Journal Search

Journal Search - issue 4, 2006


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Paul Worley
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21 December 2006 Volume 6 Issue 4


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Worley P.  Journal Search - issue 4, 2006. Rural and Remote Health 2006; 6: 708.


© Paul Worley 2006 A licence to publish this material has been given to ARHEN,

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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: (4) Fall 2006 / Automne 2006
Issue includes:

Prevalence of violence against women reported in a rural health region
Wilfreda E. Thurston, Scott Patten, Laura E. Lagendyk

Introduction: Violence against women in Canada is an important public health problem. Published research that reports prevalence of violence against women by province or region is limited, and estimates of the rates of violence experienced by rural women are sparse.
Methods: This study reports the results of a secondary analysis of data to examine the prevalence of physical and sexual assault reported by women in a rural health region in Alberta, Canada. The report of assault was then examined to determine its relationship to self-reported health conditions, behaviours and health service use.
Results: In this study, 5% of women reported experiencing physical assault in the last 12 months and 23% reported experiencing sexual assault in their lifetime. Younger women reported more assault than older women. Women who reported sexual assault were more likely to report having used illicit drugs. Women who reported physical assault within the last 12 months were significantly more likely to also report having accessed mental health services and emergency services within the past year. Most women had seen a general practitioner or family doctor within the last 12 months.
Conclusion: We argue that an integrated community-based model of service that includes the health sector is necessary to address violence against women in rural areas.

Spousal perspectives on factors influencing recruitment and retention of rural family physicians
Erin Mayo, Maria Mathews

Introduction: Recruiting and retaining medical personnel to rural communities is a human resource challenge. Studies suggest that the spouse's experiences and perceptions of a rural community are among the most influential factors in a physician's decision to remain in or leave a rural practice. This study describes the factors that both directly and indirectly influence spousal contentment and explores how these factors contribute toward recruitment and retention of physicians to rural practice locations.
Methods: In this explorative study, 13 interviews were conducted with spouses of rural physicians to gain a better understanding of spousal concerns and experience regarding rural living. Participants in the present study included the spouses of general practitioners and family physicians practising and living in rural communities (population ≤10 000) on the Burin and Bonavista peninsulas of Newfoundland and Labrador. Specialists, residents and locums were excluded from the study.
Results: The findings indicate that physician workload and community integration most highly influence spousal contentment. Other factors, including licensure, remuneration and physician demand, indirectly influence spousal contentment and, ultimately, practice location decisions. Many of the factors that directly influence spousal contentment are personal, and, as a result, it is difficult to implement policies that will influence them.
Conclusion: The physician's spouse is highly influential in the decision to move to, remain in, or leave a rural practice location. Understanding the factors that contribute to, and detract from, spouses' contentment in rural practice offers useful insights for human resource policies.

Educational needs of Australian rural and remote doctors for intermediate obstetric ultrasound and emergency medicine ultrasound
Roz Glazebrook, Dan Manahan, A. Bruce Chater

Introduction: The aim of this research was to determine the educational needs of Australian rural and remote doctors for intermediate obstetric ultrasound and emergency medicine ultrasound. The main research questions were: what educational topics would rural and remote doctors prefer to learn about in intermediate obstetric ultrasound and emergency medicine ultrasound, and what were those doctors' preferred methods of delivery for an ultrasound education program.
Method: A self-administered postal questionnaire containing a pre-paid return envelope was mailed to 344 Australian rural and remote doctors in December 2003.
Results: 107 completed questionnaires were returned, giving a response rate of 32.7%. This was after the denominator was adjusted for the 17 doctors whose letters were returned to sender. The respondents included 23 (21.5%) female and 84 (78.5%) male doctors. Eighty doctors (74.8%) stated that they used ultrasound, and 27 (25.2%) said they did not. Seventy-seven (72%) indicated they had previously participated in some ultrasound education and training.
The respondents stated that their main areas of educational need in intermediate obstetric ultrasound were ectopic pregnancy (76.6%), miscarriage (72%), intrauterine growth restriction (65.4%), transvaginal scanning (47.7%), detecting fetal abnormalities (47.7%) and morphology scanning at 18-20 weeks (41.1%).
The main areas of educational need in emergency medicine ultrasound were focused abdominal sonography in trauma (63.5%), detecting foreign bodies (40.2%), gynecological ultrasound (39.2%), gall bladder and biliary tract (37.4%), abdominal aortic aneurysm (32.7%) and trauma bleeding (31.7%).
Conclusion: Australian rural and remote doctors are using ultrasound technology to improve the clinical investigation and diagnosis of a large variety of clinical conditions in their family medical practices. This paper describes the results of research into the educational needs of this target group of doctors.

Elevated liver enzymes as a predictor of liver injury in stable blunt abdominal trauma patients: case report and systematic review of the literature
Alec H. Ritchie, David M. Williscroft

Liver injury secondary to blunt abdominal trauma is a well-defined entity in emergency medicine. A challenge exists in the diagnosis of liver trauma in the stable, well-appearing patient with a history of blunt abdominal trauma. In centres lacking advanced diagnostic modalities an elevation in hepatic transaminases may provide guidance for the rural emergency physician in seeking further imaging and/or surgical consultation. We present a case report and a discussion of the literature.
The literature provided a broad spectrum of results. There appears to be a direct relationship between blunt liver trauma and elevation in liver transaminases. These results are especially evident in the pediatric population. Our findings may help guide the rural emergency physician in transfer and disposition decisions in patients in this situation.


Journal of Rural Health

Contents: 2006; 22: (4)
Issue includes:

The Visiting Specialist Model of Rural Health Care Delivery: A Survey in Massachusetts
Jacob Drew, Suzanne B. Cashman, Judith A. Savageau, Joseph Stenger

Context: Hospitals in rural communities may seek to increase specialty care access by establishing clinics staffed by visiting specialists.
Purpose: To examine the visiting specialist care delivery model in Massachusetts, including reasons specialists develop secondary rural practices and distances they travel, as well as their degree of satisfaction and intention to continue the visiting arrangement.
Methods: Visiting specialists at 11 rural hospitals were asked to complete a mailed survey.
Findings: Visiting specialists were almost evenly split between the medical (54%) and surgical (46%) specialties, with ophthalmology, nephrology, and obstetrics/gynecology the most common specialties reported. A higher proportion of visiting specialists than specialists statewide were male (P = .001). Supplementing their patient base and income were the most important reasons visiting specialists reported for having initiated an ancillary clinic. There was a significant negative correlation between a hospital's number of staffed beds and the total number of visiting specialists it hosted (r = −0.573, P = .032); study hospitals ranged in bed size from 15 to 129.
Conclusions: The goal of matching supply of health care services with demand has been elusive. Visiting specialist clinics may represent an element of a market structure that expands access to needed services in rural areas. They should be included in any enumeration of physician availability.

Graduated Drivers License Programs and Rural Teenage Motor Vehicle Fatalities
Michael A. Morrisey, David C. Grabowski

Context: Graduated drivers license (GDL) programs have been shown to reduce motor vehicle fatalities among 15- to 17-year-olds. However, the 20 most rural states have been the least likely to enact more stringent GDL policies.
Purpose: Estimate the relationship of GDL programs and the number of traffic fatalities among 15- to 17-year-olds on rural interstate and noninterstate roadways.
Methods: Analysis of 1992-2002 Fatality Analysis Reporting System data and a compendium of state laws using a conditional negative binominal regression model with full fixed effects to control for unobservable differences across states and years.
Findings: Overall, GDL programs were associated with a 7.8% reduction in rural traffic fatalities among 15- to 17-year-olds. Virtually all of this reduction took place on noninterstate roadways. The most stringent GDL programs were associated with a nearly 22% reduction in this age group and were the only programs associated with reductions in fatalities among 15- to 17-year-old drivers.
Conclusions: Rural states should consider enacting stringent GDL programs. Had the 19 of the 20 most rural states without such programs all adopted the most stringent GDL programs in 2002, the analysis suggests that 64 traffic deaths among 15- to 17-years-olds could have been prevented.

Nonfatal All-Terrain Vehicle-Related Injuries to Youths Living on Farms in the United States, 2001
E. Michael Goldcamp, John Myers, Kitty Hendricks, Larry Layne, Jim Helmkamp

Context: Use of all-terrain vehicles (ATVs) in agriculture appears to be growing.
Purpose: To provide estimates of ATV ownership and exposure on US farms and an overview of injuries to youths as a result of ATV use on the farm in 2001.
Methods: Analysis of the National Institute for Occupational Safety and Health and US Department of Agriculture 2001 Childhood Agricultural Injury Survey. These data, collected via telephone surveys, provide information on nonfatal injuries that occurred to youths younger than 20 years living on US farms during 2001. The injuries included both occupational and nonoccupational incidents.
Findings: Of an estimated 1.1 million youths living on farms, 36% had operated an ATV in 2001. Youths younger than 16 years were more likely to have operated an ATV than a tractor on these farms. An estimated 2,246 nonfatal ATV-related injuries occurred to youths younger than 20 years on US farms during 2001. The majority of these ATV injuries (1,668, 74%) occurred to youths identified as members of the household. Males accounted for 1,145 (69%) of the ATV injuries to household youths. The majority of the injuries were to youths aged 10-15 years (1,170, 70%). Most ATV injuries were the result of recreational activities (970, 58%). In addition, many of these injury events involved youths riding without helmets and using ATVs that were larger than the recommended size for their age.

Personal Protective Equipment Use and Safety Behaviors Among Farm Adolescents: Gender Differences and Predictors of Work Practices
Deborah B. Reed, Steven R. Browning, Susan C. Westneat, Pamela S. Kidd

Context: Children on farms perform work that places them at risk for acute and chronic negative health outcomes. Despite strategies for preventing and reducing the risk of disease and injury, children's use of personal protective equipment and safely equipped farm machinery has generally remained unreported. Purpose: This paper reports the use of personal protective equipment, self-protective work behaviors, and selected risk exposures of children aged 14-19, who perform farm work.
Methods: Survey results of adolescent high school students (n = 593) enrolled in agriculture class in Kentucky, Iowa, and Mississippi. Students were part of the sample that participated in the Agricultural Disability Awareness and Risk Education Project.
Findings: Boys were at a significantly higher risk of exposure compared to girls, and boys engaged more frequently in risky behavior. Hearing and respiratory protection was used minimally and sporadically. Physical symptoms influenced use of hearing and respirator use, as did physician recommendation to use such protection. Of students who operated farm tractors, only half most frequently operated tractors with safety bars and seat belts. Sixty percent of the students reported using equipment with damaged or missing safety shields.
Conclusions: In addition to the usual risks of farm work, adolescents may be at even greater risk by not using personal protective equipment or not having access to machinery that is properly equipped for maximum protection. Health care providers should incorporate advice to adolescents and their parents on risk reduction, particularly on the use of personal protective equipment.

Pharmacist Staffing, Technology Use, and Implementation of Medication Safety Practices in Rural Hospitals
Michelle M. Casey, Ira S. Moscovice, Gestur Davidson

Context: Medication safety is clearly an important quality issue for rural hospitals. However, rural hospitals face special challenges implementing medication safety practices in terms of their staffing and financial and technical resources.
Purpose: This study assessed the capacity of small rural hospitals to implement medication safety practices, with particular focus on pharmacist staffing and the availability of technology.
Methods: A telephone survey of a national random sample of small rural hospitals was conducted from March to May 2005 (N = 387 hospitals, 94.6% response rate). Survey respondents included pharmacists (89%) and directors of nursing (11%). Multivariate analyses examined the relationships between hospital organizational and financial variables and (1) the amount of pharmacist staffing; (2) use of pharmacy computers for medication safety activities; and (3) implementation of medication safety practices.
Findings: Many small rural hospitals have limited hours of on-site pharmacist coverage. Almost one quarter of hospitals either do not have a pharmacy computer or are not using it for clinical purposes. Half of the hospitals have implemented 4 key medication safety practices. Level of pharmacist staffing, use of technology, and implementation of medication safety practices are significantly related to hospital financial status and accreditation.
Conclusions: Implementation of protocols related to medication use and key medication safety practices are areas where small rural hospitals could improve. The study results support a continuation of Medicare cost-based reimbursement policies to help ensure financial stability and support quality and patient safety activities in small rural hospitals.

General Surgery Programs in Small Rural New York State Hospitals: A Pilot Survey of Hospital Administrators
Randall Zuckerman, Brit Doty, Michael Gold, James Bordley, Patrick Dietz, Paul Jenkins, Steven Heneghan

Context: Hospitals play a central role in small rural communities and are frequently one of the major contributors to the local economy. Surgical services often account for a substantial proportion of hospital revenues. The current shortage of general surgeons practicing in rural communities may further threaten the financial viability of rural hospitals and communities.
Purpose: To describe hospital administrators' perceptions regarding the current state of general surgery programs at small rural hospitals in New York State, including the impact that surgical services have on hospital financial viability.
Methods: A list of hospitals belonging to the rural hospitals group of the Healthcare Association of New York State was obtained to determine prospective survey recipients. Sixty-eight administrators at each of the identified hospitals were subsequently surveyed and 38 respondents met all inclusion criteria. Findings: Approximately 87% of hospital administrators perceive that the general surgery program is critical to the hospital's financial viability. Forty percent of respondents report that they would be forced to close the hospital if the surgical program was lost. Among the 42% of administrators trying to recruit a general surgeon, almost two thirds have been searching for more than 1 year.
Conclusions: According to the perceptions of hospital administrators, the financial viability of rural hospitals in New York State depends in large part on their ability to provide surgical services. Additionally, general surgeons appear to be in high demand at a significant number of the surveyed institutions.

Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients
Scott J. Adams, Stanley Xu, Fran Dong, John Fortney, Kathryn Rost

Context: Federally qualified health centers across the country are adopting depression disease management programs following federally mandated training; however, little is known about the relative effectiveness of depression disease management in rural versus urban patient populations.
Purpose: To explore whether a depression disease management program has a comparable impact on clinical outcomes over 2 years in patients treated in rural and urban primary care practices and whether the impact is mediated by receiving evidence-based care (antidepressant medication and specialty care counseling).
Methods: A preplanned secondary analysis was conducted in a consecutively sampled cohort of 479 depressed primary care patients recruited from 12 practices in 10 states across the country participating in the Quality Enhancement for Strategic Teaming study.
Findings: Depression disease management improved the mental health status of urban patients over 18 months but not rural patients. Effects were not mediated by antidepressant medication or specialty care counseling in urban or rural patients.
Conclusions: Depression disease management appears to improve clinical outcomes in urban but not rural patients. Because these programs compete for scarce resources, health care organizations interested in delivering depression disease management to rural populations need to advocate for programs whose clinical effectiveness has been demonstrated for rural residents.

The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural America
Joseph P. Weingarten Jr, Susan Brittman, Wenrong Hu, Chris Przybyszewski, Judith M. Hammond, Dawn FitzGerald

Context: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level.
Purpose: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities.
Methods: Medicare beneficiaries with diabetes aged 18-75 were identified from Part A and Part B claims data from 1999 to 2001. A composite of 3 diabetes care indicators was assessed (annual hemoglobin A1c test, biennial lipid profile, and biennial eye examination).
Findings: Over 77% had a hemoglobin A1c test, 74% a lipid profile, and 69% an eye examination. Patterns of care were considerably different across the urban-rural continuum at the state, Census division, and regional levels. States in the northern and eastern portions of the country had higher indicator rates for rural than for urban residents. States in the South had much lower rates for rural residents than their urban counterparts. Despite these within-state differences, across-state comparisons found that several states tended to have low indicator rates in every level of the urban-rural continuum. A common feature of these states was the relatively high concentration of nonwhite beneficiaries. For example, southern states had much higher concentrations of nonwhite beneficiaries relative to other areas in the country and demonstrated low rates in every level of the urban-rural continuum.
Conclusions: Urban-rural quality of care differences may be a function not just of
geography but also of the presence of a large nonwhite population.

Comparison of Rural and Urban Residents' Implicit and Explicit Attitudes Related to Seeking Medical Care
Beverly L. Harju, Karl L. Wuensch, Emily A. Kuhl, Natalie J. Cross

Context: The decision whether or not to consult a physician draws from a variety of attitudes within an individual's health schema. While rural Americans are in greater need of health care, many of them have fewer external resources than urbanites available to them.
Purpose: The objective of this study was to elicit implicit and explicit attitudes related to seeking medical treatment for a condition described as fairly serious. Participants were asked to rate how often they comply with treatment regimens and practice good health habits.
Methods: The sample of rural (N = 586) and urban (N = 433) North Carolina residents was derived based on random-digit dialing. Multiple regression analyses were performed to investigate how attitudes associated with perceived compliance and health behaviors.
Findings: While rural and urban residents offered very similar responses, the associations between attitudes and behaviors were different. One healthy and 2 unhealthy schema patterns emerged. First, fear of hospitals was associated with effective compliance for rural residents and good health habits for urbanites. Second, affordability concerns were ascribed to rural community residents but seemed to reflect personally relevant implicit attitudes since they were associated with poor health adherence and habits for rural residents. Third, mistrust of doctors predicted low adherence for both groups and was also associated with poorer health habits for urbanites. With inconsistencies among implicit and explicit attitudes and behaviors, some residents seemed to be ambivalent about seeking health care.

Concordance of Patient-Physician Obesity Diagnosis and Treatment Beliefs in Rural Practice Settings
Andrea Charbonneau Ely, K. Allen Greiner, Wendi Born, Sandra Hall, Paula C. Rhode, Aimee S. James, Nicole Nollen, Jasjit S. Ahluwalia

Context: Although clinical guidelines recommend routine screening and treatment for obesity in primary care, lack of agreement between physicians and patients about the need for obesity treatment in the primary care setting may be an unexplored factor contributing to the obesity epidemic.
Purpose and Methods: To better understand this dynamic, we surveyed 439 obese patients (body mass index ³30) at the time of clinic visits in 2003 at diverse primary care settings in rural Kansas and conducted same-day interviews with their physicians (N = 28). We used Spearman's correlation to describe and compare patient and physician responses.
Findings: Most patients were women (66%). Their mean age was 55.8 years, and mean body mass index was 37.7. Half (51%) reported discussing their weight on that visit date. Overall, 51% of patients wanted to discuss weight more often with their physician and 54% wanted to discuss weight sooner. Patients and physicians gave similar assessments of the patient's preference for discussing weight loss, how often weight was discussed at visits, and the patient's motivation for weight loss. Spearman's correlations on these variables were .33, .54, and .25, respectively (all P < .001).
Conclusions: These patients and their physicians demonstrated a weak to moderate agreement on several variables crucial to initiating and continuing obesity care. Understanding patient and provider beliefs and preferences regarding obesity diagnosis and treatment is essential in designing obesity interventions for primary care.

Preventive Care in Appalachia: Use of the Theory of Planned Behavior to Identify Barriers to Participation in Cholesterol Screenings Among West Virginians
Shelli Deskins, Carole V. Harris, Andrew S. Bradlyn, Lesley Cottrell, Jessica W. Coffman, Julie Olexa, William Neal

Context: West Virginians are at increased risk for heart disease. Given that the process of atherosclerosis begins in childhood, the Coronary Artery Risk Detection in Appalachian Communities Project was developed to reduce this risk by implementing a cholesterol screening program in the schools. However, participation rates have been less than desired.
Purpose: This study examined the barriers to participation in preventive health screenings, specifically cholesterol screenings, in adults and children of West Virginia using the theory of planned behavior to guide conceptualization.
Methods: A total of 14 community leaders, 36 parents, and 92 fifth-grade children from 6 West Virginia counties with predominately rural populations participated in individual and focus group interviews. Qualitative analysis was used to examine interview transcripts.
Findings: Adult and child attitudes about preventive care were the largest barrier to cholesterol screenings. Adult attitudinal barriers included concerns with outcomes of testing, lack of knowledge about cholesterol and heart disease, concerns about needles, and traditional Appalachian cultural beliefs (resistance to change, denial, and fatalism). Children cited concerns about needles, outcomes of testing, privacy, and lack of concern about health and cholesterol. Adults also acknowledged environmental barriers to screenings. Finally, children reported a lack of social pressure to participate in prevention activities.
Conclusions: Attitudinal, social normative, and environmental barriers to health screenings may be characteristic of impoverished rural Appalachians. Interventions are being designed to target these belief barriers to improve participation in cholesterol screenings for fifth graders.


Australian Journal of Rural Health

2006; 14: (5)
issue includes:

Housing and health in Indigenous communities: Key issues for housing and health improvement in remote Aboriginal and Torres Strait Islander communities
Ross S. Bailie, Kayli J. Wayte

Indigenous people living in remote communities face some particular difficulties with regard to housing and its impact on their health. This paper reviews the contemporary international understanding of the relationship between housing and health, the history of settlement and housing conditions in remote Aboriginal and Torres Strait Islander communities, and some of the recent initiatives to improve housing in these communities.

Partnerships in specialty care: Exploring rural haemophilia provider resource needs
Andrea M. Pritchard , Marlene Reimer , Kari Simonson and Kathleen Oberle

Objective: The purpose of this study was to determine whether rural providers have adequate preparation for safe and effective haemophilia care.
Design: This qualitative study proceeded in two phases: focus group (phase I) and telephone (phase II) interviews.
Setting: Five Canadian rural hospitals served by one urban haemophilia treatment centre and providing service to at least one haemophilia family.
Participants: Phase I: focus groups of rural health professionals (site 1: n = 5; site 2: n = 6), including nursing, medicine and lab technology. Phase II: telephone interviews with nine participants from nursing, medicine, lab technology, social work and physiotherapy across three sites.
Main outcome measures: Qualitative content analysis yielded categorical themes for specialty care resource requirements in a rural context.
Results: Resource needs reflected five main categories: communication network, subjective knowledge, team roles, objective knowledge and partnerships (C-STOP).
Conclusions: The five C-STOP categories require resources and alignment of urban specialist, rural provider and family expertise. Specialty clinic efforts promoting self-care are incomplete without matched resources for rural providers.

Motorcycle deployment and rider characteristics on Victorian farms
Lesley Day , Voula Stathakis and Mary O'Hare

Objective: To describe the motorcycle fleet and rider characteristics on Victorian farms.
Design: Cross-sectional postal survey.
Setting: Victorian agricultural industries.
Participants: A total of 1382 randomly selected farmers in 2001.
Main outcome measures: Farm motorcycle characteristics, use and maintenance schedule; motorcycle rider characteristics, respondent demographics and property characteristics.
Results: A total of 70% of farms had motorcycles, with an average of 1.7 per property. A total of 49% were four-wheel, and 44% were two-wheel. The average engine size and age were 255 cc and 8.8 years, respectively. The milk cattle sector owned the largest share of the motorcycle fleet and cereal/grain farms the smallest share. Four-wheel motorcycles were often used across the entire spectrum of agricultural tasks. Two-wheel motorcycle use was concentrated more on mustering and transport. A total of 61% of farms performed motorcycle maintenance every 1-6 months. Fifteen per cent of riders were under 15 years of age, and the majority (71%) rode four-wheel motorcycles. A total of 29% of all riders had received some form of motorcycle training.
Conclusions: This study provides useful information on state-level patterns of farm motorcycle use, as well as the key safety behaviours of rider training and motorcycle maintenance. This information might serve as baseline data for future monitoring and surveillance, and might assist with planning of prevention programs.

Impact of support initiatives on retaining rural general practitioners
Maria Gardiner, Roger Sexton, Hugh Kearns and Kelly Marshall

Objective: This study aimed to evaluate the impact of the Dr DOC program, a rural doctor workforce support program, which consists of social and psychological support and practical interventions, on the well-being and retention of rural GPs.
Design: Rural GPs were assessed on different aspects of well-being and their intentions to leave rural general practice, and these were compared with similar data collected two years prior.
Setting: Rural general practices in South Australia.
Participants: Two hundred and twenty-one rural GPs (55% of South Australian rural GP workforce).
Main outcome measures: GPs completed a questionnaire assessing their levels of support, intention to leave rural practice, use of the Dr DOC program, and psychological health.
Results: Improvements were found in the support networks and in the physical and emotional health of rural GPs from time 1 to time 2. There was also a reduction in the number of GPs wanting to leave rural general practice in the short to medium term (from 30% to 25%).
Conclusions: The initial study in this series suggested that improving psychological well-being might influence rural GPs' intentions to leave rural practice. The current study confirms these suggestions by demonstrating that programs targeted at psychological and physical well-being do indeed impact on rural GPs' intentions to leave. The results of this study highlight the role of psychological well-being in retaining rural GPs and emphasise the value of developing psychologically based programs to not only boost the physical and mental health of GPs, but also to reduce departure from rural areas.

Small-area estimates of general practice workforce shortage in rural and remote Western Australia
Jessica Scott, Ann Larson, Felicity Jefferies, Bert Veenendaal

Objective: To trial a measure of rural and remote GP access for small areas.
Design: A cross-sectional study using geographical information systems software to calculate GP to population rates with a floating catchment of 100 km radius around census collection districts (CCDs).
Setting: Non-metropolitan Western Australia.
Participants: The locations and full-time equivalents of GPs and other primary-care doctors were identified through a GP workforce survey.
Main outcome measures: GP to population ratios for each CCD were classified as being above or below a benchmark of adequate GP access. CCDs with no GP sessions reported within 100 km were identified separately. These categories were investigated by divisions of general practice and by indigenous status, age and employment characteristics of the population.
Results: Small-area estimates detected greater variation in access than depicted by conventional methods. Sixty-four per cent of the non-metropolitan population live in CCDs with adequate GP access. Forty-five per cent of indigenous people and 52% of people working in rural industries live in CCDs with access below the benchmark.
Conclusions: The floating catchment method is a powerful tool to identify small areas of inadequate service. It can be applied to measure access to other professionals, medical equipment or facilities.

Factors affecting the recruitment and retention of pharmacists to practice sites in rural and remote areas of New South Wales: A qualitative study
Anthony Harding, Paula Whitehead, Parisa Aslani, Timothy Chen

Objective: To explore factors affecting recruitment and retention of pharmacists in rural/remote areas of New South Wales (NSW).
Design: Qualitative semistructured in-depth interviews.
Setting: Primary care - rural/remote community pharmacies.
Participants: Purposive sample of 12 community pharmacists.
Main outcome measures: Factors affecting recruitment and retention of pharmacists in rural/remote areas of NSW.
Results: Respondents reported a variety of personal and professional reasons for taking up rural practice, including previous rural experience and a preference for working in rural over metropolitan areas. The main factor affecting retention in rural areas was the high level of professional satisfaction and interprofessional rapport. Perceived reasons for the current under-supply of pharmacists to rural/remote areas of NSW included changing demographics of the pharmacy undergraduate degree programs and pharmacy workforce, and negative perceptions of rural pharmacy practice and rural lifestyle.
Conclusions: This study identified factors believed to affect recruitment and retention of pharmacists in rural/remote areas. There appears to be considerable overlap between the factors, with different weightings of importance for different individuals. The lack of consensus for a proposed method of resolving this problem highlights its complexity and the need for further studies in this area.

Wagga Wagga specialist outreach palliative medicine service: A report on the first 12 months of service
Andrew Broadbent and Jenny McKenzie

Objective: This paper reports on and discusses the development of a visiting palliative medicine specialist outreach service for Wagga Wagga New South Wales, Australia, and presents initial data and three case vignettes for reflection. The visiting doctor was flown from Sydney each fortnight for a day and integrated with the local nursing based palliative care team.
Methods: Demographic data was collected over the initial 12 months of service, which included the location of the consult (hospital, home, nursing home), whom the consult was from (specialist, GP), age of the patient, location of death, type of cancer, as well as the complexity of consultation from the perspective of one of the authors.
Results: The majority of referrals were for advice on cancer pain control (62.3%) and other symptoms (26.7%) confirming the expectation. Those patients referred were considered appropriate, with over 75% having a palliative care issue that was considered appropriate for direct patient contact by the specialist in palliative medicine.
Conclusions: The provision of a visiting palliative medicine specialist to rural areas has been developed over the last few years in New South Wales and the reporting of the success of this particular service aims to provide evidence for the need and the development of further services, as it is expected that this service would continue but with an increasing number of referrals as the service became increasingly known.

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