Journal Search - issue 3, 2008

full article:

Canada

Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine [in French and English]

Contents: 2008; 13:(1)
Issue includes:

The Ages and Stages Questionnaires: feasibility of use as a screening tool for children in Canada
Jorina Elbers, Andrew Macnab, Elaine McLeod, Faith Gagnon

Objective: To determine the accuracy and feasibility of a monitoring tool completed by parents for screening at-risk and community infants and children for developmental problems.
Methods: We assessed 43 children following open-heart surgery and 68 community children (aged 4-36 mo) at prescribed intervals using the Ages and Stages Questionnaires (ASQ). Subjects were followed 3 years later (at age 5-6 yr) via telephone interview with their parents concerning developmental delay identified by physicians. Responses were confirmed by telephone interviews with family physicians. We then compared the results of the ASQ with the physician assessments.
Results: Nine at-risk and 9 community children were lost to follow-up. The ASQ identified 4 of the 25 at-risk children as having developmental delay, while 2 of the 6 children assessed by a neurologist were identified as having developmental delay. The ASQ identified 2 of the 59 community children as having developmental delay, 1 of whom was assessed by a neurologist as having developmental delay. The ASQ had sensitivities of 75% in the at-risk group and 100% in the community group, and specificities of 95% and 90%, respectively. The parents were unanimous in their willingness to complete the assessments.
Conclusion: The ASQ is feasible, inexpensive, easy to use, and was appreciated by the parents. It is a sufficiently sensitive and specific monitoring tool that its use in cardiac follow-up programs and in community programs for healthy children is warranted. Although this tool should not be used to replace clinical assessment, it can be used to rationalize access to specialist developmental assessment services.

The contribution of Memorial University's medical school to rural
physician supply
Maria Mathews, James T.B. Rourke, Amanda Park


Introduction: This study identifies the characteristics and predictors of Memorial University of Newfoundland (MUN) medical graduates working in rural Canada and rural Newfoundland and Labrador (NL).
Methods: We linked data from class lists, the alumni and postgraduate databases with the Southam Medical database to determine 2004 practice locations for MUN graduates from 1973 to 1998 (26 yr, inclusive). Multiple logistic regression was used to identify predictors for each outcome.
Results: In 2004, 167 (12.6%) MUN graduates worked in rural Canada and 81 (6.1%) MUN graduates worked in rural NL. Those who were more likely to practise in rural Canada (when compared with graduates from urban backgrounds, those who had not done any residency training at MUN or specialists, respectively) were graduates from a rural background (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.38-2.76), those who had done residency training at MUN (OR 1.56, 95% CI 1.06-2.29) and family physicians (FPs)-general practitioners (GPs) (OR 6.64, 95% CI 4.31-10.23). Those who were more likely to practise in rural NL (when compared with graduates from urban backgrounds, those who had not done any residency training at MUN, specialists or non-Newfoundlanders, respectively) were graduates from a rural background (OR 2.54, 95% CI 1.57-4.11), those who had done residency training at MUN (OR 4.12, 95% CI 1.94-8.76), FP-GPs (OR 6.39, 95% CI 3.39-12.05) and Newfoundlanders (OR 7.01, 95% CI 2.16-22.71).
Conclusion: The MUN medical school has made a substantial contribution to rural physician supply in both NL and Canada. Increasing the number of local rural students as well as providing incentives to graduates to complete postgraduate training in family medicine in the province may increase the number of locally trained rural physicians.

Prevalence of psychiatric diagnoses among frequent users of rural
emergency medical services
Lewis E. Mehl-Madrona


Objective: This study aimed to determine whether there was an increased prevalence of psychiatric disorders among frequent users of rural emergency medical services.
Methods: In a matched comparison design, I compared frequent users of the emergency departments of 2 rural hospitals, both affiliated with an academic centre, with randomly selected users and with randomly selected users who had the same medical diagnoses. The main outcome measures were psychiatric diagnoses on a structured clinical interview, along with medical diagnoses and number of emergency department visits in the past year.
Results: Ninety-three percent of frequent users had at least 1 DSM-IV psychiatric diagnosis, differing from 50% of random users matched for presenting complaint. A random user group, not matched for presenting complaint, showed 28% prevalence of DSM-IV diagnoses. Frequent users were more often state insured (Medicaid) and less often insured privately. The most common diagnoses among frequent users were major depression, generalized anxiety disorder, adjustment disorder, somatoform pain disorder, substance abuse and dependence, and dysthymia. The treating emergency department physician mentioned a psychiatric diagnosis for only 9% of frequent users.
Conclusion: Frequent users have a disproportionately high prevalence of psychiatric disorders (under-documented by their physicians), which may affect their pattern of emergency department use. This suggests the need for better recognition, diversion, and management.

USA

Journal of Rural Health

Contents: 2008; 24:(3)
Issue includes:

Substance Abuse by Youth and Young Adults in Rural America

David Lambert, John A. Gale, David Hartley


Purpose: Addressing substance abuse in rural America requires extending our understanding beyond urban-rural comparisons to how substance abuse varies across rural communities of different sizes. We address this gap by examining substance abuse prevalence across 4 geographic levels, focusing on youth (age 12-17 years) and young adults (age 18-25 years).
Methods: The analysis is based on 3 years (2002-2004) of pooled data from the National Survey on Drug Use and Health. We measure rurality using a four-tier consolidation of the 2003 Rural-Urban Continuum Codes: urban, rural-adjacent, rural-large, and rural-small and medium.
Findings: Rural youth have higher alcohol use and methamphetamine use than urban youth and the more rural the area, the higher the use. Rural young adults living in rural-large areas have higher rates of substance abuse than their urban peers; those living in the most rural areas have nearly twice the rate of methamphetamine use as urban young adults. Rural youth are more likely than urban youth to have engaged in the high-risk behavior of driving under the influence of alcohol or other illicit drugs.
Conclusions: Higher prevalence rates, coupled with high-risk behavior, place rural youth and young adults at risk of continued substance use and problems associated with this use. Rural community infrastructure should be enhanced to support substance abuse prevention and intervention for these populations.

The Methamphetamine Home: Psychological Impact on Preschoolers in Rural Tennessee
Comfort B. Asanbe, Charlene Hall, Charles D. Bolden


Context: A growing number of children reside with methamphetamine-abusing parents in homes where the illicit drug is produced. Yet, the effects of a methamphetamine environment on psychological child outcome are still unknown.
Purpose: To examine whether preschoolers who lived in methamphetamine-producing homes are at increased risk for developing psychological problems.
Methods: The participants were 58 white children between the ages of 4 and 5 years; 31 with a history of living in methamphetamine-producing homes and 27 children who live in non-methamphetamine producing homes in rural Tennessee. The groups were similar in age, gender, and socioeconomic background. The groups were compared for behavioral and emotional adjustment using the behavior assessment system for children-parent rating scale-preschool (BASC-PRS-P) form. Biological or custodian parents completed a rating on their preschoolers that provided information about the children's pattern of behavior and feelings.
Findings: Preschoolers from the methamphetamine-producing homes showed more externalizing problems than their peers, but were comparable on internalizing problems. On specific behaviors, the data indicate that preschoolers in the methamphetamine group showed higher aggression symptoms than their peers from non-methamphetamine-producing homes.
Conclusions: These findings, if replicated, point to the need for mental health screening when a child is removed from a methamphetamine-producing home.

Trends in Tuberculosis Reported From the Appalachian Region: United States, 1993-2005
Ryan M. Wallace, Lori R. Armstrong, Robert H. Pratt, J. Steve Kammerer, Michael F. Iademarco


Context: Appalachia has been characterized by its poverty, a factor associated with tuberculosis, yet little is known about the disease in this region.
Purpose: To determine whether Appalachian tuberculosis risk factors, trends, and rates differ from the rest of the United States.
Methods: Analysis of tuberculosis cases reported to the Centers for Disease Control and Prevention's National Tuberculosis Surveillance System (NTSS) within the 50 states and the District of Columbia from 1993 through 2005.
Results: The 2005 rate of tuberculosis in rural Appalachia was 2.1/100,000, compared to 2.7/100,000 in urban Appalachia. Urban non-Appalachia had a 2005 tuberculosis rate of 5.4/100,000. Over the 13-year period, tuberculosis rates fell in Appalachia at an annual rate of 7.8%. In one age group (15- to 24-year-olds) the rates increased at an annual rate of 2.8%. Foreign-born Hispanics were the largest racial/ethnic group in this age group. When private providers gave exclusive care for tuberculosis disease, Appalachians were less likely to complete therapy in a timely manner when compared to non-Appalachians (OR 0.6, 95% CI 0.5-0.7).
Conclusions: Tuberculosis rates and trends are similar in urban and rural Appalachia. It is crucial for public health officials in Appalachia to address the escalating TB rate among 15- to 24-year-olds by focusing prevention efforts on the growing numbers of foreign-born cases. Due to the increased risk of treatment failure among Appalachians who do not seek care from the health department, public health authorities must ensure completion of treatment for patients who seek private providers.

Rural-Urban Analyses of Health-Related Quality of Life Among People With Multiple Sclerosis
Robert J. Buchanan, Li Zhu, Randolph Schiffer, Dagmar Radin, Wesley James


Context: Health-related quality of life (HRQOL) is a multi-dimensional construct including aspects of life quality or function that are affected by physical health and symptoms, psychosocial factors, and psychiatric conditions. HRQOL gives a broader measure of the burden of disease than physical impairment or disability levels.
Purpose: To identify factors associated with HRQOL among people with multiple sclerosis (MS) utilizing the SF-8 Health Survey.
Methods: Data presented in this study were collected in a survey of 1,518 people with MS living in all 50 states. The survey sample was randomly selected from the database of the National Multiple Sclerosis Society, using ZIP codes to recruit the survey sample. A multiple linear regression model was employed to analyze the survey data, with the Physical Component Summary and the Mental Component Summary of the SF-8 the dependent variables. Independent variables were demographic characteristics, MS-disease characteristics, and health services utilized.
Findings: People with MS in rural areas tended to report lower physically related HRQOL. Worsening MS symptoms were associated with reduced physical and mental dimensions of HRQOL. In addition, people with MS who received a diagnosis of depression tended to have reduced physical and mental dimensions of HRQOL. Receiving MS care at an MS clinic was associated with better physically related HRQOL, while having a neurologist as principal care physician was associated with better mental-related HRQOL.
Conclusion: The challenge is to increase the access that people living with MS in rural areas have to MS-focused specialty care.

Rural Emergency Department Staffing and Participation in Emergency Certification and Training Programs
Michelle M. Casey, Douglas Wholey, Ira S. Moscovice


Context: The practice of emergency medicine presents many challenges in rural areas.
Purpose: We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to provide high-quality emergency care.
Methods: A national telephone survey of a random sample of rural hospitals with 100 or fewer beds was conducted in June to August 2006. Respondents included ED nurse managers and Directors of Nursing. A total of 408 hospitals responded (96% response rate).
Findings: A majority of rural hospitals use more than one type of staffing to cover the ED. The type of staffing varies by time period and ED volume. On weekdays, about onethird of hospitals use physicians on their own medical staff; one third use contracted coverage; 18% use both; and 14% use physician assistants and/or nurse practitioners with a physician on-call. Hospitals are more likely to use a combination of medical staff and contracted coverage on evenings and weekends. Advanced Cardiac Life Support training is common, but Pediatric Advanced Life Support, Advanced Trauma Life Support, and training in working as a team are less common. More registered nurses working in rural EDs have taken the Trauma Nursing Core Course than the Emergency Nursing Pediatric Course.
Conclusions: Rural ED staff would benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams.

Rural Trauma: Is Trauma Designation Associated With Better Hospital Outcomes?
Stephen M. Bowman, Frederick J. Zimmerman, Sam R. Sharar, Margaret W. Baker, Diane P. Martin


Context: While trauma designation has been associated with lower risk of death in large urban settings, relatively little attention has been given to this issue in small rural hospitals.
Purpose: To examine factors related to in-hospital mortality and delayed transfer in small rural hospitals with and without trauma designation.
Methods: Analysis of data from the Nationwide Inpatient Sample for discharges between 1998 and 2003 of patients hospitalized with moderate to major traumatic injury in nonfederal, short-stay rural hospitals with annual discharges of 1,500 or fewer patients (N = 9,590). Logistic regression was used to control for patient and hospital characteristics, stratifying by hospital volume. Main outcome measures were in-hospital death and transfer to another acute care facility after initial admission.
Findings: A total of 333 patients (3.5%) died in-hospital. After adjusting for patient, injury and hospital characteristics, in-hospital death was more likely among patients treated at the non-designated hospitals with fewer than 500 discharges per year (OR 2.35; 95% CI 1.25-4.41) than among patients treated at similar trauma-designated hospitals. Patients admitted to non-designated hospitals were more likely to be transferred after admission, although this finding was significant only in the larger-volume hospitals with discharges of 500-1,500 per year (OR 1.41, 95% CI 1.08-1.83).
Conclusions: Associations between trauma designation and outcomes in rural hospitals warrant further study to determine whether expanding designation to more rural hospitals might lead to further improvement in trauma outcomes.

Access to Specialty Health Care for Rural American Indians in Two States
Laura-Mae Baldwin, Walter B. Hollow, Susan Casey, L. Gary Hart, Eric H. Larson, Kelly Moore, Ervin Lewis, C. Holly A. Andrilla, David C. Grossman


Context: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels.
Purpose: To examine specialty service access among rural Indian populations in two states.
Methods: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%).
Findings: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers.
Conclusions: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

Sexually Transmitted Diseases and Risk Behaviors Among California Farmworkers: Results From a Population-Based Survey
Monique Brammeier, Joan M. Chow, Michael C. Samuel, Kurt C. Organista, Jamie Miller, Gail Bolan


Context: The prevalence of sexually transmitted diseases and associated risk behaviors among California farmworkers is not well described.
Purpose: To estimate the prevalence of sexually transmitted diseases (STDs) and associated risk behaviors among California farmworkers.
Methods: Cross-sectional analysis of population-based survey data from 6 California agricultural regions was performed for participants tested for Chlamydia trachomatis (CT), Neisseria gonorrhea (GC), and syphilis, and who completed an interviewer-administered behavioral risk factor survey.
Findings: Among the 403 males and 234 females examined and interviewed, males (29.3%) were more likely than females (9.6%) to have had 2 or more sex partners in the past 5 years. Forty-two percent of males ever had sex with a commercial sex worker; unmarried males were more likely than married males to report sex with a commercial sex worker in the past 2 years. Twelve percent of males and 5% of females reported ever having had an STD. Most participants did not report any methods to protect against STDs. Of 192 males and 178 females tested for CT, 3 males and no females were positive. No cases of GC were found. Of 387 males and 194 females tested for syphilis, 4 males and 1 female had positive rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) results.
Conclusions: In this population-based survey among agricultural workers, there was low STD prevalence but high prevalence of sexual risk behaviors, particularly among males.

Urban-Rural Differences in Motivation to Control Prejudice Toward People With HIV/AIDS: The Impact of Perceived Identifiability in the Community
Janice Yanushka Bunn, Sondra E. Solomon, Susan E. Varni, Carol T. Miller, Rex L. Forehand, Takamaru Ashikaga


Context: HIV/AIDS is occurring with increasing frequency in rural areas of the United States, and people living with HIV/AIDS in rural communities report higher levels of perceived stigma than their more urban counterparts. The extent to which stigmatized individuals perceive stigma could be influenced, in part, by prevailing community attitudes. Differences between rural and more metropolitan community members' attitudes toward people with HIV/AIDS, however, have rarely been examined.
Purpose: This study investigated motivation to control prejudice toward people with HIV/AIDS among non-infected residents of metropolitan, micropolitan, and rural areas of rural New England.
Methods: A total of 2,444 individuals were identified through a random digit dialing sampling scheme, and completed a telephone interview to determine attitudes and concerns about a variety of health issues. Internal or external motivation to control prejudice was examined using a general linear mixed model approach, with independent variables including age, gender, community size, and perceived indentifiability within one's community.
Findings: Results showed that community size, by itself, was not related to motivation to control prejudice. However, there was a significant interaction between community size and community residents' perceptions about the extent to which people in their communities know who they are.
Conclusion: Our results indicate that residents of rural areas, in general, may not show a higher level of bias toward people with HIV/AIDS. The interaction between community size and perceived identifiability, however, suggests that motivation to control prejudice, and potentially the subsequent expression of that prejudice, is more complex than originally thought.

Depression and Poverty Among Rural Women: A Relationship of Social Causation or Social Selection?
Leigh A. Simmons, Bonnie Braun, Richard Charnigo, Jennifer R. Havens, David W. Wright


Context and Purpose: Depression among rural women is a major public health concern. The purpose of this study was to test the competing theories of social causation and social selection to assess the relationship between depression and economic status for a sample of rural, low-income women in the United States.
Methods: Structural equation modeling was used to analyze data from Rural Families Speak, a US Department of Agriculture-funded multi-state, longitudinal study of rural low-income families (N = 413).
Findings: Results indicated that the social causation theory yielded a better approximation of the relationship between economic status and depression (RMSEA = 0.50 for a model based on this theory) than the social selection theory (RMSEA = 0.067).
Conclusions: The association between lesser economic status and depressive symptoms is pressing in rural areas, given the high prevalence of both depression and poverty. These findings further emphasize the need for improved mental health services in this vulnerable population.

Fruit and Vegetable Dietary Behavior in Response to a Low-Intensity Dietary Intervention: The Rural Physician Cancer Prevention Project
Patricia Carcaise-Edinboro, Donna McClish, Amanda C. Kracen, Deborah Bowen, Elizabeth Fries

Context: Increased fruit and vegetable intake can reduce cancer risk. Information from this study contributes to research exploring health disparities in high-risk dietary behavior.
Purpose: Changes in fruit and vegetable behavior were evaluated to assess the effects of a low-intensity, physician-endorsed dietary intervention in a rural population.
Methods: The study was a randomized trial of 754 patients from 3 physician practices in rural Virginia. Low-literacy nutrition education materials and personalized dietary feedback were administered by mail and telephone. Mixed model analysis of variance was used to determine the effect of the intervention on fruit and vegetable intake behavior, knowledge, intentions, and self-efficacy at 1, 6, and 12 months.
Findings: The intervention effect was moderated by age, race, sex, and education. Intake at 1 and 6 months was increased for older and younger participants and those with some college, and further maintained at 12 months by those who did not complete high school. African Americans in the intervention group displayed significantly greater intentions to increase fruit/vegetable intake than whites/others. Knowledge of fruit/vegetable recommendations significantly increased in the intervention group at 12 months, particularly for men.
Conclusions: For the rural population, a low-intensity physician-endorsed self-help dietary intervention was successful in initiating fruit and vegetable dietary changes at 1 and 6 months post-intervention, and increasing intentions to change in African Americans. The relationship of the moderating effects of age, race, sex and education need to be further explored in relation to dietary intervention and dietary behavior change for the rural population.

How Does Degree of Rurality Impact the Provision of Surgical Services at Rural Hospitals?
Brit Doty, Randall Zuckerman, Samuel Finlayson, Paul Jenkins, Nathaniel Rieb, Steven Heneghan


Context: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care.
Purpose: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care.
Methods: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes.
Findings: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital.
Conclusions: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

Innovative Peer Review Model for Rural Physicians: System Design and Implementation
Josie R. Williams, Kathy Mechler, Ralitsa B. Akins


Context: The peer review process in small rural hospitals is complicated by limited numbers of physicians, conflict of interest, issues related to appropriate utilization of new technology, possibility for conflicting recommendations, and need for external expertise.
Purpose: The purpose of this project was to design, test, and implement a virtual peer review system for small rural hospitals in Texas. We sought to define the characteristics of a virtual peer review system in the context of rural health care, and to explore the benefits from peer review administration within a rural network supported by a university.
Methods: Physicians from small rural hospitals participated in pilot testing of the system. Policies and procedures reflecting the innovative character of the new peer review process were developed based on legal/regulatory requirements and desired educational focus of the process. An information technology system to support the virtual peer review was selected, tested, and deployed.
Findings: The system tests suggested feasibility of the procedures, reliability of the communication lines, and functional anonymity of the hospitals and physicians participating in the virtual peer review. Participating institutions and individual physicians expressed satisfaction with the reliability and user friendliness of the system as demonstrated during the pilot tests.
Conclusions: Hospital licensing and accreditation require a process to monitor and evaluate the care of patients. Utilizing means of virtual communication is a viable option for small rural hospitals. This process is dependable, user-friendly and provides functional anonymity to participating hospitals and physicians. The peer review system has successfully functioned since 2004.

Ethics Committees in the Rural Midwest: Exploring the Impact of HIPAA
Karen M. Having, Dena Hale, Charla J. Lautar


Context: Confidentiality of personal health information is an ethical principle and a legislated mandate; however, the impact of the Health Insurance Portability and Accountability Act (HIPAA) on ethics committees ethics committees is limited. Purpose: This study investigates the prevalence, activity, and composition of ethics committees located in rural central and southern Illinois. Additionally, the impact of the HIPAA Officer serving on the committee is reported.
Methods: Surveys were mailed to the "Administrator or Ethics Committee Chairperson" at rural Illinois hospitals and skilled care facilities. Survey items included committee composition and perception of HIPAA-related involvement.
Findings: Over one third (36.7%) of the facilities reported having formal ethics committees. Hospitals were more likely (79.3%) to have ethics committees than skilled nursing facilities (20.7%). Ethics committee members usually include an administrator, nurse, and physician. The smaller the facility (based on number of beds), the more likely it was to have a HIPAA Officer on the committee. Committees with a HIPAA Officer were more likely to be involved in monitoring and/or remediation of HIPAA privacy and security violations. Most respondents, however, did not feel the committee should be involved in these issues.
Conclusions: Although the sample size is too small to generalize, HIPAA does seem to have an effect on the issues discussed by ethics committees. Furthermore, ethics committees that include a HIPAA Officer in the membership report increased committee involvement in HIPAA related issues.

Promoting Regional Disaster Preparedness Among Rural Hospitals
Janine C. Edwards, JungEun Kang, Rasa Silenas


Context and Purpose: Rural communities face substantial risks of natural disasters but rural hospitals face multiple obstacles to preparedness. The objective was to create and implement a simple and effective training and planning exercise to assist individual rural hospitals to improve disaster preparedness, as well as to enhance regional collaboration among these hospitals.
Methods: The exercise was offered to rural hospitals enrolled with the Rural and Community Health Institute of the Texas A&M University System Health Science Center, and 17 participated. A 3-hour tabletop exercise emphasizing regional issues in a pandemic avian influenza scenario followed by a 1-hour debriefing was implemented in 3 geographic clusters of hospitals. Trained emergency preparedness evaluators documented observations of the exercise on a standard form. Participants were debriefed after the exercise and provided written feedback.
Results: Observations included having insufficient staff for incident command, facility constraints, the need to further develop regional cooperation, and operational and ethical challenges in a pandemic.
Conclusions: The tabletop exercise gave evidence of being a simple and acceptable tool for rural medical planners. It lends itself well to improving medical preparedness, analysis of weak spots, development of regional teamwork, and rapid response.

Identifying the Gaps Between Biodefense Researchers, Public Health, and Clinical Practice in a Rural Community
Jessica M. Van Fleet-Green, Frederick M. Chen, Peter House


Objective: It is essential for health care professionals to be prepared for a bioterrorist attack or other public health emergency. We sought to determine how well biodefense and emerging infectious disease research information was being disseminated to rural health care providers, first responders, and public health officials.
Methods: Semi-structured interviews were conducted at a federally funded research institution and a rural community in Washington state with 10 subjects, including researchers, community physicians and other health care providers, first responders, and public health officials.
Results: The interviews suggest there is inadequate information dissemination regarding biodefense and emerging infectious disease research and an overall lack of preparedness for a bioterrorist event among rural clinicians and first responders. Additionally, a significant communication gap exists between public health and clinical practice regarding policies for bioterrorism and emerging infectious disease. There was, however, support and understanding for the research enterprise in bioterrorism.
Conclusions: Biodefense preparedness and availability of information about emerging infectious diseases continues to be a problem. Methods for information dissemination and the relationships between public health officials and clinicians in rural communities need to be improved.

Attitudes Toward Telehealth Use Among Rural Residents: A Danish Survey
Jens F.L. Sørensen


Context: Rural communities tend to be underserved by medical services. Low access to medical services affects quality of life and may also affect settlement decisions. The use of telehealth has often been mentioned as an alternative way to provide health care services in remote, underserved areas. One prerequisite for successful delivery of health care by means of telehealth is the existence of positive attitudes toward telehealth solutions among the potential end beneficiaries.
Purpose: The purpose of this study was to examine the attitudes toward telehealth use among residents in a Danish rural area.
Method: A representative sample from the island of Ærø (n = 1,000) was selected and attitudes toward 2 telehealth applications were examined by structured telephone interviews regarding: (1) video consultation between patient and specialist, and (2) transfer of work tasks from local hospital to a hospital outside Denmark.
Findings: As many as 58% did not like the idea of having a consultation with a specialist carried out by video consultation, whereas 26% did not like the idea of having their X-rays assessed by a hospital outside Denmark. The reluctance regarding both telehealth solutions was higher among older people and people with no education beyond primary school.
Conclusions: As the rural population in Denmark, as well as in other countries, tends to be older and less educated than the national average, the introduction of telehealth services faces special challenges in rural areas.

Harnessing the social capital of rural communities for youth mental health: An asset-based community development framework
Candice P. Boyd, Louise Hayes, Rhonda L. Wilson, Cate Bearsley-Smith


In Australia, we are facing a period of mental health reform with the establishment of federally funded community youth services in rural areas of the country. These new services have great potential to improve the mental health of rural adolescents. In the context of this new initiative, we have four main objectives with this article. First, we consider the notion of social capital in relation to mental health and reflect on the collective characteristics of rural communities. Second, we review lessons learned from two large community development projects targeting youth mental health. Third, we suggest ways in which the social capital of rural communities might be harnessed for the benefit of youth mental health by using asset-based community development strategies and fourth, we consider the role that rural clinicians might play in this process.

Workplace stressors experienced by physiotherapists working in regional public hospitals
Robyn Lindsay, Lisa Hanson, Melanie Taylor, Helen McBurney


Objective: To identify and measure the effects of workplace stressors experienced by Victorian regional physiotherapists.
Design: Survey questionnaire.
Setting and participants: A questionnaire was distributed to three Victorian regional public physiotherapy departments and data were collected from 80 physiotherapists.
Main outcome measures: The type and frequency of workplace stressors, the nature and frequency of common signs and symptoms of stress and the amount of leave taken as a result of stress were measured.
Results: Caseload quantity, complexity of patients, constant excessive workload, covering staff on leave and staff shortages, were reported as key workplace stressors. Physiotherapists aged between 20 and 29 years were significantly more likely to report a higher number of workplace stressors (F = 4.173, n = 80, P = 0.009). Inpatient rehabilitation physiotherapists were significantly more likely to report stress at a higher frequency than physiotherapists working in other areas (χ2 = 14.359, n = 73, P = 0.002). Eleven per cent of all respondents reported taking leave from work as a result of stress with no significant difference identified between those who took leave and those who did not. There was, however, a trend identified with senior staff (Z = 1.792, n = 80, P = 0.073) and those who work in inpatient rehabilitation (χ2 = 6.926, n = 80, P = 0.074) being more likely to take leave as a result of stress. Many of these physiotherapists did not make their employers aware of the reasons for the leave (77%, n = 9).
Conclusions: High caseloads, periods of increased activity and staff shortages are some of the factors that contribute to stress in regional physiotherapists. Younger therapists were more likely to identify stressors with greater frequency. Strategies to monitor, prevent and manage stress should be implemented to minimise burnout in regional physiotherapists.

Retention of general practitioners in rural Nepal: A qualitative study
Katrina Butterworth, Bruce Hayes, Bhusan Neupane


Objectives: To explore the key issues that influence GP retention in rural areas of Nepal.
Design: A qualitative study using triangulation of data from one postal questionnaire, one hand-delivered questionnaire with semistructured interview and focus group discussions. Data from a small community survey from 13 rural districts also included.
Participants: Sixty-two Nepali GPs, 25 doctors in General Practice training programs, 11 individuals involved in policy development and rural health care.
Results: The key issues identified by this study as critical to the retention of Nepali GPs in rural areas were:
? Career/promotion prospects
? Status/recognition
? Financial incentives
? Working conditions
? Education for children
? Continuing medical education
? Political stability and security
Conclusions: The strongest theme was that of career development. This must be addressed by the Government of Nepal if there is to be any hope of improving retention of GPs in rural areas. GPs need to have a clear career ladder, with recognition of the value of service in rural areas. There is, however, no one single answer to the complex interacting factors that impact on GP retention in rural Nepal. A multifaceted, holistic response is necessary. From the level of community awareness, a career structure and financial remuneration to adequately set up hospitals, functional teams, family support, continuing professional development and a secure working environment - each area must be addressed for the whole to function.

Creating a database to facilitate multilevel analyses of mental health determinants and outcomes in rural and remote areas
Philip Lane, Helen J. Stain, Brian Kelly, Terry J. Lewin, Nick Higginbotham


Objective: The lack of consistent findings regarding comparisons of mental health between rural and urban areas has been attributed in part to methodological shortcomings, including poor conceptualisation of 'rurality'. To address the diversity of rural and remote communities, an interdisciplinary collaboration sought to establish a database incorporating a range of domains hypothesised to be major influences on the mental health of individuals, families and communities.
Design: The database domains included health (physical and mental), health service utilisation, sociodemographic characteristics, climate patterns, agricultural activity and primary industry. Important steps in the development of the database were addressing issues related to ethics, ownership, accessing data sources, sustainability of the database and integration of differing outcomes sought by the collaborators.
Results: The paper describes the database while an illustrative example of analysis demonstrates its application. The potential for multilevel analyses between the database and other datasets is discussed as well as challenges for the future development of this valuable resource for rural mental health research.
Conclusion: The Centre for Rural and Remote Mental Health database will be a valuable resource for rural mental health research.

Quality of life in Hepatitis C virus infection: Assessment of rural patients living in north-western New South Wales
Sanjeevani Gunasekera, John Fraser, Christian Alexander


Objective: To measure the health-related quality of life (HRQOL) of rural Australian Hepatitis C virus (HCV)-infected patients living in north-western New South Wales.
Design: A cross-sectional survey, including the Short Form 36 (SF36) questionnaire as well as topics concerning demographic data and items relating to the perceived mode and duration of HCV infection.
Subjects: A total of 80 patients with HCV infection were identified, using non-random, convenience sampling, during October 2004 to June 2005. These patients attended either the Hepatitis C clinic, the Alcohol and Other Drugs clinic or general practitioner surgeries in rural north-western New South Wales. Of the 80 patients selected, 65 completed the survey instrument, yielding a response rate of 81%.
Measurements: HRQOL in terms of the standard eight SF36 subscores as well as aggregate physical and Mental Component Summary (MCS) scores based on the SF36.
Results: Patients attending the Alcohol and Other Drugs clinic had a significantly (P = 0.024) lower vitality score than patients attending either the Hepatitis C clinic or the general practice surgeries. Otherwise, the three groups had similar scores in respect of the remaining seven SF36 dimensions. Most participants (86%) stated that their families are aware of their HCV status and 74% of participants mentioned that their families are supporting them in respect of their HCV status.
Conclusion: Our rural HCV-infected patients have comparable HRQOL measures to their counterparts selected from patients attending the Liver Diseases Clinic or the Infectious Diseases Clinic in Adelaide. Both groups have reduced HRQOL compared with the Australian population norm.

Rural carers online: A feasibility study
Briony Dow, Kirsten Moore, Peter Scott, Amodha Ratnayeke, Kate Wise, Jane Sims, Keith Hill


Objective: To test the feasibility (for a potential randomised controlled trial) of a computer intervention for improving social interaction and promoting the mental health of rural carers.
Design: The study combined pre- and post-intervention measures with interviews to determine the feasibility of the intervention and the acceptability of the study design to participants. The intervention consisted of providing 14 rural carers with computers and a 4-week training program on basic computer skills, using email and the Internet.
Setting: The study was conducted in a rural community setting.
Participants: The carers were 12 women and two men, aged from 50 to 81 years, with an average of 65.5 years.
Main outcome measures: Measures of social isolation (UCLA Loneliness Scale), depression (Geriatric Depression Scale), carer burden (Zarit Burden Interview) and computer confidence were taken at baseline and at a 3-month follow-up. Interviews were completed at follow-up to discuss outcomes of the study. A focus group discussion was conducted with 11 participants to discuss the study and resolve computer issues.
Results: Most carers reported increased confidence in email and Internet use. There was improvement for most participants in depressive symptoms and social isolation, but little change in carer burden. Participants identified many social benefits associated with the computer intervention, such as intergenerational connection, community building, skills and confidence and preparation for the future.
Conclusion: The intervention was found to be practical and acceptable for a group of older carers. It was concluded that it would be feasible to conduct a large randomised controlled trial of the intervention.

Integrated Community Policy Uptake Model: Responding to select Manitoba and Saskatchewan rural women's experiences of health reform/renewal
Pammla Petrucka, Donna Lynn Smith


Objective: To explore the impacts and implications of health reform/renewal for rural women in Saskatchewan and Manitoba, Canada.
Design: The study was a multiple case study approach using mixed methods of focus groups, individual interviews, and trends/utilization analysis.
Setting: Three rural communities - two in Saskatchewan; one in Manitoba.
Participants: Rural women; non-health providers.
Interventions: None.
Outcome Measures: None.
Results: This paper presents a four phase Integrated Community Policy Uptake Model which is derived from the experiences of rural women during the operationalizing of health reform policy. The model depicts a four phase integration of the health reform or renewal policy; specifically, 'Taking In', 'Taking On', 'Taking Over', and 'Taking Beyond'. The Integrated Community Policy Uptake Model is firmly rooted in the perceptions and opinions of rural women, and is informed by their understanding of health policy.
Conclusion: The involvement of rural women in the policy process is necessary. The model proposed potentially encourages women to become more directly engaged in future health policy making and planning. There is also significant potential for this model to inform decision makers of the perceptions, needs, and solutions offered by stakeholders such as rural women.

Public support for anti-smoking legislation varies with smoking status
Trudy Dwyer, Julie Bradshaw, William K. Mummery, Kerry R. Searl, Dolene Rossi, Marc Broadbent


Objective: Rural Australians have higher rates of smoking than their urban counterparts, contributing to poorer health outcomes. In 2004, the Queensland Government introduced legislation to reduce the impact of environmental tobacco smoke on the community. The aims of the study were to describe smoking behaviours and associations between smoking behaviour and agreement with current anti-smoking laws.
Participants: A total of 1208 people over the age of 18 years and living in rural, remote and very remote central Queensland participated in this telephone survey.
Results: About 22% (n = 130) of female and 21% of male (n = 125) participants identified themselves as smokers. No difference existed between the mean age of smokers (47.3 years) and non-smokers (47.1 years). While there is high level of support for smoking restrictions in public places (75%), attitudes vary with smoking status. Smokers were less likely than smokers to agree that the legislation would create a healthier environment, reduce exposure to passive smoking or agree that 'it is right to ban smoking in public places'. Smokers were significantly more likely to agree that the legislation had gone too far.
Conclusion: The gradual implementation of the anti-smoking legislation is changing social beliefs on what are acceptable smoking practices. It is likely that the legislation within Queensland and the subsequent forced changes in social conditions for smokers will continue to reduce the number of people smoking and reduce exposure to environmental tobacco smoke.

Rural inpatient rehabilitation by specialist outreach: Comparison with a city unit
Malcolm Bowman, Steven Faux, Stephen Wilson


Objective: To examine the effectiveness of a rural inpatient rehabilitation service provided by specialist outreach, and to compare outcomes with a large inner city unit.
Design: Descriptive study using health service outcome data.
Setting: Rural base hospital and inner city tertiary referral centre.
Participants: A total of 329 patients (234 city and 95 rural) admitted for inpatient rehabilitation.
Main outcome measures: Length of hospital stay, Functional Independence Measure, discharge destination.
Results: Functional Independence Measure gain per week was 5.4 for the rural outreach unit, compared with 5.5 for the city unit. Length of stay was shorter for the rural unit, with a higher proportion of patients discharged to nursing home.
Conclusions: Similar rates of functional improvement are achievable with rural inpatient rehabilitation provided by specialist outreach compared with a large inner city unit. Local factors probably account for the shorter length of stay in the rural unit.

Learning and being a first-time student supervisor: Challenges and triumphs
Robert B. Pereira


The transitions made from a student to a practitioner can be daunting for recent graduates when they enter the 'real world' and apply theory, frames of reference and idealistic goal setting to achieve the best outcome for their clients experiencing dysfunction, disruption or disability. The exponential rate of learning that the recent graduate experiences is phenomenal and can either promote their development as innovative and prepared practitioners or lead towards an early career change or feelings of incompetence. Retention in the allied health professions is of upmost importance for the ongoing development of professional scholarship, reputation and continued responsibility to the community. This is especially true for those working, or considering to work in regional, rural and remote areas where there is an ever-growing need for flexible, resourceful and culturally sensitive health professionals