Journal Search

Journal Search - issue 2, 2007


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Paul Worley
1 PhD, Editor in Chief *


*Prof Paul Worley


1 Rural and Remote Health


29 June 2007 Volume 7 Issue 2


RECEIVED: 27 June 2007

ACCEPTED: 29 June 2007


Worley P.  Journal Search - issue 2, 2007. Rural and Remote Health 2007; 7: 811.


© Paul Worley 2007 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 North American and Australian rural health journals.


Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Contents, 2007; 12: (2) Spring 2007 / Printemps 2007
Issue includes:

Different practice patterns of rural and urban general practitioners are predicted by the General Practice Rurality Index
Sayo Olatunde, Eugene R. Leduc, Jonathan Berkowitz

Introduction: There are differences between rural and urban general medical practice. However, research in this area has been hampered by the lack of a practical and valid definition of "rural." This study attempts to validate the General Practice Rurality Index (GPRI) by showing that it can predict the fee-for-service billing patterns of general practitioners in British Columbia.
Methods: We obtained one year of fee-for-service billing data for all general practitioners in BC, apportioned by local health area (LHA). The total numbers of each type of service in each LHA were categorized into logical groups and expressed as a percentage of total services for that LHA. Each LHA was given a full GPRI score and a simplified GPRI (GPRI-S) score. We then compared the scores and percentage of services in each fee category.
Results: We found significant correlations between the degree of rurality and the percentage of certain services. The GPRI-S produced more significant correlations than the full GPRI.
Conclusions: This study provides evidence that both the full GPRI and a simplified version can be used to predict practice patterns of BC general practitioners. Further study is needed to prove whether either of these indices will be an accurate and reliable measure of rurality across Canada.

Bridging the gap in population health for rural and Aboriginal communities: a needs assessment of public health training for rural primary care physicians
Jane A. Buxton, Veronic Ouellette, Alison Brazier, Carl Whiteside, Rick Mathias, Meena Dawar, Andrea Mulkins

Introduction: The literature identifies significant inequalities in the health status of rural and Aboriginal populations, compared with the general population. Providing rural primary care physicians with public health skills could help address this issue since the patterns of mortality and morbidity suggest that prevention and health promotion play an important role. However, we were unable to identify any community needs assessment for such professionals with dual skills that had been performed in Canada.
Methods: We conducted key informant interviews and focus groups in 3 rural and Aboriginal communities in British Columbia (chosen through purposive sampling). We analyzed transcripts following standard qualitative iterative methodologies to extract themes and for discussing content.
Results: There was broad support for a program to train primary care physicians in public health. The characteristics identified as necessary in such a physician included a long-term commitment to the community with partnership building, advocacy, communication and cultural sensitivity skills. The communities we studied identified some priority challenges, most notably that the current remuneration structure does not support physicians engaging in public health or research.
Conclusion: There is great potential and support for the training of rural primary care practitioners in public health to improve population health and engage communities in this process.

Rural maternity care services under stress: the experiences of providers
Stefan Grzybowski, Jude Kornelsen, Elizabeth Cooper

Introduction: Between 2000 and 2004, 17 small rural maternity care services in British Columbia (BC) closed or were placed under moratoria. This paper explores the experiences of care providers in 4 rural BC communities that have lost or are at risk of losing their local maternity services.
Methods: We conducted qualitative, semistructured interviews and focus groups with 27 health care providers (doctors and nurses) and 3 administrators. The analysis used modified grounded theory. We chose 4 rural communities to include a diversity of characteristics, including community size, geography, distance to the nearest hospital capable of performing cesarean section, and cultural and ethnic subpopulations.
Results: Care providers identified significant stressors related to the provision of maternity care services, including the development and maintenance of competency in the context of decreasing birth volume, the safety of local maternity care without cesarean section and the desire to balance women's needs with the realities of rural practice.
Conclusions: Maternity care providers in small rural communities are experiencing stress due in part to the absence of evidence-based policy and planning for rural maternity care services. This stress may contribute to challenges in the retention of rural maternity care providers, thus risking the future of small rural maternity services.

Myocardial infarction in Québec rural and urban populations between 1995 and 1997
Julie Loslier, Alain Vanasse, Théophile Niyonsenga, Josiane Courteau, Gabriela Orzanco, Abbas Hemiari

Introduction: There is abundant evidence of health inequities between urban and rural populations. The purpose of this paper is to describe the socioeconomic characteristics of Québec urban and rural populations and the relation between rurality and incidence of myocardial infarction (MI), care management and outcomes.
Methods: Socioeconomic data by census subdivisions were available from the 1996 Canadian census, representing 7 137 245 individuals. Data on patients with MI were taken from the provincial administrative health database (MED-ECHO), which is managed by the Ministry of Health and contains clinical and demographic information collected when patients are released from acute care hospitals in Québec.
Results: We included a total of 37 678 cases compiled over the 3 years of follow-up in the analyses. Residents of rural areas with low urban influence have higher MI incidence rates than all of the other populations in the study. In comparison with urban populations, their observed rural counterparts are at a disadvantage with regard to education, employment and income. Although angioplasty and coronary artery bypass graft surgery rates were higher in more urban areas, the survival rate was lower than in rural areas.
Conclusion: This study revealed geographic heterogeneity of MI incidence, revascularization rates and survival rates among urban and rural populations.

The occasional shoulder reduction
Len Kelly

The shoulder is the most mobile joint in the body. With this relative instability, it is no surprise that it is the most common joint dislocation seen in the emergency department. With an annual incidence of 17 per 100 000 people, rural physician group serving 10 000-20 000 patients may encounter only several each year. Reduction methods can be confusing, if only because there are multiple options. In this article I offer what pearls there are and I review the 10 reduction methods in the literature. Most emergency physicians will need their chosen approach as well as one or 2 backup methods.


Journal of Rural Health

Contents: 2007; 23: (3)
Issue includes:

Rural Hospital Patient Safety Systems Implementation in Two States
Daniel R. Longo, John E. Hewett, Bin Ge, Shari Schubert

Context and Purpose: With heightened attention to medical errors and patient safety, we surveyed Utah and Missouri hospitals to assess the "state of the art" in patient safety systems and identify changes over time. This study examines differences between urban and rural hospitals.
Methods: Survey of all acute care hospitals in Utah and Missouri at 2 points in time (2002 and 2004). Factor analysis was used to develop 7 latent variables to summarize the data, comparing rural and urban hospitals at each point in time and on change between the 2 survey times.
Findings: On 3 of the 7 latent variables, there was a statistically significant difference between rural and urban hospitals at the first survey, with rural hospitals indicating lower levels of implementation. The differences remained present on 2 of those latent variables at the second survey. In both cases, 1 of those variables was computerized physician order entry (CPOE) systems. Rural hospitals reported more improvement in systems implementation between the 2 survey times, with the difference statistically significant on 1 of the 7 latent variables; the greatest improvement was in implementation of "root cause analysis."
Conclusions: Adoption of patient safety systems overall is low. Although rates of adoption among rural versus urban hospitals appear lower, most differences are not statistically significant; the gap between rural and urban hospitals relative to quality measures is narrowing. Change in rural and urban hospitals is in the right direction, with the rate of change higher in rural hospitals for many systems.

The Supply of Dentists and Access to Care in Rural Kansas
R. Andrew Allison, Richard J. Manski

Context: Rural deficits in dental care and oral health are well documented and are typically attributed to the low number of dentists practicing in rural areas, but the relationships between rural residence, dental supply, and access to care have not been firmly established, impeding the development of effective public policy.
Purpose: The purpose of this study is to develop a conceptual framework for observed variations in dental supply, oral health, and access to dental care in rural versus nonrural areas, and to test key empirical implications of this framework (eg, whether lower levels of utilization are associated with the lack of dentists and/or other aspects of residence in a rural area).
Methods: This study employs descriptive statistics, bivariate analyses, and multiple logistic regression to describe the relationship between oral health, access to care, and the supply of dentists in rural versus nonrural populations. Data analyzed includes Kansas' dental licensure records and the 2002 Behavioral Risk Factor Surveillance System.
Findings: Bivariate results confirm that dental supply, access to care, and oral health are lower for populations living in rural areas. Multivariate models indicate that dentist supply has a positive and independent association with utilization, but that rurality is not associated with utilization and oral health after controlling for demographics and dentist supply.
Conclusions: Findings are consistent with a conceptual framework linking the geography of rural residence, individual preferences for services such as dental care, and the financial disincentives for dentists to locate in rural areas.

Retention of Physician Assistants in Rural Health Clinics
Lisa R. Henry, Roderick S. Hooker

Context: Improvement of rural health care access has been a guiding principle of federal and state policy regarding physician assistants (PAs).
Purpose: To determine the factors that influence autonomous rural PAs (who work less than 8 hours per week with their supervising physician) to remain in remote locations.
Methods: A qualitative exploratory study was undertaken in 8 rural Texas towns, including direct observation of clinics, semi-structured interviews with PAs, and focus groups with community residents.
Findings: The major factors contributing to retention among autonomous rural PAs include: confidence in the ability to provide adequate health care, desire for small-town life, residing in the community, and being involved with the community. Both PAs and residents thought the level of their town's health care was moderately good but could be improved. The clinic allowed easy access for primary care and minor injuries. Town residents and PAs also expressed a desire for major improvements including a pharmacy, visiting specialists, and additional medical equipment. Not all residents sought medical care at the clinic, with some electing to travel to physicians in larger towns.
Conclusions: Rural community residents have more confidence in and satisfaction with PAs who have remained in a clinic for several years. In order to increase retention rates, PAs committed to autonomous, rural primary care would benefit from additional training, particularly in emergency medicine, the benefits of community involvement, and adaptation to the local culture.

Differential Effects of Economic Factors on Specialist and Family Physician Distribution in Illinois: A County-Level Analysis
Martin J. Mistretta

Context: Uneven distribution of physicians across geographic areas of the United States remains a significant problem that may have implications for health.
Purpose: To develop a statistical model of physician distribution in Illinois counties that predicts where specialists and family physicians practice, and to suggest policy strategies for alleviating shortages.
Methods: Three-stage least squares, an estimation technique, was utilized to create a model where 19 variables suggested by the literature predicted specialist and family physician distribution within geographic areas, specifically counties in Illinois.
Findings: Non-economic quality of life factors seemed to be related to specialist physician practice location (eg, percent graduates and professionals located in the area, public school expenditures, nonpublic teachers per capita, and sufficient hospital beds). In contrast, economic factors were related to family physician practice location (eg, per capita income, total population [an indicator of demand for medical care]).
Conclusion: Indicators suggest quality of life factors appear important in specialist location and retention, whereas indicators suggest economic factors appear important to family physician location and retention. Subsidies are suggested to encourage more family physicians to locate and remain in rural areas.

Physician Perceptions of Practice Environment and Professional Satisfaction in California: From Urban to Rural
Kyle Luman, John Zweifler, Kevin Grumbach

Context: Few studies have systematically examined the experience of rural practice from the physician's perspective or included physicians from an array of specialties, particularly non-primary care.
Purpose: To better understand differences between rural and urban physicians in perceptions of their practice environment.
Methods: In 2001-2002, self-administered questionnaires were sent to a probability sample of primary care and specialist physicians identified from the American Medical Association's Physician masterfile in California. Logistic regression was performed to model the effect practice location had on key variables, controlling for physician demographics, specialty, and the insurance profile of the physician's patients.
Findings: Completed questionnaires were obtained from 1,365 of 2,240 eligible urban physicians (61%), and 398 of 632 rural physicians (63%). Among primary care physicians, those in rural areas defined as nonadjacent or small non-metropolitan counties were the least likely to report pressures to see more patients, limit referrals, and limit treatment options. In contrast, among specialists, those in rural areas within metropolitan areas (or in large adjacent non-metropolitan counties) were more likely than urban specialists to report practice pressures. Although rural physicians in both primary care and specialist fields were more likely than urban physicians to report difficulty attracting new physicians to their communities, they perceived their overall practice climate to be better. Physicians in the nonadjacent-or-small non-metropolitan category were the most satisfied, but specialists in the nonadjacent-or-small non-metropolitan category were the least satisfied.
Conclusion: Physicians in rural California appear to have maintained a greater sense of clinical autonomy and higher professional satisfaction compared with their urban counterparts.

Rurality and Ethnicity in Adolescent Physical Illness: Are Children of the Growing Rural Latino Population at Excess Health Risk?
K. A. S. Wickrama, Glen H. Elder Jr, W. Todd Abraham

Context and Purpose: This study's objectives are to: investigate potential additive and multiplicative influences of rurality and race/ethnicity on chronic physical illness in a nationally representative sample of youth; and examine intra-Latino processes using a Latino sub-sample. Specifically, we examine how rurality and individual psychosocial processes reflected by acculturation proxies (generational status and use of the English language at home) link to chronic physical illness of Latino youth. Finally, we examine whether these associations and the levels of chronic illness differ across Latino subgroups.
Methods: Logistic-normal (binomial) modeling analyses examine multilevel influences on physical health using longitudinal data from a nationally representative sample (N = 13,905) of white, African American, Latino, Asian, and Native American adolescents between the ages of 12 and 19 participating in the National Longitudinal Study of Adolescent Health.
Findings: Prevalence rates of certain chronic illnesses (obesity, asthma, and high cholesterol) among Latino adolescents exceed rates for the same illnesses among white adolescents. Comparisons between rural and non-rural youth reveal a rurality disadvantage in terms of any chronic illness likelihood among Latino, Asian, and Native American youth not evident among whites or African Americans. Among Latino youth (N = 2,505), Mexican Americans show lower health risk for any chronic illness compared to other Latino groups. However, third generation Latinos and those who primarily speak English at home experience higher risk for any chronic illness than do those of first or second generation status, with amplification of the risk linked to English use at home among Latino youth living in rural areas.

Predictors of Colorectal Screening in Rural Colorado: Testing to Prevent Colon Cancer in the High Plains Research Network
Walter F. Young, Joe McGloin, Linda Zittleman, David R. West, John M. Westfall

Context: Colorectal cancer is the second leading cause of cancer death in the United States, yet screening rates are well below target levels. Rural communities may face common and unique barriers to health care, particularly preventive health care.
Purpose: To establish baseline attitudinal, knowledge, belief, and behavior measures on colorectal cancer screening and to identify barriers to or predictors of colorectal cancer screening.
Methods: As part of a controlled trial using a quasi-experimental, pretest, post-test design, we conducted a baseline telephone survey of 1,050 rural eastern Colorado residents aged 50 years and older. Smaller counties were over-sampled to ensure a minimum of 30 completed interviews per county.
Findings: Seventy-seven percent reported they ever had a colorectal cancer screening test and 59% were up-to-date on at least 1 test. The most important independent predictors of being up-to-date were having visited a doctor or other health care practitioner for a checkup in the past year, having personal or family history of colon polyps or cancer, and having asked for a colorectal cancer screening test. Financial concerns were reported reasons for not obtaining fecal occult blood testing by 18% and colonoscopy by 21%.
Conclusions: This study suggests that health care providers should be vigilant in counseling their patients 50 and older to have a colorectal cancer test. Community programs designed to promote colon cancer screening should encourage residents to have regular contact with their primary care physician and ask their doctor for a screening test. Additionally, programs should provide financial assistance for testing for low-income and uninsured patients.

The Association of Health and Functional Status with Private and Public Religious Practice among Rural, Ethnically Diverse, Older Adults with Diabetes
Thomas A. Arcury, Jeanette M. Stafford, Ronny A. Bell, Shannon L. Golden, Beverly M. Snively, Sara A. Quandt

Purpose: This analysis describes the association of health and functional status with private and public religious practice among ethnically diverse (African American, Native American, white) rural older adults with diabetes.
Methods: Data were collected using a population-based, cross-sectional, stratified, random sample survey of 701 community-dwelling elders with diabetes in two rural North Carolina counties. Outcome measures were private religious practice, church attendance, religious support provided, and religious support received. Correlates included religiosity, health and functional status, and personal characteristics. Statistical significance was assessed using multiple linear regression and logistic regression models.
Findings: These rural elders had high levels of religious belief, and private and public religious practice. Religiosity was associated with private and public religious practice. Health and functional status were not associated with private religious practice, but they were associated with public religious practice, such that those with limited functional status participated less in public religious practice. Ethnicity was associated with private religious practice: African Americans had higher levels of private religious practice than Native Americans or whites, while Native Americans had higher levels than whites.
Conclusions: Variation in private religious practice among rural older adults is related to personal characteristics and religiosity, while public religious practice is related to physical health, functional status, and religiosity. Declining health may affect the social integration of rural older adults by limiting their ability to participate in a dominant social institution.

Estimating Uncompensated Care Charges at Rural Hospital Emergency Departments
Kevin J. Bennett, Charity G. Moore, Janice C. Probst

Context: Rural hospitals face multiple financial burdens. Due to federal law, emergency departments (ED) provide a gateway for uninsured and self-pay patients to gain access to treatment. It is unknown how much uncompensated care in rural hospitals is due to ED visits.
Purpose: To develop a national estimate of uncompensated care from patients utilizing the ED in rural hospitals.
Methods: Clinical data from the National Hospital Ambulatory Medical Care Survey-ED (NHAMCS-ED) from 1999 and 2000 were linked to billing data from South Carolina. National estimates of utilization and charges were calculated, with rurality and self-pay status being the variables of focus.
Findings: Applying South Carolina billing data to national clinical data yields a national estimate for 1999-2000 of nearly $441 billion in charges being generated through emergency departments, with self-pay patients representing 9.0% of total charges. Rural self-pay patients accounted for an estimated $3.5 billion in charges in 1999 and $5.3 billion in 2000. These charges may represent a total financial burden of more than $4 billion to rural hospitals.
Conclusions: Efforts should be made to reduce the uncompensated care burden on rural hospitals to ensure their viability. These efforts may include Medicaid/SCHIP expansions, FQHCs or RHCs, Critical Access Hospital Designation, or other indigent care programs that would reduce the need for self-pay patients to utilize EDs.

Risk Factors for Rural Residential Fires
Veerasathpurush Allareddy, Corinne Peek-Asa, Jingzhen Yang, Craig Zwerling

Context and Purpose: Rural households report high fire-related mortality and injury rates, but few studies have examined the risk factors for fires. This study aims to identify occupant and household characteristics that are associated with residential fires in a rural cohort.
Methods: Of 1,005 households contacted in a single rural county, 691 (68.8%) agreed to participate. One household with missing information on a reported fire was excluded from the analysis. We used logistic regression to examine the independent association of occupant and household characteristics with reported fires, controlling for years lived in the residence. We also examined the association between the occurrence of previous fires and the adoption of safety measures.
Findings: A total of 78 (11.3%) households reported a residential fire. Occupant characteristics that were associated with significantly higher odds of reported fires included the presence of an occupant with alcohol problems (OR = 1.82, 95% CI = 1.01-3.28) and being married (OR = 2.11, 95% CI = 1.14-3.91). Rural farm households were associated with significantly higher odds (OR = 1.72, 95% CI = 1.01-2.93) of reporting a fire when compared to residences in towns, after controlling for all other occupant and household characteristics. The presence of a fire extinguisher (OR = 2.00, 95% CI = 1.10-3.64) was the only fire safety measure that had a statistically significant association with reported fire.
Conclusions: Rural farm households report higher incidences of fire when compared to households located in towns. Experiencing a fire is not associated with an increased likelihood of adopting safety measures to prevent injuries once a fire has started.

Health Communications in Rural America: Lessons Learned from an Arthritis Campaign in Rural Arkansas
Appathurai Balamurugan, Mark Rivera, Kim Sutphin, Debbie Campbell

Context: Lack of awareness about diseases and associated risk factors could partially account for some rural health disparities. Health communications campaigns can be an effective means of increasing awareness in these areas.
Purpose: To review findings and lessons learned from a rural health communications campaign.
Methods: The health communications campaign titled "Physical Activity. The Arthritis Pain Reliever," developed by the Centers for Disease Control and Prevention, was implemented in a rural Arkansas county to promote awareness about arthritis and the beneficial effects of physical activity among residents 45-64 years of age with arthritis. The campaign was implemented through radio spots, print ads in local newspapers, and distribution of brochures and posters. A survey of 193 residents with arthritis assessed the reach of the campaign.
Findings: Whereas 86% of respondents reported having seen or heard the messages related to arthritis during the 13-week period of the campaign, only 11% recalled messages from the "Physical Activity. The Arthritis Pain Reliever" campaign. Challenges faced during campaign implementation included limited fiscal resources, distrust, and staff and time constraints.
Conclusion: Challenges to health communications campaigns in rural areas can decrease campaign reach and effectiveness. If resource constraints exist, leveraging partnerships and building trust among residents of the community are important for achieving campaign success.


Australian Journal of Rural Health

2007; 15: (3)
issue includes:

Growing old and getting sick: Maintaining a positive spirit at the end of life
David M. Clarke

End of life throws up significant mental health challenges. A high proportion of people in the terminal stages of illness experience depressive symptoms. This paper integrates a theory of hierarchy of human needs and empirical research describing experiences of grief and depression in terminal illness, to develop a model of care aimed at reducing depression and suffering. This care attends to physical, psychological, social and spiritual aspects, taking into account the concerns of patients and their families. Professional help can be offered to patients to restore dignity and hope, strengthen their ways of coping, and encourage social connections. To offer this, a well-resourced and coordinated, multidisciplinary and skilled workforce is needed.

Building sustainable rural research capacity: The experiences of a brain injury rehabilitation service
Lizette Salmon, Michael Curtin, Denis Ginnivan, Robert Neumayer

There is an emerging recognition of the need for health research that is conducted by and for rural people. Rural research promotes excellence in clinical practice and can improve staff recruitment and retention. A group of clinicians from a regional brain injury service collaborated with academics at their local university to form the Rural Rehabilitation Research on Brain Injury initiative. This initiative has funded four peer-reviewed research projects, secured an Australian Research Council grant and established the beginnings of a state-wide rural research collective involving all Brain Injury Rehabilitation Programs in New South Wales. Sustainable research enterprises such as this have significant potential as a 'prototype' for building research capacity in other rural health sectors. Governments and funding bodies should support these initiatives.

Evaluation of the national pharmacy preceptor education program
Lisa Dalton, Rosalind Bull, Susan Taylor, Kirsten Galbraith, Jennifer Marriott, Helen Howarth

Objective: The process evaluation findings and key issues from a trial of the effectiveness and national applicability of a national online educational curriculum for pharmacist preceptors are presented.
Design: A multi-method triangulated research design was used to elicit qualitative and quantitative data preceptors. The data collection method involved an anonymous questionnaire with both quantitative components and open-ended qualitative responses.
Setting: An online education program for preceptors of Australian pharmacy students in rural areas.
Participants: Rural pharmacists in the three states were invited to trial the package and participate in the associated research/evaluation project.
Main outcome measures: The Australian Pharmacy Preceptor Education (APPE) program is an important and valuable educational tool for the professional development of pharmacists. It contained pertinent information and appropriate activities, and the delivery strategy was well accepted. The evaluation findings support a national implementation.
Results: Program strengths include the ease of access, self-directed learning and the interactive nature emphasising the benefit of sharing ideas and feedback. Potential program limitations include technical delays and unclear instructions for undertaking the program.
Conclusion: The online APPE program is a flexible delivery strategy which has the potential to dramatically improve the skills and knowledge of pharmacists acting as preceptors and, thereby, impact on the learning provided in rural hospitals and community pharmacies for undergraduate students and new graduates alike.

Can a rural community-based work-related activity program make a difference for chronic pain-disabled injured workers?
Debra A. Dunstan, Tanya Covic

Objective: To assess the effectiveness of a clinical guidelines-informed multidisciplinary work-related activity program, and to improve the physical, psychological and occupational functioning of chronic pain-disabled injured workers.
Design: An uncontrolled, repeated-measures, pilot study was conducted.
Setting: The intervention was delivered in a community setting in regional New South Wales.
Participants: Participants (n = 30), mean age of 41 years, had a compensable musculoskeletal injury: 60% were male, 63% had back injuries; the mean time off work was 13 months.
Intervention: A cognitive-behavioural, interdisciplinary intervention was delivered using a multi-contributor provider model (a clinical psychologist and physiotherapist from separate practices, working in liaison with the participant's occupational rehabilitation provider and treating doctor). Groups of six participants attended for one half day per week for six weeks.
Main outcome measures: The outcome measures included: physical functioning, pain intensity and psychological variables, which were assessed pre- and post-program; and medical certification and work participation, which was recorded pre-program and at six-month follow up.
Results: Significant gains were made in pain intensity, physical and psychological functioning, and medical certification. The mean effect size of the intervention was medium to large (d = 0.70). There was no significant change in employment status at six-month follow up.
Conclusions: The results of this pilot study suggest that independent, rural or community-based practitioners, working collaboratively using an integrated treatment program, can produce positive outcomes for pain-disabled injured workers, and achieve results similar to those reported by metropolitan-based pain clinics.

Benefits and challenges of providing transitional rehabilitation services to people with spinal cord injury from regional, rural and remote locations
Susan Booth, Melissa Kendall

Objective: To identify the factors influencing participation and outline the benefits and challenges of providing transitional rehabilitation for people with spinal cord injury (SCI) from rural and regional locations.
Design: Grounded Theory analysis of service records and policy documents.
Setting: One transitional rehabilitation service for people with SCI.
Participants: Service records of 40 individuals with SCI from non-metropolitan locations who participated in transitional rehabilitation and 29 individuals with SCI who declined transitional rehabilitation over a two-year period.
Interventions: Home-based transitional rehabilitation programs offered by a multidisciplinary team including physiotherapy, occupational therapy, nursing and social work.
Measures: Participation was measured using the percentage of people from non-metropolitan locations who decline transitional rehabilitation. The benefits and challenges of transitional rehabilitation were identified using open, axial and selective coding of service records.
Results: People with SCI from non-metropolitan areas were underrepresented among transitional rehabilitation participants, with 69% of those declining transitional rehabilitation coming from regional or rural areas. The study identified five functions of transitional rehabilitation that presented both benefits and challenges of this model in assisting people from non-metropolitan locations. These included: (1) the identification, education, coordination and funding of local care providers; (2) family involvement in rehabilitation; (3) contact with social and community supports; (4) specialist support to problem-solve discharge needs; and (5) skill acquisition and transfer in a community environment.
Conclusions: The transitional rehabilitation model offers many advantages over traditional hospital-based rehabilitation but still faces challenges in offering an equitable model for people with SCI from non-metropolitan locations.

Junior medical officer recruitment: Challenges and lessons from the Northern Territory
Robert McDonald, Vino Sathianathan

Objective: To examine the influence of newspaper and Internet advertising, word-of-mouth endorsement and student experience in attracting applicants for junior medical officer positions in the Northern Territory.
Design: A retrospective study.
Participants: Fifty-four applicants for junior medical officer positions.
Main outcome measure: Proportion of applicants who reported newspaper advertising, Internet advertising, word of mouth or personal experience in attracting their application for an intern or resident medical officer position.
Results: Nineteen per cent of applicants saw the newspaper advertisement and 52% of the Internet advertisement. Eighty-seven per cent of applicants were influenced by word-of-mouth endorsement and 52% by student experience in the Northern Territory or Indigenous health.
Conclusion: These results suggest that word-of-mouth endorsement has the greatest influence in attracting applicants for junior medical officer positions in Northern Territory hospitals.

Diagnosing dementia in rural New South Wales
Patricia A. Logan-Sinclair, Alastair Davison

Objective: Review of dementia screening case profiles that included brain blood flow imaging to determine contribution to diagnosis.
Design: Retrospective medical case audit.
Setting: Rural New South Wales.
Participants: Eighty-eight rural patients who underwent investigations for dementia diagnosis.
Main outcome measure: Contribution of brain blood flow imaging (single photon emission tomography, SPECT) to the dementia screening regime.
Results: The age range of those referred was 21-88 years, the average being 70 years. There were 44 men and 44 women. Vascular causes of dementia accounted for 27% of all those referred for brain blood imaging. Senile dementia of the Alzheimer's type accounted for 40% of all referrals. The occurrence of mixed disease was 6%. Matching neuropsychological reports and computer tomography were available for 18 of the blood flow studies. Of these, 65% were in agreement or semi-agreement for the diagnostic outcome. Only five studies failed to reach consensus. GPs were responsible for 31% of the imaging referrals, and the remaining referrals were from the regions: two gerontologists, three physicians and two neurologists.
Conclusions: Brain blood flow imaging did contribute to the final diagnosis of dementia type for these patients, influencing patient management.

Trends in private dental service provision in major city and other Australian locations
David Brennan, A. John Spencer

Objective: To investigate time trends in dental service provision by location.
Design: Five cross-sectional surveys across a 20-year period.
Setting: Australian private general dental practice.
Participants: A random sample of dentists.
Methods: Mailed questionnaires were collected in 1983, 1988, 1993, 1998 and 2003 (response rates 71-76%).
Main outcome measures: Annual services per dentist.
Results: Decreases in the provision of restorative services, and increases in diagnostic and preventive services, occurred in major city locations but not in other locations. While decreases over time were observed in extraction rates in both major city and other locations, higher extraction rates persisted outside of major city locations. Denture and endodontic services fluctuated over time in both major city and other locations, with no difference by location observed in 2003-2004. No changes over time were observed for crown and bridge services, but crown and bridge services remained higher in major city compared with other locations in 2003-2004.
Conclusions: While the overall content of dentist workloads has changed to include less emphasis on removal and replacement of teeth and more effort on diagnosis and prevention aimed at retention of natural dentitions, a gap by location remains, with dentist workloads outside of major city locations marked by higher rates of tooth extraction and lower rates of preventive services.

Australian rural adolescents' experiences of accessing psychological help for a mental health problem
Candice Boyd, Kristy Francis, Damon Aisbett, Krystal Newnham, Jessica Sewell, Graham Dawes, Sarah Nurse

Objective: This study aims to explore Australian rural adolescents' experiences of accessing help for a mental health problem in the context of their rural communities.
Design and setting: A qualitative research design was used whereby university students who had sought help for a mental health problem during their adolescence were interviewed about their experiences. Interviews were conducted face-to-face at the university.
Main outcome measures: A semi-structured interview schedule was designed around the study's main research questions. Audio-taped interviews were transcribed and thematically coded using a constant comparative method.
Participants: Participants were first-year undergraduate psychology students between the ages of 17 and 21 years who sought help for a mental health issue during their adolescence and who at that time resided in a rural area.
Results: Participants highlighted various barriers to seeking help for mental health problems in the context of a rural community, including: social visibility, lack of anonymity, a culture of self-reliance, and social stigma of mental illness. Participants' access to help was primarily school-based, and participants expressed a preference for supportive counselling over structured interventions. Characteristics of school-based helpers that made them approachable included: 'caring', 'nonjudgemental', 'genuine', 'young', and able to maintain confidentiality.
Conclusions: The findings support previous research that reveals barriers to help seeking for mental health problems that are unique to the culture of rural communities. The study raises questions about the merit of delivery of primary mental health care to young people via GPs alone and suggests that school-based counsellors be considered as the first step in a young person's access to mental health care.

Depression and remoteness from health services in South Australia
Robert D. Goldney, Anne W. Taylor, Marcus A. Bain

Objective: To determine whether the prevalence of depression, its associated quality of life, treatment and mental health literacy about depression varied according to accessibility to health services.
Design: Face-to-face interviews with a random and representative sample of the South Australian population (aged ≥ 15 years) were conducted between March and June 2004, with the respondents stratified using the Accessibility and Remoteness Index of Australia into categories of 'highly accessible', 'accessible', and 'moderately accessible and remote'.
Results: From 4700 households selected, 3015 participants were interviewed (65.9% response rate). The prevalence of major depression and other depressions was not significantly different between each of the categories, although there was a trend for those from moderately accessible and remote areas to be less depressed overall. A significantly lower proportion of respondents from moderately accessible and remote locations reported that they had family or close friends who had suffered from symptoms consistent with depression, or that they had ever had treatment for those symptoms. However, there was no significant difference between the groups in those who had ever had or who were currently taking antidepressant medication. For those who were depressed, a significantly higher proportion from the accessible, and moderately accessible and remote regions had seen a community or district health service, social worker or other counsellor as compared with those from the highly accessible area.
Conclusions: These findings indicate that depression is no more prevalent in less accessible regions of South Australia, and that when it is present, its treatment, in terms of antidepressants, which can be considered as a proxy marker for the overall management of depression, is similar to treatment in more accessible areas.

Prevalence of depression among adults in Oyo State, Nigeria: A comparative study of rural and urban communities
Olorunfemi Amoran, Taiwo Lawoyin, Victor Lasebikan

Objective: This study was designed to assess the current prevalence of depression in Oyo State, Nigeria and the rural-urban variation in prevalence.
Setting: This is a two-phase community-based cross-sectional study. The urban areas selected for the study are the Ibadan North-West and Egbeda local government areas. The rural area selected was the Saki-East local government area.
Participants: A total of 1105 participants were recruited into the study. Multistage sampling technique was used to obtain a representative sample of the participants from the communities in Oyo State. The study was conducted using an interviewer-administered structured questionnaire, and the general health questionnaire (GHQ 12) as a screening tool. The second phase of the interview was conducted only for those participants with a score of more than 3 using the GHQ 12. These participants were then clinically examined using the Structured Clinical Interview DSM IV for assessment of clinical depression.
Main outcome measure: Prevalence of depression.
Results: A total of 721 (65.2%) were from urban communities, while 384 (34.8%) were from the rural community. The overall prevalence of depression was found to be 5.2%. Depression was more prevalent among women than men (5.7% vs 4.8%, χ2 = 0.36 P = 0.55), and among adolescents (9.6%, P = 0.04). Furthermore, depression was more common in the rural areas than in the urban areas (7.3% vs 4.2%, χ2 = 4.94 P = 0.02).
Conclusion: Depression is more common in rural than urban areas in the Nigerian population. Mental health education for adolescents and secondary school students should be encouraged in rural communities.

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