Journal Search

Journal Search - issue 1, 2008


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Paul Worley
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*Prof Paul Worley




31 March 2008 Volume 8 Issue 1


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ACCEPTED: 31 March 2008


Worley P.  Journal Search - issue 1, 2008. Rural and Remote Health 2008; 8: 984.


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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

The first 2008 issue of Canadian Journal of Rural Medicine is not yet available yet. To browse back issues of CJRM, take this link


Journal of Rural Health

Contents: 2008; 24: (1)
Issue includes:

Uninsured Rural Families
Erika C. Ziller, Andrew F. Coburn, Stephenie L. Loux

Context: Although research shows higher uninsured rates among rural versus urban individuals, prior studies are limited because they do not examine coverage across entire rural families.
Purpose: This study uses the Medical Expenditure Panel Survey (MEPS) to compare rural and urban insurance coverage within families, to inform the design of coverage expansions that build on the current rural health insurance system. Methods: We pooled the 2001 and 2002 MEPS Household Component survey, aggregated to the family level (excluding households with all members 65 and older). We examined (1) differences in urban, rural-adjacent, and rural nonadjacent family insurance coverage, and (2) the characteristics of rural families related to their patterns of coverage.
Findings: One out of 3 rural families has at least 1 uninsured member, a rate higher than for urban families-particularly in nonadjacent counties. Yet, three fourths of uninsured rural families have an insured member. For 42% of rural nonadjacent families, this is someone with public coverage (Medicaid/SCHIP or Medicare); urban families are more likely to have private health insurance or a private/public mix. Conclusions: Strategies to expand family coverage through employers may be less effective among rural nonadjacent than urban families. Instead, expansions of public coverage or tax credits enabling entire families to purchase an individual/self-employment plan would better ensure that rural nonadjacent families achieve full coverage. Subsidies or incentives would need to be generous enough to make coverage affordable for the 52% of uninsured rural nonadjacent families living below 200% of the federal poverty level.

Rural-Urban Differences in Physical Activity, Physical Fitness, and Overweight Prevalence of Children
Roxane R. Joens-Matre, Gregory J. Welk, Miguel A. Calabro, Daniel W. Russell, Elizabeth Nicklay, Larry D. Hensley

Context: The increasing prevalence of overweight in youth has been well chronicled, but less is known about the unique patterns and risks that may exist in rural and urban environments. A better understanding of possible rural-urban differences in physical activity profiles may facilitate the development of more targeted physical activity interventions.
Methods: Participants (1,687 boys; 1,729 girls) were recruited from fourth, fifth, and sixth grade classes in schools from urban areas, small cities, and rural areas. Multilevel modeling analysis was used to examine rural-urban differences in physical activity and prevalence of overweight. Physical activity was assessed by self-report and body mass index was calculated from measured height and weight.
Findings: Prevalence of overweight was higher among rural children (25%; P < .001) than children from urban areas (19%) and small cities (17%). Urban children were the least active overall (Cohens' d = −0.4), particularly around lunchtime while at school (d = −0.9 to −1.1). Children from small cities reported the highest levels of physical activity.
Conclusions: The results of this study suggest there are rural-urban differences in children's prevalence of overweight and physical activity even within a fairly homogenous Midwestern state.

The Relationship Between Food Insecurity and Obesity in Rural Childbearing Women
Christine M. Olson, Myla S. Strawderman

Context: While food insecurity and obesity have been shown to be positively associated in women, little is known about the direction of the causal relationship between these 2 constructs.
Purpose: To clarify the direction of the causal relationship between food insecurity and obesity.
Methods: Chi-square and logistic regression analysis of data from a cohort of 622 healthy childbearing women living in a 10-county rural area of upstate New York and followed from early pregnancy until 2 years postpartum.
Findings: Obesity in early pregnancy was associated with increased risk of food insecurity at 2 years postpartum. Initial food insecurity was not associated with increased risk of obesity at 2 years postpartum. Women who were both obese and food insecure in early pregnancy were at greatest risk of major weight gain over the pregnancy and postpartum period.
Conclusions: Obesity appears to lead to food insecurity rather than the converse. Obesity combined with food insecurity present the greatest risk for major weight gain in this sample of childbearing women.

Training Health Care Professionals to Manage Overweight Adolescents: Experience in Rural Georgia Communities
David A. Dennison, Zenong Yin, Debra Kibbe, Susan Burns, Frederick Trowbridge

Context: The obesity epidemic threatens the present and future health of adolescents in the United States. Yet, health care providers lack specific training for pediatric obesity assessment and management.
Purpose: This study examined the adherence of rural Georgia primary care practitioners to an overweight adolescent management protocol. The study also documented the prevalence of obesity-associated physiological and behavioral risk factors among overweight adolescent patients.
Methods: Ten rural clinics (58 providers) were recruited and received a 90-minute adolescent overweight assessment and management training session. Select biochemical, dietary, physical activity, and physical inactivity behaviors were assessed in overweight adolescent patients. Medical charts were abstracted to assess practitioner compliance with an overweight assessment protocol and patient adherence to a 16-week follow-up visit.
Findings: Providers were receptive to training and complied with the recommended protocol. Eighty-five overweight adolescents were assessed, but only 49 (57%) completed the scheduled 16-week follow-up visit. Physical, biochemical, and behavioral assessments revealed that 13%-27% of the participants had abnormal levels of lipids, fasting glucose, and glucose/insulin ratio, and 80.5% had waist circumferences above the 90th percentile.
Conclusions: Practitioners complied with the assessment and follow-up protocol, leading to the discovery of previously unrecognized risk factors in many overweight adolescent patients. Lack of patient adherence to follow-up was the greatest limiting factor for obesity management. Further efforts are needed to implement and evaluate training to improve the management of adolescent overweight, especially in rural communities.

Body Mass Index in Rural First Grade Schoolchildren: Progressive Increase in Boys
Derek T. Smith, Mandolyn Jade Vendela, R. Todd Bartee, Lucas J. Carr

Context: Childhood overweight is a global health problem. Monitoring of childhood body mass index (BMI) may help identify critical time periods during which excess body weight is accumulated.
Purpose: To examine changes in mean BMI and the prevalence of at-risk-for overweight in repeated cross-sectional samples of rural first grade schoolchildren between 1999 and 2004.
Methods: BMI was determined in 479 first graders from a rural Wyoming school district. BMI and gender-specific BMI-for-age percentiles were determined and evaluated over the 6 years. Children were also classified as normal or at-risk-for overweight according to CDC classification procedures.
Findings: From 1999 to 2004, there was a significant increase in the average BMI of first graders, 15.8 ± 2.2 kg/m2 versus 16.8 ± 2.2 kg/m2, respectively (P < .05). First grade boys had a progressive increase in BMI from 1999 to 2004 (15.6 ± 2.2 kg/m2 compared to 17.3 ± 2.2 kg/m2, respectively), but no change was evident for first grade girls. There was an approximate 4-fold increase in the percentage of rural first grade boys classified as at-risk-for overweight between 1999 and 2004.
Conclusions: A progressive increase in the BMI and the significant increase in prevalence of at-risk-for overweight in rural first grade boys highlight the need for future gender and age group-specific investigations. Focus should be given to primary prevention programs targeting potentially vulnerable time periods when excess weight gain may be occurring.

Impact of Discontinued Obstetrical Services in Rural Missouri: 1990-2002
Dan Sontheimer, Larry W. Halverson, Laird Bell, Mark Ellis, Pamela Wilbanks Bunting

Purpose: This study examines the potential relationship between loss of local obstetrical services and pregnancy outcomes.
Methods: Missouri Hospital Association and Missouri Department of Health birth certificate records were used as sources of information. All member hospitals of the Missouri Hospital Association that were located in cities of 10,000 or less were identified and surveyed by telephone.
Results: Frequency of low birth weight babies originating from service areas where hospitals closed services was statistically increased in the first year after service closures. This effect was transient.
Conclusions: Transient increases in the rate of lower birth weights may reveal difficulties in service access after closure. These outcomes merit further investigation into the consequences of disruptions in access to maternity care in rural communities.

Appalachian Women's Perceptions of Their Community's Health Threats
Nancy E. Schoenberg, Jennifer Hatcher, Mark B. Dignan

Context: Decades of behavioral research suggest that awareness of health threats is a necessary precursor to engage in health promotion and disease prevention, findings that can be extended to the community level.
Purpose: We sought to better understand local perspectives on the main health concerns of rural Appalachian communities in order to identify the key health priorities. While Kentucky Appalachian communities are often described as suffering from substandard health, resource, and socioeconomic indicators, strong traditions of community mobilization make possible positive, home-grown change.
Methods: To assess what women, the key health gatekeepers, perceive as the most significant health threats to their rural communities, 10 focus groups were held with 52 Appalachian women from diverse socioeconomic backgrounds. Tape-recorded narratives were content analyzed and a codebook was developed. Measures designed to increase data trustworthiness included member checks, negative case evidence, and multiple coding.
Findings: The following rank-ordered conditions emerged as posing the greatest threat to the health of rural Appalachian communities: (1) drug abuse/medication dependence; (2) cancer; (3) heart disease and diabetes (tied); (4) smoking; (5) poor diet/overweight; (6) lack of exercise; and (7) communicable diseases. These health threats were described as specific to the local environment, deriving from broad ecological problems and were connected to one another.
Conclusion: Drawing on participants' community-relevant suggestions, we suggest ways in which rural communities may begin to confront these health concerns. These suggestions range from modest, individual-level changes to broader structural-level recommendations.

Community Partnerships, Food Pantries, and an Evidence-Based Intervention to Increase Mammography Among Rural Women
Marcyann Bencivenga, Susan DeRubis, Patricia Leach, Lisa Lotito, Charles Shoemaker, Eugene J. Lengerich

Context: Multiple national agencies and organizations recommend that women age 40 years and older have an annual screening mammogram. Women who are poor, less educated, lack a usual source of care, and reside in rural Appalachia are less likely to have had a recent mammogram.
Purpose: To increase use of mammography among a rural Appalachian population.
Methods: Formed in 1992, the Indiana County Cancer Coalition (ICCC) serves the cancer control needs of medically underserved families in Indiana County, Pennsylvania, through collaborative partnerships. During 2005, the ICCC adapted and implemented the American Cancer Society's Tell a Friend® program in a network of 18 local food pantries of the Indiana County Community Action Program.
Findings: Of 302 age-eligible women, 158 (52.4%) were in need of scheduling a mammogram. Of the 158 women, 138 (87.3%) received a mammogram as a result of the adapted Tell A Friend® program. Three (2.2%) women were diagnosed with breast cancer and received treatment. The number of breast cancer screenings provided to underserved Indiana County residents increased by 46 (28.2%) during 2005.
Conclusions: Implementation of this evidence-based intervention in a network of local food pantries successfully provided mammography to rural women and demonstrated potential impact from a community cancer coalition in Appalachia. The initiative worked closely with local partners who are affiliated with a national infrastructure, thereby suggesting potential future dissemination.

Cultural Perspectives Concerning Adolescent Use of Tobacco and Alcohol in the Appalachian Mountain Region
Michael G. Meyer, Mary A. Toborg, Sharon A. Denham, Mary J. Mande

Context: Appalachia has high rates of tobacco use and related health problems, and despite significant impediments to alcohol use, alcohol abuse is common. Adolescents are exposed to sophisticated tobacco and alcohol advertising. Prevention messages, therefore, should reflect research concerning culturally influenced attitudes toward tobacco and alcohol use.
Methods: With 4 grants from the National Institutes of Health, 34 focus groups occurred between 1999 and 2003 in 17 rural Appalachian jurisdictions in 7 states. These jurisdictions ranged between 4 and 8 on the Rural-Urban Continuum Codes of the Economic Research Service of the US Department of Agriculture. Of the focus groups, 25 sought the perspectives of women in Appalachia, and 9, opinions of adolescents.
Findings: The family represented the key context where residents of Appalachia learn about tobacco and alcohol use. Experimentation with tobacco and alcohol frequently commenced by early adolescence and initially occurred in the context of the family home. Reasons to abstain from tobacco and alcohol included a variety of reasons related to family circumstances. Adults generally displayed a greater degree of tolerance for adolescent alcohol use than tobacco use. Tobacco growing represents an economic mainstay in many communities, a fact that contributes to the acceptance of its use, and many coal miners use smokeless tobacco since they cannot light up in the mines. The production and distribution of homemade alcohol was not a significant issue in alcohol use in the mountains even though it appeared not to have entirely disappeared.
Conclusions: Though cultural factors support tobacco and alcohol use in Appalachia, risk awareness is common. Messages tailored to cultural themes may decrease prevalence.

Tobacco Use Among the Amish in Holmes County, Ohio
Amy K. Ferketich, Mira L. Katz, Ross M. Kauffman, Electra D. Paskett, Stanley Lemeshow, Judith A. Westman, Steven K. Clinton, Clara D. Bloomfield, Mary Ellen Wewers

Purpose: The objective of this study was to estimate tobacco use prevalence among the Amish in Holmes County, Ohio, using both self-report and a biochemical marker of nicotine exposure.
Methods: Amish adults (n = 134) were interviewed as part of a lifestyle study. Self-reported tobacco use was measured using standardized questions, and cotinine was measured from a saliva sample. The prevalence of smoking, total tobacco use, and misclassification were estimated separately by gender, and then compared to 2 non-Amish groups. One group was selected from 2 counties contained within the Holmes County Amish settlement (n = 154) and the other was representative of non-Hispanic whites in the United States (n = 4,099).
Findings: No Amish women reported current tobacco use and only 2 reported former use. This was significantly different (P < .0001) from the patterns observed among non-Amish in the settlement counties (15.7%) and US white (23.3%) women. The prevalence of tobacco use among Amish men was 17.6% and this was significantly lower than estimates from non-Amish in the settlement counties (38.8%, P = .04) and US white (32.2%, P = .005) men. No Amish women and only 2 Amish men underreported tobacco use and misclassification was similar in the comparison groups.
Conclusions: Tobacco use is significantly lower among adults in the largest Amish settlement in the world compared to their non-Amish neighbors in Appalachia Ohio and US whites. A strength of this study is that self report was verified with a marker of nicotine, a critical measure to include in any study conducted in a group that stigmatizes tobacco use.

Enhancing the Care Continuum in Rural Areas: Survey of Community Health Center-Rural Hospital Collaborations
Michael E. Samuels, Sudha Xirasagar, Keith T. Elder, Janice C. Probst

Context: Community Health Centers (CHCs) and Critical Access Hospitals (CAHs) play a significant role in providing health services for rural residents across the United States.
Purpose: The overall goal of this study was to identify the CAHs that have collaborations with CHCs, as well as to recognize the content of the collaborations and the barriers and facilitators to collaborations.
Methods: The target population was CAHs within 60 miles of CHCs. Surveys were mailed to 386 chief executive officers of CAHs in 41 states who met the study criteria. The response rate was 40.9%. A descriptive analysis using chi-square tests compared the status of partnerships along with factors identified as barriers and facilitators to collaboration.
Findings: Out of the 161 CAH respondents, 24 (14.9%) reported having a collaborative agreement with a CHC, and 2 indicated that they planned to develop a collaborative agreement. A common reason given for not collaborating was lack of awareness of a CHC within the service area. Other barriers identified were competition with CHCs and organizational differences. External funding to start a collaborating service was the most frequently cited factor to facilitate collaborations.
Conclusions: The findings indicate that collaborations between CAHs and CHCs are a largely untapped resource. The rural health care services continuum may benefit from increased collaborations.


Australian Journal of Rural Health

2008; 16: (2)
issue includes:

Addressing the health disadvantage of rural populations: How does epidemiological evidence inform rural health policies and research
Karly B. Smith, John S. Humphreys, Murray G. A. Wilson

We reviewed evidence of any apparently significant 'rural-urban' health status differentials in developed countries, to determine whether such differentials are generic or nation-specific, and to explore the nature and policy implications of determinants underpinning rural-urban health variations. A comprehensive literature review of rural-urban health status differentials within Australia, New Zealand, Canada, the USA, the UK, and a variety of other western European nations was undertaken to understand the differences in life expectancy and cause-specific morbidity and mortality. While rural location plays a major role in determining the nature and level of access to and provision of health services, it does not always translate into health disadvantage. When controlling for major risk determinants, rurality per se does not necessarily lead to rural-urban disparities, but may exacerbate the effects of socio-economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions. Programs to improve rural health will be most effective when based on policies which target all risk determinants collectively contributing to poor rural health outcomes. Focusing solely on 'area-based' explanations and responses to rural health problems may divert attention from more fundamental social and structural processes operating in the broader context to the detriment of rural health policy formulation and remedial effort.

Implementing a chronic disease strategy in two remote Indigenous Australian settings: A multi-method pilot evaluation
Peter d'Abbs, Barbara Schmidt, Kathryn Dougherty, Kate Senior

Objective: To test an evaluation framework designed to evaluate implementation of the North Queensland Indigenous communities between August and December 2005.
Setting: Both communities are located in Cape York, North Queensland. Community A has an estimated population of around 600 people; Community B has an enumerated population of 750, although health centre records indicate a higher number.
Participants: Process evaluation involved health centre staff in both communities; clinical audits used random samples from the adult population (each sample n = 30); ethnographic fieldwork was conducted with resident population.
Main outcome measures: Health centre scores and qualitative findings using a System Assessment Tool; clinical audits - extent to which scheduled services recorded; selected primary health performance indicators; qualitative ethnographic findings.
Results: On almost all indicators, implementation of NQICDS had progressed further in Community A than in Community B; however, some common issues emerged, especially lack of linkages between health centres and other groups, and lack of support for client self-management.
Conclusions: The evaluation framework is an effective and acceptable framework for monitoring implementation of the NQICDS at the primary health centre level.

Lukumbat marawana: A changing pattern of drug use by youth in a remote Aboriginal community
Kate Senior, Richard Chenhall

Objective: To examine marijuana use by youth in a remote Aboriginal community in Northern Australia over a 5-year period.
Design: Participant observation, structured and unstructured interviews.
Setting: Remote Indigenous Australian community.
Participants: Young Aboriginal people and adult community members.
Main outcome measure: Emergent themes of the attitudes towards marijuana use among remote Indigenous residents are reported.
Results: Restrictions in the availability of alcohol and petrol have led to increased use of marijuana with serious social and community consequences.
Conclusions: Efforts to control licit substances, such as alcohol, in remote communities need to be addressed in the context of understanding of the dynamics of alcohol and drug use in totality as well as interventions that address underlying structural and social inequalities.

Mobilising a rural community to lose weight: Impact evaluation of the WellingTonne Challenge
David Lyle, Janet Hobba, Karen Lloyd, Debbie Bennett, Trish George, Nicolla Giddings, Norma Griffin, Patrick C. L. Chew, Mark Harris, Gaynor Heading

Objective: To evaluate the impact of the WellingTonne Challenge.
Design: Before-after study.
Setting: The National Action Agenda for the prevention and control of obesity in Australia identified community action and development as a key theme. The WellingTonne Challenge was a whole-of-community project designed to support a small rural community to lose weight and reduce their risk of chronic disease.
Participants: Adult residents of the Wellington Local Government Area who were overweight or obese.
Results: The project successfully engaged the community with around 10% of the target group formally participating in the Challenge. Participants achieved a weight reduction of around 3 kg each, as well as positive changes in diet and physical activity. A total of 59% of those who signed up for the Challenge achieved an accumulated loss of 687 kg at the end of the 12-week program - less than the community goal of 1000 kg.
Conclusion: The WellingTonne Challenge is a promising intervention. Wider implementation of this approach in other small rural communities might make a significant contribution to the national effort. The opportunity should be taken to undertake a more rigorous evaluation to determine whether this approach benefits communities in the longer term.

Rural obesity, healthy weight and perceptions of risk: Struggles, strategies and motivation for change
Gaynor Heading

Objective: To explore risk logics, embodiment (the interplay between the physical, social and subjective body) and issues related to adult obesity in remote New South Wales.
Design: Qualitative multiple-method design using semistructured interviews and visual aids (food and exercise palm cards) to explore the saliency of food and exercise options. A one-page demographic survey incorporated self-reported body mass index.
Participants: A total of 19 rural adults (13 female; six male).
Setting: Community in remote New South Wales, Australia.
Results: Thematic analysis revealed 14 major weight-related themes. Respondents raised numerous explanations for their weight gain, reported struggles with weight loss, revealed a range of motivations for weight loss and a variety of approaches to risk, not all of which are aligned to dominant health discourse. The need for realistic interventions incorporating social meaning and pleasure seeking is revealed.
Conclusion: Obesity interventions promoting 'easy' healthy choices also need to acknowledge embodiment and social status linked to consumption. Interventions that ignore the complexity surrounding consumption (e.g. the interplay of social taste, group distinction and embodiment) will have lower relevance and effectiveness.

Physical activity behaviours of adults in the Greater Green Triangle region of rural Australia
Clare Vaughan, Annamari Kilkkinen, Benjamin Philpot, Joanne Brooks, Adrian Schoo, Tiina Laatikainen, Anna Chapman, Edward D. Janus, James A. Dunbar

Objective: To assess physical activity (PA) behaviours of adults in rural Australia.
Design and setting: Three cross-sectional surveys in the Greater Green Triangle area covering the south-east of South Australia (Limestone Coast), and south-west (Corangamite Shire) and north-west (Wimmera) of Victoria during 2004-2006.
Participants: A total of 1546 persons, aged 25- 74 years, randomly selected from the electoral roll.
Main outcome measures: Overall PA, leisure-time PA, occupational PA, active commuting and moderate-to-vigorous PA.
Results: Approximately 80% of participants, more women than men, engaged in 30 minutes or more of daily PA. Only 30% (95% CI 26.3, 33.0) of men and 21% (95% CI 18.3, 23.9) of women did moderate-to-vigorous PA for at least 20-30 minutes four or more times a week. In leisure time, most participants were moderately active; almost one-fifth were inactive and another fifth highly active. Two-thirds of men engaged in high-level occupational PA, compared with one-sixth of women. Only 30% of participants actively commuted to work. There was a tendency for a positive association between income level and leisure-time PA.
Conclusions: One-fifth of adults in rural Australia were inactive. While there was a high prevalence of participants who engaged in daily PA, few did so at moderate-to-vigorous intensity to achieve health benefits. As occupational PA is difficult to change, improvements in levels of PA are more likely during leisure-time and for some people by engaging in commuting PA.

An evaluation of a community pharmacy-based rural asthma management service
Bandana Saini, Julija Filipovska, Sinthia Bosnic-Anticevich, Susan Taylor, Ines Krass, Carol Armour

Objective: To compare the effect of a pharmacist-delivered rural asthma management service (RAMS) on health outcomes for people with asthma in a rural/regional area with 'standard care' delivered through community pharmacies.
Design: A parallel group controlled repeated measures study.
Setting: Community pharmacies in Central West New South Wales.
Intervention: Standardised protocols and resources based on national asthma management guidelines, delivered by specially trained community pharmacists. Patients visited the pharmacy at baseline and 1, 3 and 6 months after baseline in the intervention group and at baseline plus 6 months after baseline in the control group.
Participants: The intervention pharmacists (n = 12) were trained to deliver the RAMS model, while control pharmacists (n = 8) provided standard asthma care to their recruited patients. Fifty-one and 39 patients were recruited by intervention and control pharmacists.
Main outcome measure: Asthma severity score which was a composite score based on recency, frequency and severity of asthma symptoms, and asthma history.
Results: Data compared at the final visit between groups indicated that the RAMS patient group demonstrated a significant reduction in the asthma severity scores (7.9 ± 2.6 versus 10.4 ± 2.6, P < 0.001); a reduction in the risk of non-adherence to medication scores (1.6 ± 0.7 versus 2.3 ± 1.1, P < 0.001); and an increase in the proportion of patients owning a written action plan (50% versus 23%, P = 0.04).
Conclusions: These results indicated that the community pharmacy-based RAMS model can improve asthma outcomes for patients in rural settings, and similar models for asthma and other chronic diseases should be tested rigorously and adopted in rural primary care practice.

Evaluation of iodine levels in the Riverina population
Leanne J. Uren, Geoff McKenzie, Helen Moriarty

Objective: To assess the iodine status in a random group of adults in a rural region.
Design: A cross-sectional study; urinary iodine concentrations (UIC) were correlated with results of a questionnaire that collected demographic information.
Setting: Primary care.
Participants: A total of 173 adults from the Riverina region provided a morning midstream urine sample and completed a questionnaire. There were no exclusion criteria.
Main outcome measures: Iodine status was based upon mean UIC (MUIC) values and categorised according to World Health Organisation criterion. Subgroups were classified according to sex, age, town, salt usage, vitamin/supplement usage, pregnant or breast-feeding status and diet.
Results: The MUIC for the study population was 79 μg L−1 ; 29% were iodine-replete, 52% had mild deficiency and 18.5% were moderately to severely deficient. Use of iodised salt produced a non-clinically significant increase in MUIC of 81 μg L−1 compared with 71 μg L−1 (P = 0.1907). Daily vitamin supplementation led to iodine sufficiency with a MUIC of 111 μg L−1 (P = 0.0011). Participants aged 50-59 years had a significantly lower MUIC than participants aged 18-39 years (67 versus 89 μg L−1 , respectively, P = 0.0106). Further, the MUIC decreased with age from 18 to 59 years (P = 0.0208).

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