receiving hospital because paramedics are considering their own time commitments when making patient transport decisions, this could have revenue implications for rural hospitals. Attracting appropriate local ambulance patients to the smaller hospitals may provide an income source that is currently lost to the crowded major receiving hospital's emergency department.

Accessibility Assessment of the Health Care Improvement Program in Rural Taiwan
Hsiu-Fen Tan, Hung-Fu Tseng, Chen-Kang Chang, Wender Lin, Shih-Huai Hsiao

Context: An experimental Health Care Improvement Program (HCIP) was initiated by the Bureau of National Health Insurance in 1997 to improve the accessibility of health care in several rural, mountainous districts.
Purpose: This longitudinal study evaluated service availability, utilization patterns, and effectiveness of services under the HCIP in the A-Li Mountain District.
Methods: Outpatient claims made by residents in the A-Li Mountain District were extracted from the database of the National Health Insurance program. Changes in utilization pattern and volume were analyzed. Satisfaction levels were assessed by 2-stage face-to-face interviews with local residents.
Findings: After the HCIP, the average population served by each doctor decreased 75%, and total outpatient visits increased 15.4%. The total number of indistrict outpatient visits increased 83.6%. The proportion of in-district outpatient visits to all visits increased from 22.1% to 35.1%. The total in-district outpatient visit fee claimed increased 100.2%, and the total out-of-district outpatient visit fee claimed increased only 7.2%. About 60.4% of the residents were not satisfied with overall health care services before the HCIP. The proportion decreased to 32.4% after the HCIP.
Conclusions: The HCIP improved accessibility, enriched local medical care resources, changed the utilization pattern of some residents, and increased residents?satisfaction level. A well-managed program with stabilized financial resources is more likely to succeed if it also respects cultural differences and responds to community needs.


Australian Journal of Rural Health

2005; 13 (6)
issue includes:

Experiences of female general practice registrars: Are rural attachments encouraging them to stay?
Donnetta M Charles, Alison M Ward, Derrick G Lopez

Objective: To establish whether a six-month rural attachment influenced female GP registrars' future plans to work in a rural area. Secondary aims include establishing the adequacy of postgraduate training in preparing the registrars for the attachment, opinions regarding rural practice and suggestions to improve the attachment.
Design: A six-page questionnaire was sent to eligible participants via state branches of General Practice Education Australia.
Subjects: Female GP registrars who undertook a six-month rural attachment during 2002.
Main outcome measure: Whether the six-month rural attachment influenced female registrars to practise in the country.
Results: The rural attachment was a positive experience for 82% of participants. One-third were more likely, as a result of the attachment, to practise rurally in the future. In total, 14% were influenced against working rurally as a result of the attachment. Those who had previously resided or studied in a rural area were more likely to plan to work rurally. Level of vocational preparation was adequate for the majority with notable deficits in obstetrics and gynaecological procedural skills. Main negatives associated with the attachment included working long hours and social isolation. Recommendations for change focused on amending these issues along with improved child-care facilities and improved remuneration.
Conclusion: The rural attachment is a predominantly positive experience for female registrars with the exception of professional and personal hardships associated with relocating to rural practice. The attachment dissuades only a small proportion of its female counterparts, which is promising considering the increasing role of female practitioners in the workforce.

Do the learning needs of rural and urban general practitioners differ?
James A Allan, Di Schaefer

Introduction: The challenges of rural general practice have given rise to a separate rural training stream and a separate rural professional body. The differences are characterised by the nature of the work undertaken by rural GPs and reflected in the continuing medical education topic choices made when surveyed.
Methods: In 2001 a survey was designed and distributed by the Royal Australian College of General Practitioners and Divisions of General Practice in South Australia and Northern Territory. The survey utilised a list of 104 topics. The topic choices of rural and urban GPs were compared.
Results: The survey was distributed to approximately 1762 GPs and yielded 578 responses (33%). Rural GPs were more likely to select the following topics: Anaesthetics, Aboriginal Torres Strait Islander health, Population Health, Renal medicine, Cardiology, Teaching skills, Obstetrics, Neonates, Arrhythmias, Fracture management, Tropical medicine and Therapeutics. Urban GPs were more likely to select Menopause, Travel medicine and Palliative care (P < 0.05).
Discussion: Many of the areas of difference reflected aspects of rural general practice. There were also many similarities in topic choices between these two groups.

Palliative care in the hinterlands: A description of existing services and doctors' attitudes
Glenn J Pereira

Objective: To describe palliative care services as they exist in the hinterlands (towns away from regional centres) of Midwest New South Wales, including an estimation of the numbers of cases treated by local doctors, and the service they provide to their patients. Generalist doctors' attitudes to palliative care are also explored, as this information is lacking in the literature but is important for service provision.
Design: Descriptive survey.
Setting: Rural primary care and district hospitals.
Participants: Generalist doctors in hinterland areas.
Results: In total, 38% (19/50) of surveys were returned. 'Visiting rights' to the district hospital were held by 78.9% of local doctors, and patients are admitted under the care of their own doctor for symptom control and terminal care, 94.1% and 76.5% of the time, respectively. All doctors surveyed perform home visits for terminally ill patients, and 68.4% make themselves routinely available after hours. Doctors surveyed estimated that they managed a mean of 8.4 deaths due to chronic illness in the past 12 months. Most (78.9%) said that they would continue to manage dying patients even if they had a choice, and they feel between moderately and very satisfied that they provide quality care. However, only 21.1% considered their undergraduate training in palliative medicine to be adequate, and all said that they would refer to a specialist service if it were available.
Conclusions: Generalist rural doctors not only treat many dying patients, but also provide a continuity of care that is rarely seen in other settings. Proposals of models for 'rural' palliative care should, therefore, take this unique setting into account. One such suggestion is given in this article.

Patterns of home and community care service delivery to culturally and linguistically diverse residents of rural Victoria
Bernadette M Ward, Karen S Anderson, Maria S Sheldon

Objective: To describe and compare patterns of Home and Community Care (HACC) utilisation among culturally and linguistically diverse (CALD) people and Australian-born residents of rural Victoria.
Design: The HACC Minimum Data Set provides information regarding levels of service provision and coverage in Victoria. Data from January to June 2002 were analysed to provide a profile of client characteristics and service usage in rural Victoria. Patterns of service utilisation were compared with the profile of the CALD population in the 2001 Census.
Results: The proportion of CALD residents who are HACC clients is consistent with demographic profiles. However, their extent of service usage is not consistent with patterns of use by Australian-born residents. HACC clients born in non-English-speaking countries, receive 35% less hours of HACC service than their Australian-born counterparts. HACC clients born overseas in English-speaking countries receive nine per cent less hours of HACC service than the Australian-born group (F = 8.9, P = 0.00). Both groups of overseas-born clients use a smaller range of HACC services (F = 1.9, P = 0.16).
Conclusion: Planners and service providers need to monitor levels of HACC service delivery among population groups to ensure that CALD population groups receive equitable levels of HACC services. The HACC Minimum Data Set is one source of data that can assist in this process.

Do health and medical workforce shortages explain the lower rate of rural consumers' complaints to Victoria's Health Services Commissioner?
Judith A Jones, John S Humphreys, Beth Wilson

Objective: To identify which explanations account for lower rural rates of complaint about health services ?(i) fear of consequences where there is little choice of alternative provider; (ii) a higher complaint threshold for rural consumers; (iii) lack of access to complaint mechanisms; or (iv) reduced access to services about which to complain.
Design: Ecological study incorporating consumer complaint, population and workforce distribution data sources.
Setting: All health care providers practising in Victoria.
Participants: De-identified records of all closed consumer complaints made to the Health Services Commissioner, Victoria, between March 1988 and April 2001 by Victorian residents (13 856 records).
Main outcome measures: Differences in the percentage of under-representation in complaint rates in total and for each of four categories of health services providers for different size communities.
Results: No consistent relationship was observed between community size and either degree of under-representation of complaints against any category of provider, or the proportion of serious or substantial complaints. Rural under-representation was highest (41%) for dentists, the provider category with the lowest proportion working in rural areas (17%), and lowest (18%) for hospitals, with the highest representation in rural areas (28% of beds). More rural complaints were about access issues (10.7% rural and 8.4% metropolitan).
Conclusions: Reduced opportunity to use health services due to rural health and medical workforce shortages was the best-supported explanation for the lower rural complaint rate. Workforce shortages impact on the quality of rural health services and on residents' opportunities to improve their health status.

Health needs in rural areas and the efficacy and cost-effectiveness of doctors and nurses
Ioannis M Vlastos, Antonios G Mpatistakis, Kalliopi K Gkouskou

Objective: Because of a lack of GPs in rural areas of Greece it is mandatory for junior doctors to offer medical service in those areas for a year. The aim of this study is to determine the possibility of replacement of internships with nurses and to suggest the most cost-effective way of covering health needs in remote areas.
Design: Regional survey.
Setting and participants: Patients of primary care offices in two remote areas of Crete, Greece within a year.
Main outcome measures: Comparative analysis of the level of preventive medicine (estimated by questionnaires) and health needs in the two areas. The reasons for visiting medical offices, references rates, percentages of glucose and blood pressure regulation are also studied.
Results: Prescription of drugs for chronic diseases and blood pressure counting were the main reasons for office visits (2868/4594). Respiratory track infections (364/4594) follow. Apart from the high percentages of uncontrolled patients with blood pressure (34%) and diabetes mellitus (14%) there is a high percentage of ignorance or wrong opinions concerning preventive medicine, for example only 63% knew the value of a pap test.
Conclusions: More than two-thirds of 'medical' visits in rural areas were for acts that nurses could easily do. The easy access to a junior doctor did not promote preventive medicine. Replacement of junior doctors with properly trained nurses cooperating with GPs responsible for greater regions would be more cost-effective than junior doctors improving health in rural areas. Legislation should change, mainly with regard to repeat prescriptions, in order to reduce house visits.