Journal Search

Journal Search - issue 2, 2006


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Paul Worley
1 PhD, Editor-in-Chief *


*Prof Paul Worley


1 Rural and Remote Health


30 June 2006 Volume 6 Issue 2


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ACCEPTED: 30 June 2006


Worley P.  Journal Search - issue 2, 2006. Rural and Remote Health 2006; 6: 612.


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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 Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Contents, 2006; 11: (2) Spring 2006 / Printemps 2006
Issue includes:

Feasibility of same day discharge after mini-laparotomy cholecystectomy - a simulation study in a rural teaching hospital
Somprakas Basu, Partha S Giri, Debabrata Roy

Objective: Open cholecystectomy is still widely practised, more so in the developing countries, due to the high cost of laparoscopic cholecystectomy. However, the long traditional postoperative stay (7-8 days) prevents rapid turnover and adds to the waiting list. The aim of this study was to evaluate whether mini-laparotomy cholecystectomy (MLC) can be done as a day surgery or extended day surgery in a rural setting
Methods: A nonrandomized, uncontrolled study was done prospectively at the North Bengal Medical College and Hospital. The subjects underwent mini-laparotomy cholecystectomy under general or epidural anesthesia. Postoperatively they were encouraged to be ambulant early and to accept oral fluids. In the evening they were assessed, by preset criteria, for fitness for discharge. None were actually discharged but were observed overnight and reassessed the next morning, by the same criteria, for any adverse effects that could have occurred had they actually been discharged on the same day. They were discharged after removal of stitches. Any complications of the surgery were also noted.
Results: Thirty-two patients (26 females, 6 males) formed the study group. General anesthesia was given in 19 cases and epidural in 13. Using the scoring system, 25 (78.1%) patients were considered fit for discharge on the evening of surgery. The most prominent reasons for non discharge were vomiting and pain. Re-evaluation on the following morning showed that 30 (93.75%) patients were in a position to be discharged. None showed any complication that would have required readmission. There were no significant complications pertaining to the procedure itself.
Conclusion: Mini-laparotomy cholecystectomy as day surgery or extended day surgery is feasible and a safe, well tolerated procedure in a wide range of age groups. It may be a good alternative to laparoscopic cholecystectomy in developing countries, where resources are limited and waiting lists are long.

Introducing a nurse practitioner: experiences in a rural Alberta family practice clinic
Trish Reay, Eileen M Patterson, Lisa Halma, Wesley B Steed

Objective: To report on the experiences of introducing a nurse practitioner (NP) into a rural physicians' clinic in Taber, Alberta.
Design: Case study, grounded theory qualitative approach.
Setting: A rural community-based family practice in Taber, Alberta.
Participants: Twenty relevant stakeholders, including physicians, office staff, Regional Health Authority health professionals and community members.
Method: Open-ended interviews supplemented with a patient survey, billing and work time records.
Main findings: Successful introduction of the NP in the Taber clinic relied on: 1) flexibility in the first stages of developing the role; 2) strong connections to key individuals outside the clinic to maintain integration with the community; 3) support and guidance provided by a mentor group who assisted in developing positive working relationships; and 4) cost sharing (matched with benefits) by the clinic and provincial health system for sustainability of the position.
Conclusions: The NP role in Taber was viewed positively by clinic physicians and other stakeholders because of high patient satisfaction with the NP, billing potential that surpassed salary costs, and increased integration of physician services with RHA initiatives.

Health promotion needs of women living in rural areas: an exploratory study
Elan C. Paluck, Marilee Allerdings, Kinda Kealy, Heather Dorgan

Objectives: To describe the types of health-promoting activities currently engaged in by women who live in rural communities, to explore perceived barriers and facilitators to staying healthy in rural communities, and to examine how these factors may differ for women throughout their adult life.
Design: Qualitative pilot study.
Participants and setting: Women aged 18 years and older living in a small rural community in Saskatchewan.
Method: Eight focus groups were conducted with a total of 44 participants who had been stratified into 3 age groups. Content analysis of the focus group transcripts was undertaken.
Main findings: Older women were more likely to report that they engage in a balance of activities to promote their physical and mental health. Middle and younger aged women, however, were more likely to engage in activities to promote their physical health, with less emphasis on their mental health. Among the 3 age groups, exercise and nutrition-related activities were most commonly reported. Social support and the "rural way of life" were the most commonly reported community supports available to these women. Younger women were more likely to discuss family commitments as a barrier to maintaining physical fitness, and older women discussed the impact that loneliness and lack of appropriate exercise options had on healthy living in their community.
Conclusion: The interviews provided a chance for a group of rural women to paint their own picture of promoting and maintaining their health in their own community. The activities engaged in by women to maintain their health, and the barriers and facilitators to staying healthy were different for women of different ages. It is useful for health planners to understand how women's health promotion needs vary across their adult life span.

Sealer's finger
Colin P White

The people of Newfoundland continue to make a living from the ocean, and the seal hunt is an occupation and source of livelihood for Newfoundlanders in many rural areas of the province. Occupational injuries have always been associated with this fishery. We present a case of sealer's finger (or seal finger) that was recently seen at a hospital in rural Newfoundland.


Journal of Rural Health

Contents: 2006; 22 (2)
Issue includes:

Expected Annual Emergency Miles per Ambulance: An Indicator for Measuring Availability of Emergency Medical Services Resources
P. Daniel Patterson, Janice C. Probst, Charity G. Moore

Context: To ensure equitable access to prehospital care, as recommended by the Rural and Frontier Emergency Medical Services (EMS) Agenda for the Future, policymakers will need a uniform measure of EMS infrastructure.
Purpose and Methods: This paper proposes a county-level indicator of EMS resource availability that takes into consideration existing EMS resources (ambulances), population health and demographics, and geographic factors. The indicator, the EXpected annual emergency miles per AMBulance (EXAMB), provides a basis for comparing ambulance availability across counties within states. A method for calculating the EXAMB indicator is demonstrated using data from 5 states.
Findings: The EXAMB indicator was negatively correlated with ambulance availability per 100,000 population in 4 of the 5 states in the study. The indicator was positively correlated with rurality in 3 states. In Mississippi, South Carolina, and Wyoming, whole-county health professional shortage areas had median EXAMB values 45%-81% higher than those of the non-health professional shortage areas counties.
Conclusions: Future research should explore the relationship of the EXAMB to EMS outcomes, with the ultimate goal of developing a nationally recognized indicator of "adequate" EMS resource availability.

Prevalence and Trends in Smoking: A National Rural Study
Mark P. Doescher, J. Elizabeth Jackson, Anthony Jerant, L. Gary Hart

Context: Cigarette smoking is the leading preventable cause of death in the United States.
Purpose: To estimate the prevalence of and recent trends in smoking among adults by type of rural location and by state.
Methods: Random-digit telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 (n = 342,055) and 2000-2001 (n = 385,384). The main outcome measure was current cigarette smoking, defined as persons who smoke every day or some days, while nonsmokers were those who smoke not at all or reported never having smoked as many as 100 cigarettes.
Findings: The prevalence of smoking changed little from the mid-1990s; in 2000-2001, it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural nonadjacent areas, and 24.9% in small rural nonadjacent areas. For rural locations combined, smoking prevalence was not below the 12% goal of Healthy People 2010 for any state, although the 12.5% prevalence in rural Utah approached this target. Prevalence was ≥28% for rural residents of Kentucky, Ohio, and Indiana. Since the mid-1990s, the prevalence of smoking for rural respondents decreased by more than 2 percentage points in 6 states: California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2 percentage points or more in 10 states: Alabama, Delaware, Georgia, Massachusetts, Michigan, Mississippi, New Hampshire, Oklahoma, South Carolina, and Texas.
Conclusions: Smoking remains a refractory public health problem. Better ways to curb smoking in rural America are needed.

Antitobacco Media Awareness of Rural Youth Compared to Suburban and Urban Youth in Indiana
Terrell W. Zollinger, Robert M. Saywell Jr, Amanda D. Overgaard, Michael J. Przybylski, Mohan Dutta-Bergman

Purpose: This study examined the awareness and impact of antitobacco media messages among rural, suburban, and urban youth.
Method: Self-administered questionnaires were received from 1,622, 1,059, and 1,177 middle school (sixth, seventh, and eighth grade) students in rural, suburban, and urban locations, respectively. Logistic regression compared media awareness and impact among the groups, controlling for grade, gender, race, and smoking behavior.
Results: Compared to rural youth, suburban youth were more likely to recall media messages about the dangerous health effects of tobacco use (odds ratio [OR] = 1.94) and have their personal choice to use tobacco affected by the messages (OR = 1.85). Suburban and urban youth more often recalled antitobacco messages (OR = 2.00 and 2.15), reported that the messages made them think about the dangers of tobacco use (OR = 2.02 and 1.47), believed that these ads prevent youth from initiating tobacco use (OR = 3.21 and 1.46) and stop youth from using tobacco (OR = 2.25 and 1.47), and recalled seeing specific campaign television ads (OR = 3.72 and 3.57). Urban youth were more likely to recall specific campaign messages on the radio (OR = 1.58). Neither suburban nor urban youth differed from the rural youth on whether the campaign-specific radio and television ads made them think about not using tobacco.
Conclusions: The results support the need for targeting antitobacco media announcements to youth, based on their residence.

Rural-Urban Differences in Colon Cancer Risk in Blacks and Whites: The North Carolina Colon Cancer Study
Anita Yeomans Kinney, Janna Harrell, Marty Slattery, Christopher Martin, Robert S. Sandler

Context: Geographic and racial variations in cancer incidence have been observed. Studies of colorectal carcinoma indicate a higher incidence and mortality rate for blacks than for whites in the United States.
Purpose: We evaluated the effect of rural versus urban residence on colon cancer risk and stage of disease at diagnosis in blacks and whites.
Methods: Interviews were conducted with 558 colon cancer cases and 952 controls enrolled in the North Carolina Colon Cancer Study, a population-based case-control study of blacks and whites residing in 33 contiguous counties.
Findings: Residence in a rural area was associated with increased colon cancer risk (odds ratio, 1.4; 95% confidence interval, 1.1-1.8). This association was no longer significant after controlling for recent use of colorectal cancer screening tests (odds ratio, 1.2; 95% confidence interval, 0.9-1.6). Risk estimates were not modified by race nor were they markedly different for extent of disease at diagnosis. However, colorectal cancer screening rates were lower for blacks than for whites.
Conclusion: Our findings suggest that rural blacks and whites are at increased risk of colon cancer regardless of stage of disease at diagnosis than their urban counterparts; this relationship may be mediated by screening behavior.

Psychosocial Differences Between Whites and African Americans Living With HIV/AIDS in Rural Areas of 13 US States
Bernadette Davantes Heckman

Context: Acquired immunodeficiency syndrome (AIDS) prevalence rates are increasing rapidly in rural areas of the United States. As rural African Americans are increasingly affected by human immunodeficiency virus (HIV), it is important to identify psychosocial factors unique to this group so that AIDS mental health interventions can be culturally contextualized to meet their unique needs.
Purpose: The current study characterized psychosocial functioning in 43 rural African Americans living with HIV/AIDS and compared their levels of functioning to those of 196 HIV-infected rural white persons. Methods: All participants were recruited through AIDS service organizations in 13 US states. Surveys were completed as part of a preintervention phase of a randomized clinical trial evaluating 2 mental health interventions for HIV-infected rural persons.
Findings: Compared to their white counterparts, fewer African Americans had progressed to AIDS. African American participants also reported higher levels of coping self-efficacy, more support from family members, and marginally fewer depressive symptoms, and they engaged in more active coping. African Americans who had greater HIV disease severity also received less support from family members and experienced more loneliness. Conclusions: Study findings caution that rural African Americans and whites living with HIV disease should not be considered a homogeneous group.

Geographic Access to Health Care for Rural Medicare Beneficiaries
Leighton Chan, L. Gary Hart, David C. Goodman

Context: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care.
Purpose: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington.
Methods: Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient's and the provider's zone improvement plan codes.
Findings: There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Rural residents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists.
Conclusions: Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.

Characteristics of Registered Nurses in Rural Versus Urban Areas: Implications for Strategies to Alleviate Nursing Shortages in the United States
Susan M. Skillman, Lorella Palazzo, David Keepnews, L. Gary Hart

Methods: This study compares characteristics of rural and urban registered nurses (RNs) in the United States using data from the 2000 National Sample Survey of Registered Nurses. RNs in 3 types of rural areas are examined using the rural-urban commuting area taxonomy.
Findings: Rural and urban RNs are similar in age and sex; nonwhites and Hispanics are underrepresented in both groups. Rural RNs have less nursing education, are less likely to work in hospitals, and are more likely to work full time and in public/community health than urban RNs. The more rural an RN's residence, the more likely he/she commutes to another area for work and the lower salary he/she receives.
Conclusions: Strategies to reduce nurse shortages should consider differences in education, work patterns, and commuting behavior among rural and urban RNs. Solutions for rural areas require understanding of the impact of the workplace on these behaviors.

Technology, Job Satisfaction, and Retention: Rural Mental Health Practitioners
Deborah Meyer

Context: Job satisfaction as it relates to retention of mental health professionals is a major problem in rural areas. Several authors have suggested that technology can positively influence job satisfaction and thus improve retention.
Objectives: This study examined technology use and technology expertise in relationship to job satisfaction. It is based on a theoretical framework that asserts as technology use increases, communication among providers and access to educational and consultative resources increase as well, resulting in a boost in professional support and a reduction in isolation.
Methods: Surveys were sent to 320 providers in rural southeast Ohio; 163 returned usable surveys. Findings: There was a statistically significant relationship between the combination of technology use and expertise and job satisfaction. Use alone, however, was not significant. Despite the fact that over 90% of respondents had access to both a computer and the Internet, just 45% used technology to communicate with peers and nearly 96% indicated that they never or rarely used the Internet for educational programs.
Conclusions: The results challenge the assertion that technology plays a major role in job satisfaction and rural retention since access and perceived expertise did not guarantee technology usage. Decisions to stay or leave a rural practice involve a complex array of factors. Technology, with its ability to link providers to resources outside the geographic bounds of an individual's practice, may play a role, but since its adoption can be costly in both time and money, future studies need to determine its place in the retention model.

Physical Activity Among Rural Older Adults With Diabetes
Thomas A. Arcury, Beverly M. Snively, Ronny A. Bell, Shannon L. Smith, Jeanette M. Stafford, Lindsay K. Wetmore-Arkader, Sara A. Quandt

Purpose: This analysis describes physical activity levels and factors associated with physical activity in an ethnically diverse (African American, Native American, white) sample of rural older adults with diabetes.
Method: Data were collected using a population-based, cross-sectional stratified random sample survey of 701 community-dwelling elders with diabetes completed in 2 rural North Carolina counties. Outcome measures were as follows: first, physical activity in the past year, and second, days physically active in the prior week (0-7). Potential correlates included personal and health characteristics and were evaluated for statistical significance using logistic regression models.
Findings: About half (52.5%) of the participants stated that they had engaged in physical activity in the past year. Among those, 42.5% stated that they had no days with at least 30 minutes of continuous physical activity in the prior week, while 21.5% reported daily physical activity. Common activities were walking and housework. Correlates of physical activity in the past year and days active in the prior week included measures of physical health and mobility.
Conclusions: Physical activity in this ethnically diverse sample of rural elders with diabetes is limited. Effort must be invested to increase physical activity in these groups.

Planning and Providing End-of-life Care in Rural Areas
Donna M. Wilson, Christopher Justice, Sam Sheps, Roger Thomas, Pam Reid, Karen Leibovici

Context: Approximately 20% of North Americans and 25% of Europeans reside in rural areas. Planning and providing end-of-life (EOL) care in rural areas presents some unique challenges.
Purpose: In order to understand these challenges, and other important issues or circumstances, a literature search was conducted to assess the state of science on rural EOL care.
Methods: The following databases were searched for articles published from 1988 through 2003: EMBASE, Medline, CINAHL, AHMED, Psychinfo, ERIC, HealthStar, Sociological Abstracts, and Cochrane. All articles were systematically reviewed.
Findings: Thirty-six research articles were identified. Only 1 randomized controlled trial was located. Most research was single site, small sample, and exploratory/descriptive in design. Four distinct foci in this body of research were noted: (1) identifying and describing differences between urban and rural EOL care; (2) exploring rural EOL care; (3) assessing the EOL needs and wishes of terminally ill or dying persons, their family members, and health care professionals in rural areas; and (4) exploring EOL education for rural EOL care providers.
Conclusions: Although rural EOL care research is not extensive, the existing literature is helpful for realizing the importance of EOL care in rural communities, as well as for conceptualizing and planning EOL care in rural communities. One of the chief considerations for rural EOL care is that dying at home is a common wish, with home-based nursing care a key factor for this to become a reality. Another chief consideration is ensuring all rural health care professionals are both prepared for and supported while delivering EOL care.

Family Perspectives on Pathways to Mental Health Care for Children and Youth in Rural Communities
Katherine M. Boydell, Raymond Pong, Tiziana Volpe, Kate Tilleczek, Elizabeth Wilson, Sandy Lemieux

Context: There is insufficient literature documenting the mental health experiences and needs of rural communities, and a lack of focus on children in particular. This is of concern given that up to 20% of children and youth suffer from a diagnosable mental health problem.
Purpose: This study examines issues of access to mental health care for children and youth in rural communities from the family perspective.
Methods: In-depth interviews were conducted in rural Ontario, Canada, with 30 parents of children aged 3-17 who had been diagnosed with emotional and behavioral disorders.
Findings: Interview data indicate 3 overall thematic areas that describe the main barriers and facilitators to care. These include personal, systemic, and environmental factors. Family members are constantly negotiating ongoing tension, struggle, and contradiction vis-à-vis their attempts to access and provide mental health care. Most factors identified as barriers are also, under different circumstances, facilitators. Analysis clustered around the contrasts, contradictions, and paradoxes present throughout the interviews.
Conclusions: The route to mental health care for children in rural communities is complex, dynamic, and nonlinear, with multiple roadblocks. Although faced with multiple roadblocks, there are also several factors that help minimize these barriers.

The Characteristics of Successful Family Physicians in Rural Nebraska: A Qualitative Study of Physician Interviews
Elisabeth L. Backer, Helen E. McIlvain, Paul M. Paulman, Ryan C. Ramaekers

Context: In studying physician shortage issues, few studies have utilized individual interviews, allowing rural physicians to voice their own stories.
Purpose: To explore rural physicians' unique characteristics affecting their decisions and satisfactions with practice in a rural area.
Methods: A qualitative interview study with 11 Nebraska family physicians practicing in rural (frontier) areas.
Findings: Previous experience and preference for a rural lifestyle, desire for autonomy, a wide scope of practice, and close relationships with patients defined those physicians choosing rural practice.


Australian Journal of Rural Health

2006; 14 (3)
issue includes:

Australian issues in the provision of after-hours primary medical care services in rural communities
Kathryn Zeitz, Geri Malone, Paul Arbon, Jenny Fleming

Objective: In 2003 the Rural Doctors Workforce Agency in South Australia (SA) facilitated the 'SA Rural Hospital After Hours Triage Education and Training Program'. It was designed to improve communication between rural general practitioners (GPs) and nurses undertaking after-hours triage, provide training in triage for rural nurses and develop local collaborative after-hours primary medical care models that can be applied in other settings.
Design: The program consisted of a series of three workshops. The first workshop provided an opportunity for GPs and nurses to discuss local issues relating to after-hours primary medical care service delivery. This was followed by a one-day workshop on triage for nurses. A follow-up refresher workshop was conducted approximately six months later.
Setting: Twenty-three rural communities in SA.
Participants: Rural GPs and nurses working in rural communities.
Results: This paper reports on the issues highlighted by clinicians in providing after-hours primary medical care in rural and remote communities. These included community expectations, systems of care, scope of practice, private practice/public hospital interface, and medico legal issues.
Conclusion: The issues facing after-hours health services in rural communities are not new. There are many opportunities for improvement of systems. A formal program including workshops and training has provided a useful forum to commence service improvements.

Far West Area Health Service Mental Health Integration Project: Model for rural Australia?
David A. Perkins, Russell Roberts, Tuana Sanders, Alan Rosen

Objective: To see if a new model of service delivery ensures that individuals with a mental illness in rural and remote settings could be assessed, treated and cared for in a more appropriate way.
Design: Community mental health teams (CMHTs), general practitioners (GP) and other agencies were provided with clinical and broader support services by consultant psychiatrists from public and private sectors. The occasions of service were logged, audited and relevant provider groups were interviewed. Ethics approval was provided by Human Research Ethics Community of University of New South Wales.
Setting: Far West Area Health Service (FWAHS), remote New South Wales.
Participants: An enhanced service was provided for residents, specialist mental health and other healthcare providers.
Results: Regular access to psychiatrists for primary and secondary care was achieved in remote communities in FWAHS. 3908 new patients were seen by CMHTs between July 2002 and December 2003 and 380 by visiting psychiatrists between January 2002 and July 2003. Secondary consultation, mentoring and education opportunities were made available by tele-conference and face-to-face for CMHTs and others in FWAHS. GPs and CMHTs in remote settings were satisfied with improved access to psychiatrist care.
Conclusions: This model appears to be sustainable with reasonable levels of funding in FWAHS and may be applicable to other remote contexts.

Maternity emergency care: Short course in maternity emergencies for remote area health staff with no midwifery qualifications
Sue Kildea, Sue Kruske, Libby Bowell

Objective: To improve the maternity emergency skills and knowledge of health service providers, without midwifery qualifications, in remote Australia.
Design: A descriptive paper utilising data from a needs assessment and course evaluations used to develop and refine a short course in maternity emergencies.
Subjects: Remote area health providers.
Interventions: A multidisciplinary short course, targeting non-midwives in remote areas, aimed at improving knowledge and skills in detection, management and referral of maternity emergencies.
Results: Ten courses have been delivered to 175 participants. Evaluations demonstrate a highly valued program, well received and supported by remote health staff.
Conclusions: The course is an important strategy to improve the maternity services offered to women in remote Australia.

Rural pharmacy not delivering on its health promotion potential
Bruce Sunderland, Suzanne Burrows, Andrew Joyce, Alexandra McManus, Bruce Maycock

Objective: To investigate the level and perceived quality of health promotion advice received from rural pharmacists.
Design: Self-administered written survey on access to and quality of pharmacy services in rural Western Australia completed by rural residents.
Setting: Rural pharmacy.
Participants: Four hundred and eighty-three respondents who regularly used a pharmacy.
Outcome measures: Items in the survey included frequency of receiving prevention advice and satisfaction ratings on health and pharmacy services.
Results: Eighty-eight per cent of respondents had never discussed exercise or diet with their pharmacist and 65% had never discussed preventing health problems. Receiving good prevention advice predicted satisfaction with health services in general but not satisfaction with pharmacy services.
Conclusion: Pharmacies are being underutilised with respect to their capacity to deliver heath prevention advice and ways to capitalise on this potential need to be investigated.

Patterns of drug use and associated harms among rural injecting drug users: Comparisons with metropolitan injecting drug users
Carolyn Day, Elizabeth Conroy, Julia Lowe, Jude Page, Kate Dolan

Objective: Given the harms associated with injecting drug use to both individuals and community and the paucity of such data from rural areas, the study aimed to compare: patterns of drug use, harms, and service access and utilisation among rural and metropolitan injecting drug users (IDU).
Design: Cross-sectional survey, using interviewer-administered structured questionnaire.
Participants: One hundred and sixty-four rural and 96 metropolitan IDU from seven different New South Wales Area Health Services, recruited through needle and syringe programs (NSPs), snowballing techniques and advertisement.
Results: Age, gender, education and employment were similar for rural and metropolitan participants. Both samples reported use of a range of drugs, but rural participants were less likely than metropolitan participants to report daily heroin use (2% vs 10%), but more likely to report having injected morphine (50% vs 21%) in the last six months. Similar proportions reported using a needle/syringe after another person. Rural participants were less likely to report use of NSPs (36% vs 80%) and reported a number of barriers to NSP access and also to drug treatment services. Rural participants reported a significantly longer period of time between blood-borne virus testing.
Conclusion: Samples of rural IDU are similar to metropolitan, although report some differences in patterns of drug use. Service provision, including access to new injecting equipment, blood-borne virus testing and drug treatment was found to cause considerable problems for rural IDU. These issues warrant further consideration.

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