Journal Search

Journal Search - issue 3, 2007


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Jennifer Richmond1
PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


27 September 2007 Volume 7 Issue 3


RECEIVED: 25 September 2007

ACCEPTED: 27 September 2007


Richmond J.  Journal Search - issue 3, 2007. Rural and Remote Health 2007; 7: 867. Available: www.rrh.org.au/journal/article/867


© Jennifer Richmond 2007 A licence to publish this material has been given to ARHEN, arhen.org.au

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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: (3) Summer 2007 / Ete 2007
Issue includes:

Graduates of northern Ontario family medicine residency programs practise where they train
Denis Heng, Raymond W. Pong, Benjamin T.B. Chan, Naushaba Degani, Tom Crichton, James Goertzen, William McCready, Jim Rourke

Objective: To examine where graduates of the Northeastern Ontario Family Medicine (NOFM) residency program in Sudbury and the Family Medicine North (FMN) program in Thunder Bay practise after graduation, using cross-sectional and longitudinal analyses.
Methods: Data from the Scott's Medical Database were examined. All physicians who graduated from NOFM and FMN between 1993 and 2002 were included in this analysis. Differences in the location of first practice between NOFM and FMN graduates were tested using chi-squared tests. Logistic regression analyses were used to examine the impact of the training program on a physician's first, as well as continuing, practice location.
Results: Between 1993 and 2002, FMN graduates were 4.56 times more likely (95% confidence interval [CI] 2.34-8.90) to practise in rural areas, compared with NOFM graduates, but NOFM graduates were 2.50 times more likely than FMN graduates (95% CI 1.35-4.76) to practise in northern Ontario. There was no statistically significant difference between the graduates of the 2 programs in the likelihood of working in either northern Ontario or a rural area. About two-thirds (67.5%) of all person-years of medical practice provided by NOFM and FMN graduates took place in northern Ontario or rural areas outside the north.
Conclusion: NOFM and FMN have been successful in producing family physicians to work in northern Ontario and rural areas. Results from this study add to the growing evidence from Canada and abroad that rural or northern medical education and training increases the likelihood that the graduates will practise in rural or northern communities.

Big cities and bright lights: rural- and northern-trained physicians in urban practice
Raymond W. Pong, Benjamin T.B. Chan, Tom Crichton, James Goertzen, William McCready, Jim Rourke

Introduction: Rural medical education is increasing in popularity in Canada. This study examines why some family physicians who completed their residency training in northern Ontario decided to practise in urban centres.
Methods: We used a qualitative research method. We interviewed 14 graduates of the Family Medicine North program and the Northeastern Ontario Family Medicine program. The interview transcripts were content-analyzed.
Results: There were different pathways leading to urban practice. While some pathways were straightforward, others were more complicated. Most participants offered multiple reasons for choosing to work in urban areas, suggesting that the decision-making processes could be quite complex. Family and personal factors were most frequently mentioned as reasons for choosing the urban option. The needs of the spouse and the children were especially important. Most of the participants had no plans to return to rural medical practice, but even these physicians retained some vestiges of rural practice.
Conclusion: Most Canadian medical schools now offer some rural medical training opportunities. The findings of this study provide some useful insights that could help medical educators and decision-makers know what to expect and understand how practice location decisions are made by doctors.

A comparative analysis of the perceived continuing medical education needs of a cohort of rural and urban Canadian family physicians
Vernon R. Curran, David Keegan, Wanda Parsons, Greg Rideout, David Tannenbaum, Normand Dumoulin, Lisa J. Fleet

Objective: To assess the perceived continuing medical education (CME) needs of a cohort of Canadian family physicians.
Methods: We distributed a questionnaire survey to Canadian family physicians who became Certificant members of the College of Family Physicians in 2001 and practised outside the province of Quebec. Main outcome measures were self-reported CME needs, professional development needs and preferences for CME delivery methods.
Results: We distributed 482 surveys and 197 questionnaires were returned for a response rate of 40.9%. Significant differences between rural and urban respondents' self-reported CME needs were found in the clinical areas of dermatology, endocrinology, emergency medicine, musculoskeletal, ophthalmology, otolaryngology, psychiatry and urology. Generally, a greater proportion of rural respondents reported significantly higher CME needs in emergency medicine. Urban respondents reported a significant preference for consulting colleagues as a method of CME, while rural respondents reported a significant preference for videoconferencing.
Conclusion: Self-reported CME needs and preferences for CME delivery methods differ on the basis of region of practice and size of the community in which family physicians' practise.

The needs of rural and urban young, middle-aged and older adults with a serious mental illness
Michel Bédard, Carrie Gibbons, Sacha Dubois

Objective: The delivery of mental health services is often provided through agencies set up to serve both young and older adults. Young and older adults with a severe mental illness (SMI) have different needs; this study was designed to identify important differences.
Methods: This is a descriptive study based on a representative sample of mental health services users from northwestern Ontario (n = 532 [one-half rural and one-half urban]). The service provider most familiar with each user completed a questionnaire. We compared the characteristics and needs of users aged 18-29, 30-59 and 60 years and older.
Results: The results showed that a greater proportion of individuals in the older group (55.3%) had physical comorbidities, compared with people in the younger and middle-aged groups (30.3% and 45.2%, respectively; p = 0.004), and more people in the older group used psychotropic medications (83.0% v. 62.9% and 75.5%, respectively; p = 0.006). Although the level of need was great for all age groups, the older group had greater need for medication management, physical health care, self-care and other activities of daily living (p < 0.05). A greater need for support was also identified for the family of older adults (p = 0.005). A lesser need was identified for psychotherapy or counselling, vocational training, and correction, probation or parole matters (p < 0.05).
Conclusion: We identified important differences in the needs of young, middle-aged and older people with an SMI. Addressing the needs of the older adults assumes a system that is responsive to their particular situations. Further work to ensure that the treatment of older adults reflects these differences and is based on best practices should be conducted.


Journal of Rural Health

Contents: 2007; 23: (4)
Issue includes:

Urban-Rural Flows of Physicians
Thomas C. Ricketts, Randy Randolph

Context: Physician supply is anticipated to fall short of national requirements over the next 20 years. Rural areas are likely to lose relatively more physicians. Policy makers must know how to anticipate what changes in distribution are likely to happen to better target policies.
Purpose: To determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs.
Methods: Individual records from merged AMA Physician Masterfiles for 1981, 1986, 1991, 1996, 2001, and 2003 were used to track movements from urban to rural and rural to urban counties. Individual physician locations were tracked over 5-year intervals during the period 1981 to 2001, with an additional assessment for movements in 2001-2003.
Findings: Approximately 25% of physicians moved across county boundaries in any given 5-year period but the relative distribution of urban-rural supply remained relatively stable. One third of all physicians remained in the same urban or rural practice location for most of their professional careers. There was a small net movement of physicians from urban to rural areas from 1981 to 2003.
Conclusions: The data show a net flow from urban to rural places, suggesting a geographic diffusion of physicians in response to economic forces. However, the small gain in rural areas may also be explained by programs that are intended to counter normal market pressures for urban concentrations of professionals. It is likely that in the face of an overall shortage, rural areas will lose physician supply relative to population.

The Experience of Rural Independent Pharmacies With Medicare Part D: Reports From the Field
Andrea Radford, Rebecca Slifkin, Roslyn Fraser, Michelle Mason, Keith Mueller

Context: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created prescription drug coverage for Medicare beneficiaries through a new Part D program, the single largest addition to Medicare since its creation in 1965. Prior to program implementation in January 2006, concerns had been voiced as to how independent pharmacies, which represent a higher proportion of all retail pharmacies in rural areas, would fare under the new program.
Purpose: This article describes first-hand reports from rural pharmacist-owners about their experiences with Medicare Part D plans in the first 7 months of 2006 in order to gain a more thorough understanding of the challenges faced by rural independent pharmacies as a result of program implementation.
Methods: A semi-structured interview protocol was utilized in telephone interviews with 22 pharmacist-owners of rural independent pharmacies in 10 states.
Findings: The rural independent pharmacists interviewed are experiencing major changes in payment, administrative burden, and interaction with patients as a result of the shift of patients into Medicare Part D plans. While administrative burden has greatly increased, payment and clinical interaction have decreased.
Conclusion: Actions should be considered that would help rural independent pharmacists adjust to the new circumstances of having Medicare patients mirror, for administrative and payment purposes, commercially insured patients. Long-term modification of existing policies and regulations may be necessary to assure reasonable access to pharmaceuticals for rural populations. Further study is needed to determine how best to target these modifications to essential pharmacies.

Pharmacy Access to Emergency Contraception in Rural and Frontier Communities
Jeri L. Bigbee, Richard Abood, Sharon Cohen Landau, Nicole Monastersky Maderas, Diana Greene Foster, Susan Ravnan

Context: Timely access to emergency contraception (EC) has emerged as a major public health effort in the prevention of unintended pregnancies. The recent FDA decision to allow over-the-counter availability of emergency contraception for adult women presents important rural health implications. American women, especially those living in rural and frontier areas, have one of the highest rates of unintended and teen pregnancy among developed countries.
Purpose: This study, conducted prior to the recent FDA ruling, evaluated the participation among California pharmacies in the pharmacy access program in December 2005, specifically comparing rural/frontier and urban pharmacies.
Methods: The sample consisted of 862 California pharmacies, including 50 in rural/frontier areas, which were randomly selected and surveyed by telephone.
Findings: The results indicated that similar proportions of rural/frontier pharmacies and urban pharmacies provided direct pharmacy access services (28% vs 22%, P = 0.32). However, of the 13 rural/frontier counties included in the survey, eight (62%) had no emergency contraception pharmacies. The rural/frontier pharmacies that provided emergency contraception services tended to be small, independent pharmacies in the most remote areas of the state. Among rural/frontier pharmacies that did not participate in the program, the primary reasons included lack of training or demand for emergency contraception. Only one rural/frontier pharmacist cited moral or religious opposition to providing emergency contraception.
Conclusions: In light of the current limited over-the-counter status of emergency contraception, the role of rural and frontier pharmacies in ensuring access to emergency contraception will increase in the future.

Variations in Financial Performance Among Peer Groups of Critical Access Hospitals
George H. Pink, George M. Holmes, Roger E. Thompson, Rebecca T. Slifkin

Context: Among the large number of hospitals with critical access hospital (CAH) designation, there is substantial variation in facility revenue as well as the number and types of services provided. If these variations have material effects on financial indicators, then performance comparisons among all CAHs are problematic.
Purpose: To investigate whether indicators of financial performance and condition systematically vary among peer groups of CAHs.
Methods: Suggestions from CAH administrators, a literature review, expert panel advice, and statistical analysis were used to create peer groups based on whether a CAH: (1) had less than $5 million, $5-10 million, or over $10 million in net patient revenue; (2) was owned by a government entity; (3) provided long-term care; and (4) operated a provider-based Rural Health Clinic.
Findings: Significant differences in financial performance and condition exist among CAH peer groups.
Conclusions: CAHs should ensure that they use appropriate peer comparators when assessing their financial performance and condition. If quality, outcome, safety and access are affected by financial performance and condition, it may also be important for research in these areas to control for peer group differences among CAHs.

Starting a General Surgery Program at a Small Rural Critical Access Hospital: A Case Study From Southeastern Oregon
Brit Cruse Doty, Steven Heneghan, Randall Zuckerman

Context: Surgical services are frequently unavailable in rural American communities. Therefore, rural residents often must travel long distances to receive surgical care. Rural hospitals commonly have difficulty providing surgical services despite potential economic benefits.
Purpose: The purpose of this project was to identify the key challenges and describe the initial outcomes experienced by Harney District Hospital (HDH), a rural critical access facility in Oregon, as it develops a surgical program. Since few models exist, this information will be valuable for those considering offering surgical services in a rural setting.
Methods: This project employed a single case study design. Qualitative information was gathered from semi-structured interviews, a focus group, reviews of historical documents, and informal observations. Quantitative data sources included HDH financial and utilization records, US Census records, and economic and demographic statistics from the state of Oregon, Harney County, and the city of Burns.
Findings: HDH is learning that initiating a change such as expanding surgical services within an organization is a challenging process requiring collaboration among the administration, staff, and community. Preliminary findings indicate that the new surgical program has resulted in significant financial gains for the hospital.
Conclusions: While starting a rural surgery program is a complex undertaking, there are benefits for the hospital. If a rural hospital is to be successful in this mission, collaboration and adaptability must be key components of the process.

Rural, Suburban, and Urban Variations in Alcohol Consumption in the United States: Findings From the National Epidemiologic Survey on Alcohol and Related Conditions
Tyrone F. Borders, Brenda M. Booth

Context: Alcohol consumption is a major public health problem nationally, but little research has investigated drinking patterns by rurality of residence.
Purpose: To describe the prevalence of abstinence, alcohol use disorders, and risky drinking in rural, suburban, and urban areas of the United States.
Methods: Analyses of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were conducted to estimate prevalence rates for abstinence, a current alcohol use disorder, and exceeding recommended daily and weekly drinking limits. Logistic regression analyses were conducted to test for rural and urban versus suburban differences after adjusting for potential confounders. Additional analyses were stratified by Census Region.
Findings: Nationally, the odds of abstinence and, among drinkers, the odds of a current alcohol disorder and exceeding daily limits were higher in rural than suburban areas. Stratified analyses revealed differences in the associations between rurality of residence and drinking across Census Regions. Rural residents of the Northeast, Midwest, and South and urban residents of the Northeast had higher odds of abstinence than their suburban peers. Among drinkers, rural and urban residents of the Midwest had higher odds of a current alcohol disorder and exceeding daily limits; urban residents of the Midwest had higher odds of exceeding weekly limits.
Conclusions: Abstinence is particularly common in the rural South, whereas alcohol disorders and excessive drinking are more problematic in the urban and rural Midwest. Health policies and interventions should be further targeted toward those places with higher risks of problem drinking.

Impact of a Health Promotion Nurse Intervention on Disability and Health Care Costs Among Elderly Adults With Heart Conditions
Hongdao Meng, Brenda R. Wamsley, Gerald M. Eggert, Joan F. Van Nostrand

Context: Patients with heart conditions in rural areas may have different responses to health promotion-disease Self-management interventions compared to their urban counterparts.
Purpose: To estimate the impact of a multi-component health promotion nurse intervention on physical function and total health care expenditures among elderly adults with heart conditions and to examine the impact of rural residence on the intervention effect.
Methods: We analyzed data on 281 community-living Medicare beneficiaries with heart conditions from the Medicare Primary and Consumer-Directed Care Demonstration (a randomized controlled trial). We estimated ordinary least squares (OLS) models to determine the effect of the intervention on the change in functional status and log-linear models to determine the impact of the intervention on total health care expenditures over a 2-year period.
Results: The OLS models showed that the nurse intervention resulted in fewer impairments in Activities of Daily Living (ADL) (-0.307 on 0-6 scale, P = .055) at the end of 2 years. The effect of the intervention on ADL appeared to be stronger for rural than for urban participants (-0.490 vs -0.162, respectively). However, the difference was not statistically significant (P = .150). The effect of the intervention on Instrumental Activities of Daily Living (IADL) was not significant (P = .321). Average total health care expenditures were 6.5% ($1,981, 95% CI: -$8,048, $4,087) lower in the nurse group.
Conclusions: The nurse intervention led to better physical functioning and has potential to reduce total health care expenditures among high-risk Medicare beneficiaries with heart conditions.

Ethnic and Sex Differences in Ownership of Preventive Health Equipment Among Rural Older Adults With Diabetes
Ronny A. Bell, Thomas A. Arcury, Jeanette M. Stafford, Shannon L. Golden, Beverly M. Snively, Sara A. Quandt

Context: Diabetes self-management is important for achieving successful health outcomes. Different levels of self-management have been reported among various populations, though little is known about ownership of equipment that can enhance accomplishment of these tasks.
Purpose: This study examined diabetes self-management equipment ownership among rural older adults.
Methods: Participants included African American, American Indian, and white men and women 65 years of age and older. Data included equipment ownership overall and by ethnicity and sex across diabetes self-management domains (glucose monitoring, foot care, medication adherence, exercise, and diet). Associations between equipment ownership and demographic and health characteristics were assessed using logistic regression.
Findings: Equipment ownership ranged from 85.0% for blood glucose meters to less than 11% for special socks, modified dishes, and various forms of home exercise equipment. Equipment ownership was associated with ethnicity, living arrangements, mobility, poverty status, and formal education.
Conclusions: Rural older adults with diabetes are at risk because they lack equipment to perform some self-management tasks. Providers should be sensitive to and assist patients in overcoming this barrier.

Characteristics of Crashes With Farm Equipment That Increase Potential for Injury
Corinne Peek-Asa, Nancy L. Sprince, Paul S. Whitten, Scott R. Falb, Murray D. Madsen, Craig Zwerling

Context: Crash fatality and injury rates are higher on rural roadways than other roadway types. Although slow-moving farm vehicles and equipment are risk factors on rural roads, little is known about the characteristics of crashes with farm vehicles/equipment.
Purpose: To describe crashes and injuries for the drivers of farm vehicles/equipment and non-farm vehicles involved in an injury crash. Passengers are not included in this analysis.
Methods: Injury crashes were included that involved a farm vehicle/equipment and at least one non-farm vehicle reported in Iowa Department of Transportation crash data from 1995 to 2004. Odds ratios were calculated through logistic regression to identify increased odds for injury among drivers of non-farm vehicles and farm vehicles/equipment. We examined frequently occurring crash characteristics to identify crash scenarios leading to the highest odds for injury.
Findings: Non-farm vehicle drivers were 5.23 times more likely to be injured than farm vehicle/equipment drivers (95% CI = 4.12-6.46). The absence of restraint use was a significant predictor of injury for both farm vehicle/equipment drivers (OR = 2.85; 95% CI = 1.14-7.13) and non-farm vehicle drivers (OR = 2.53; 95% CI = 1.54-4.15). Crash characteristics increasing the odds of injury for non-farm vehicle drivers included speeding, passing the farm vehicle/equipment, driving on a county road, having a frontal impact collision, and crashing in darkness. Ejection was the strongest predictor of injury for the farm vehicle/equipment driver.
Conclusion: Non-farm vehicle drivers were much more likely to be injured than farm vehicle/equipment drivers, suggesting that farm vehicle/equipment crash prevention should be a priority for all rural road users. Prevention strategies that reduce motor vehicle speed, assist in safe passing, increase seat belt use, and increase conspicuousness of the farm vehicle/equipment are suggested.

Injury and Illness Costs in the Certified Safe Farm Study
Kelley J. Donham, Risto H. Rautiainen, Jeffrey L. Lange, Sara Schneiders

Context: The Certified Safe Farm (CSF) intervention program aims to reduce occupational injuries and illnesses, and promote wellness to reduce health care and related costs to farmers, insurers, and other stakeholders.
Purpose: To evaluate the cost effectiveness of CSF.
Methods: Farms (316) located in a 9-county area of northwestern Iowa were recruited and randomized into intervention and control cohorts. Intervention farms received occupational health screenings, health and wellness screening, education, on-farm safety reviews, and performance incentives. For both cohorts, quarterly calls over 3 years were used to collect self-reported occupational injury and illness information, including costs to the farmers and their insurers.
Findings: Annual occupational injury and illness costs per farmer paid by insurers were 45% lower in the intervention cohort ($183) than in the control cohort ($332). Although out-of-pocket expenses were similar for both cohorts, combined costs of insurance and out-of-pocket expenses were 27% lower in the intervention cohort ($374/year per farmer) compared to the control cohort ($512/year per farmer). Within the cohort of intervention farmers, annual occupational injury and illness cost savings were directly associated with on-farm safety review scores. Reported health care costs were $237 per farmer in the safest farms (those farms scoring in the highest tertile) versus $485 per farmer in the least safe farms (lowest tertile).
Conclusions: Results suggest that farmers receiving the intervention had lower health care costs for occupational injuries and illnesses than control farmers. These cost savings more than cover the cost of providing CSF services (about $100 per farm per year).

The Impact of Drought on the Emotional Well-Being of Children and Adolescents in Rural and Remote New South Wales
John Dean, Helen J. Stain

Context and Purpose: Between 2002 and 2006 New South Wales was in the grip of the worst drought for more than 100 years. Financial hardships have led governments to declare "Exceptional Circumstances." Little social research has investigated the impact of drought on children. For this study, children from rural and remote regions of New South Wales were asked for their interpretations of the impacts of drought on their lives.
Methods: A multi-strategy approach combining qualitative and quantitative approaches was used to reveal deeper understanding of the impacts of drought. Students in Years 5 through 12 from six Central Schools in the rural southwest of New South Wales participated in focus groups and completed self-report questionnaires.
Results: Quantitative self-reports indicated these students were not significantly more distressed than Australian norms. However, the themes that emerged from the students' statements indicated that the drought had been a very significant event for them. This qualitative information also indicated connections for these students to their families, schools, and communities.
Conclusions: The emotional impacts of changes to family and community life appear to have been moderated by these students' positive attitudes toward their country lifestyle. These students have discussed the impact of drought on their environment, their livestock, financial resources, and their families. In the face of declining rural community networks, children should be supported through programs that maintain resilience in the face of recurring environmental stressors.


Australian Journal of Rural Health

2007; 15: (5)
issue includes:

Where is the evidence that rural exposure increases uptake of rural medical practice?
Geetha Ranmuthugala, John Humphreys, Barbara Solarsh, Lucie Walters, Paul Worley, John Wakerman, James A. Dunbar, Geoff Solarsh

Australian Government initiatives to address medical workforce shortages in rural Australia include increasing the intake of students of rural background and increasing exposure to rural medicine during training. Rural-orientated medical training programs in the USA that selectively admit students from rural backgrounds and who intend to practise as family practitioners have demonstrated success in increasing uptake of practice in rural/underserved areas. However, in examining the specific contribution of rural exposure towards increasing uptake of rural practice, the evidence is inconclusive, largely due to the failure to adjust for these critical independent predictors of rural practice. This paper identifies this evidence gap, examines the concept of rural exposure, and highlights the need to identify which aspects of rural exposure contribute to a positive attitude towards rural practice, thereby influencing students to return to rural areas. The cost of rural exposure through student placements is not insignificant, and there is a need to identify which aspects are most effective in increasing the uptake of rural practice, thereby helping to address the medical workforce shortage experienced in rural Australia.

Informing rural and remote students about careers in health: Factors influencing career decisions
Elizabeth Buikstra, Robert M. Eley, Natalie Hindmarsh

Objective: Since 1994 a state-wide program has been operating in Queensland to provide non-metropolitan secondary school students with information about health careers. Determination of the factors influencing the career decisions of rural and remote students was one objective of the evaluation of that program.
Design: Telephone interviews.
Setting: Secondary schools.
Subjects: People who had previously attended Year 10 residential health career workshops run by Queensland Health. Ninety-four of 277 past participants to Year 10 Health Careers Workshops responded to a postal questionnaire and were invited to take part in a telephone questionnaire to collect further information related to the course and career choices.
Main outcome measures: Self-reported factors affecting career decisions of students from rural and remote areas.
Results: Of the 94 past workshop participants, interviews were held with 70. All participants had left secondary education and had either undertaken or were undertaking some form of tertiary study. The most influential of nine factors to both undergraduate and postgraduate course choices was self-interest. Various other factors differentially contributed to undergraduate and postgraduate course choices among them were the health careers workshops, which played a major influence on undergraduate course decisions of students.
Conclusion: Self-interest is the largest self-reported factor to career decision making among students from rural and remote areas. Finance and career advice from school are not considered to be highly influential. However, these independent decisions can be substantially influenced by external information provided through health career workshops.

Diabetes risk factors, diabetes and diabetes care in a rural Australian community
David Simmons, Lisa Bourke, Edward Yau, Mary Hoodless

Objective: To comprehensively describe diabetes-related risk factors, quality of care and patient-perceived barriers to care in a rural community.
Design: Cross-sectional mail study, self-completed survey and retrospective chart review.
Setting: Community and health services in Corryong, rural Victoria, Australia.
Participants: Ninety-seven patients with diabetes and 495 with other diseases in the mail study, 84 with diabetes in the self-completed survey and 101 diabetic patient chart reviews.
Main outcome measures: Self-reported lifestyle activities, uptake of health checks, metabolic measures and uptake of medication, and self-reported barriers to diabetes care.
Results: Most residents without diabetes had recently had their blood pressure and cholesterol checked; 60.4% were trying to control their weight and 73.9% were exercising regularly (although only 30.7% to an adequate level). Those with diabetes reported a greater uptake of healthy living messages, and had a mean HbA1c of 7.3%, total cholesterol of 5.0 mmol L 1 ; 12.9% had a diastolic blood pressure ≥85 mmHg. Foot checks were infrequent (18%). There was substantial room to increase antiplatelet, blood pressure, antihyperglycaemia and lipid-lowering therapy. Most patients reported psychological (84.5%) and educational (82.1%) barriers to care, with few perceiving physical barriers to care.
Conclusion: Living in a rural area with predominantly GP care can be associated with comparatively good metabolic control, although psycho-educational barriers are frequently present. In the wider community, risk factors for diabetes remain common, and the majority have been screened for components of the metabolic syndrome in the previous year.

Improving access to and outcomes from mental health care in rural Australia
Belinda Morley, Jane Pirkis, Lucio Naccarella, Fay Kohn, Grant Blashki, Philip Burgess

Objective: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes.
Design and method: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant.
Results: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures.
Conclusion: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.

Where do I go from here: We've got enough seniors?
Selena Gillham, Eli Ristevski

Objective: To identify recruitment and retention issues for allied health professionals at two rural health services.
Design: A qualitative study using semi-structured interviews was used to collect the data which were analysed using thematic analysis.
Setting: A regional public health service and a community health service in central eastern Victoria, Australia.
Participants: Eight final-year allied health students, 7 allied health or discipline managers, 18 current allied health staff and 10 former allied health staff participated in the interviews. Participants' professional backgrounds included: dentistry, dietetics, occupational therapy, physiotherapy, psychology, social work and speech pathology.
Main outcome measures: Recruitment and retention themes identified from the interview transcripts.
Results: Career opportunities and social and community connections were significant for both recruitment and retention of all the participant groups. Financial incentives were important for recruiting staff, while organisational management and policy were important for retaining staff. Health service resources were a specific issue for the recruitment of dentists, but were found to be a significant factor in the retention of all allied health staff.
Conclusion: A number of strategies can be used by health care organisations in rural areas to recruit staff, including: career progression, mentoring and profession development, connecting people with social networks and providing financial remuneration. To maximise staff retention, it is important to ensure that there are career progression pathways within the organisation, and that organisational management and policy provides support and opportunities for staff. Staff also need to be included as part of a social network in the community.

Self-reported confidence and skills of general practitioners in management of mental health disorders
Mark Oakley Browne, Adeline Lee, Radha Prabhu

Objective: To identify the predictors of self-reported confidence and skills of GPs in management of patients with mental health problems.
Design: Cross-sectional survey, with questionnaire presented to 246 GPs working in 62 practices throughout Gippsland.
Setting: Rural general practices in Gippsland.
Participants: One hundred and thirty-four GPs across Gippsland.
Main outcome measures: GPs completed a questionnaire assessing self-perception of knowledge and skills in recognition and management of common mental health problems.
Results: Of 134 GPs, 45% reported that they have a specific interest in mental health, and 39% of GPs reported that they had previous mental health training. Only 22% of GPs describe having both an interest and prior training in mental health care. Age and years since graduation are not significantly related to self-reported confidence and skills.
Conclusions: The results of this study highlight that self-professed interest and prior training in mental health are associated. Self-professed interest in mental health care predicts confidence and self-perceived skills in recognition, assessment and management of common mental health disorders. Similarly, prior training in mental health care predicts confidence and self-perceived skills in recognition, assessment and management of common mental health problems. Self-professed interest in mental health issues is also associated with hours of participation in continuing medical education related to mental health care. Unfortunately, only a minority described having both interest and prior training in mental health care.

Cardiovascular risk levels in general practice patients with type 2 diabetes in rural and urban areas
Qing Wan, Mark F. Harris, Gawaine Powell-Davies, Upali W. Jayasinghe, Jeff Flack, Andrew Georgiou, Joan R. Burns, Danielle L. Penn

Objective: To investigate the change of cardiovascular risk factor from 2000 to 2002 in general practice patients with type 2 diabetes in urban and rural areas, and the association between cardiovascular risk (both single risk factors and coronary heart disease absolute risk (CHDAR)) and rurality in three years.
Methods: In total, 6305 patients were extracted from 16 Divisions (250 practices). Multivariate regression at Division, practice and patient levels was conducted with adjustment for age and gender.
Results: In each of the three years, most single individual risk factors and CHDAR were high. Comparing 2002 with 2000: for urban patients in 2002 total cholesterol (OR 0.85) and low-density lipoprotein (OR 0.81) significantly decreased, and high-density lipoprotein (HDL) (OR 1.16) significantly increased; for rural patients in 2002 HbA1c (OR 0.85) significantly decreased and HDL (OR 1.22) significantly increased; and CHDAR significantly improved only in urban patients (OR 0.93) in 2002. In 2002 rural patients were still more likely to be overweight/obese (OR 1.16), be current smokers (OR 1.36), and have worse HDL (OR 0.84) and triglycerides (OR 1.23) than their urban counterparts.
Conclusion: Some key individual risk factors and CHDAR did not improve in rural patients with type 2 diabetes despite a number of programs designed to provide comprehensive care to rural patients with diabetes. More emphasis is needed on supporting access to lifestyle changes (such as smoking, diet and physical activity) in rural primary health care.

Supporting an emerging workforce: Characteristics of rural and remote therapy assistants in Western Australia
Ivan Lin, Belinda Goodale, Karen Villanueva, Suzanne Spitz

Objective: Multidisciplinary therapy assistants (TAs) are an emerging but poorly understood rural and remote allied health workforce. As an aid to planning and support of TA programs in rural and remote Western Australia (WA), the number, locality and a range of practice variables of rural and remote TAs in WA were determined.
Design: Survey questionnaire.
Setting: Rural and remote regions of WA.
Participants: Allied health professionals, TAs, TA coordinators and managers of allied health in country regions of WA.
Main outcome measures: Information was gathered on TA location, qualifications, employing organisation, allied health disciplines TAs work with, supervision practices, role and work scenarios.
Results: Ninety-eight TAs were identified in rural and remote WA with a further 23 vacant TA positions. Most TAs work across multiple allied health disciplines, half are located at a distance to their supervisors, and very few have a recognised qualification for their TA work.
Conclusion: A substantial rural and remote TA workforce was found. A range of TA characteristics were identified that have considerable relevance to the future planning of TA initiatives in rural and remote WA.