Journal Search - issue 3, 2005

full article:

Use of seat belts in rural Alberta: an observational analysis
Kathy L. Belton, Don Voaklander, Laureen Elgert, Steve MacDonald

Objective: This paper details an observational study that estimates rates for wearing seat belts in rural Alberta and compares them with rates derived from a similar study conducted in 1999.
Method: Direct observations of drivers and front-seat passengers of 72 593 light-duty vehicles were carried out at 334 survey locations in communities with populations of fewer than 25 000, throughout northern, central and southern Alberta. In addition to seat belt use, information collected included vehicle type, gender of drivers and passengers and, at intersections controlled by a stop sign, whether or not the vehicle came to a complete stop.
Results: The results indicate that in 2001 in rural Alberta the estimated proportion of driver and front-seat passengers of light-duty vehicles using seat belts was 76.1%. When compared with 1999 data, this represents a 6.9% increase in seat belt wearing rates. The data was desegregated further to show differential wearing rates between drivers of different vehicle types, males and females, drivers and passengers, and between those who came to a complete stop at a stop sign and those who did not. The time of day in which data collection took place also had some influence on seat belt wearing rates.
Discussion: This study contributes valuable information to programs and initiatives that aim to increase the use of seat belts in rural Alberta.

Assessing the standard of care for child and adolescent attention-deficit hyperactivity disorder in Elgin County, Ontario: a pilot study
Natalie Kotowycz, Susan Crampton, Margaret Steele

Objective: To examine the current practice of rural family physicians in managing children with attention-deficit hyperactivity disorder (ADHD).
Design: Chart review of children and adolescents with a recorded diagnosis of ADHD. The data collected include the patient's age at diagnosis, the diagnosing physician, the number and type of presenting symptoms, whether the Diagnostic Statistical Manual, 4th ed (DSM-IV) criteria were met, pertinent treatment regimens, family history and comorbid conditions. Participating physicians were asked to complete a questionnaire.
Setting: Elgin County, Ontario
Results: Thirty-six family physicians were contacted and 11 agreed to participate. Thirty-nine charts were reviewed. The average number of presenting symptoms was 2.9 for ADHD-inattentive subtype and 2.1 for ADHD-hyperactivity subtype. A diagnostic protocol was included in 20.5% of the charts. Of the 39 charts reviewed, 25.6% had sufficient information for the patients to meet the ADHD criteria. Family physicians diagnosed 5.1% of the cases, and the duration of time between referral to specialist and appointment was 47.2 weeks.
Conclusions: Together the lack of symptom recording, the long duration between referrals, and the low percentage of family physicians diagnosing ADHD all suggest the need for developing diagnostic protocols for family physicians and increasing their knowledge of diagnosing and managing ADHD.

Potential gaps in congestive heart failure management in a rural hospital
Margaret D. Sanborn, Douglas G. Manuel, Ewa Ciechanska, Douglas S. Lee

Introduction: Congestive heart failure (CHF) is increasingly recognized as an important cause of morbidity and mortality. Previous studies in urban settings have shown that patients frequently are not receiving recommended therapy. There is a paucity of studies that have evaluated CHF management in a rural setting. We therefore reviewed hospital and outpatient care in this setting as an initial step toward improving CHF care.
Method: A retrospective chart review was used to examine the care of all 34 patients hospitalized for CHF from 2000-2001 in a small rural hospital, to assess the need for improved CHF management.
Results: The median age of the patients was 78 yr, and a number of them had many co-morbid cardiovascular risks. Similar to other studies, only 23% of patients were prescribed recommended doses of angiotensin-converting enzyme (ACE) inhibitors. Use of beta-blockers was far below expected rates. Although there was follow-up care for nearly all patients (97%), few patients had echocardiography performed (38%) or had their medications altered in the outpatient setting.
Conclusion: There is a need for improved management of CHF in the rural setting. Approaches to improving CHF care should use the continuity of care advantage provided by primary care physicians to optimize outpatient medical treatment regimens and improve access to diagnostic services such as echocardiography.

If all ambulances could fly: putting provincial standards of emergency care access to the test in Northern British Columbia
Jessica McGregor, Neil Hanlon, Scott Emmons, Don Voaklander, Karen Kelly

Introduction: Geographic access to emergency treatment remains an important public policy concern as rural emergency medical systems respond to various pressures to centralize services. Geographical Information Systems (GIS) are effective tools to determine what proportion of a given population is adequately served by existing or proposed service distributions.
Methods: This study compares 2 GIS approaches to determining whether recent standards of emergency care access established by the British Columbia Ministry of Health Services are being met in Northern British Columbia. In particular, we compare results obtained using the more commonly used straight-line, or "as the crow flies," method with those obtained using a more sophisticated method that estimates travel time using digitally referenced road network data.
Results: Both methods reveal that provincial standards of emergency access are not being met in Northern British Columbia.
Conclusion: In terms of comparing the 2 approaches, the network technique indicated a lower level of access and was more accurate in identifying populations residing inside and outside the "golden hour" of emergency care.

The occasional removal of an ingrowing toenail
Harvey V. Thommasen, C. Stuart Johnston, Amy Thommasen

The ingrowing toenail is a painful foot condition that can be treated by most rural physicians. If it is not too severe, conservative management can be initiated first. If the situation is not improving or is worsening, removal of the nail plate with destruction of the nail matrix, by either surgical or chemical matricectomy, is indicated. Neither matricectomy technique is particularly complicated. Quick healing, minimal postoperative morbidity, high success rates and cosmetically acceptable results are the rule. Risks associated with the procedure include infection, chronic ulcer formation, pain, prolonged healing, irregular nail regrowth and recurrence. Patients should be aware of these risks before the matricectomy is performed.

Primary and Specialty Medical Care Among Ethnically Diverse, Older Rural Adults With Type 2 Diabetes: The ELDER Diabetes Study
Ronny A. Bell, Sara A. Quandt, Thomas A. Arcury, Beverly M. Snively, Jeanette M. Stafford, Shannon L. Smith, Anne H. Skelly


Purpose: Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes.
Methods: Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n = 220), Native American (n = 181), and white (n = 297) Medicare beneficiaries _65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year.
Findings: Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported seeing .1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P,.01), while men were more likely than women to have seen a bladder specialist (P =.02), kidney specialist (P =.001), and heart specialist (P =.004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health.
Conclusions: These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.

Perceived Barriers to Health Care Access Among Rural Older Adults: A Qualitative Study
R. Turner Goins, Kimberly A. Williams, Mary W. Carter, S. Melinda Spencer, Tatiana Solovieva


Context: Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access.
Purpose: To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication.
Methods: During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access. Findings: Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration.
Conclusions: Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

Changes in Age-Adjusted Mortality Rates and Disparities for Rural Physician Shortage Areas Staffed by the National Health Service Corps: 1984-1998
Donald E. Pathman, George E. Fryer, Larry A. Green, Robert L. Phillips


Objective: This study assesses whether the National Health Service Corps's legislated goals to see health improve and health disparities lessen are being met in rural health professional shortage areas for a key population health indicator: age-adjusted mortality.
Methods: In a descriptive study using a pre-post design with comparison groups, the authors calculated age-adjusted mortality rates at baseline (1981-1983) and follow-up (1996-1998) for the populations of 448 rural whole-county health professional shortage areas arrayed into 3 groups based on the number of study years they were staffed by National Health Service Corps physicians, physician assistants, and nurse practitioners (terms of 1 to 7, 8 to 11, and 12 to 15 years). The authors compared changes over time in age-adjusted mortality rates in the 3 county groups that had National Health Service Corps staffing with rate changes in 172 whole-county rural health professional shortage areas and 772 non-health professional shortage area rural counties that had no National Health Service Corps. Results: At baseline, age-adjusted mortality was higher in all 4 health professional shortage area county groups than in the non-health professional shortage area county group. Age-adjusted mortality rates improved with time in all groups, including health professional shortage area counties both with and without National Health Service Corps support, and non-health professional shortage area counties. Essentially, baseline differences in age-adjusted mortality rates between health professional shortage areas and non-health professional shortage area counties did not diminish with time, whether or not there was National Health Service Corps support.
Conclusions: From the early 1980s through the mid-1990s, the National Health Service Corps's goal to see health improve in rural health professional shortage areas was met, but its goal to diminish geographical health disparities was not. Because age-adjusted mortality rates improved in all county groups, the authors conclude that improvement was likely due to a variety of factors, including decreasing poverty and unemployment rates and increasing primary care physician-to-population ratios, to which the National Health Service Corps may have contributed.

Physicians for Rural America: The Role of Institutional Commitment Within Academic Medical Centers
John R. Wheat, John C. Higginbotham, Jing Yu, James D. Leeper


Context: Prior study suggests that contextual characteristics of medical schools (eg, state demographics, public vs private, NIH research effort) predict output of rural physicians without also considering the effects of the medical schools' own policies and programs.
Purpose: This study examines medical school commitment to rural policies and programs and its relationship to contextual characteristics and rural physician output.
Methods: A survey of 122 US allopathic medical schools provided data to construct a 32-item Rural Commitment Index for each medical school. Data for other characteristics were linked from published sources. Correlations, t tests, and multiple regression analysis were used to study the association between variables and percentage of medical school graduates (1988-1996) who were in rural primary care practice in 2000.
Findings: Among 90 medical schools (response rate, 73.8%), the Rural Commitment Index correlated with the percentage of the state population that is rural and whether the school is public or private, and it joined percentage state population rural, public vs private, and National Institutes of Health support in correlating with percentage of graduates in rural primary care. In a regression model that explained 48.4% of variation in the percentage of graduates in rural primary care, the Rural Commitment Index explained most variation, followed by percentage state population rural, public vs private, National Institutes of Health support, and the interaction between the Rural Commitment Index and public vs private.
Conclusions: The findings support the proposition that observable institutional commitment affects rural physician output and provide justification for a definitive study to verify that a change in medical school commitment to rural medicine produces a change in rural physician output.

High School Census Tract Information Predicts Practice in Rural and Minority Communities
Susan Hughes, John Zweifler, Sean Schafer, Mark A. Smith, Sukhdeep Athwal, H. John Blossom


Purpose: Identify census-derived characteristics of residency graduates' high school communities that predict practice in rural, medically underserved, and high minority-population settings.
Methods: Cohort study of 214 graduates of the University of California, San Francisco-Fresno Family Practice Residency Program (UCSF-Fresno) from its establishment in 1970 through 2000. Rural-urban commuting area code; education, racial, and ethnic distribution; median income; population; and federal designation as a medically underserved area were collected for census tracts of each graduate's (1) high school address and (2) practice location.
Findings: Twenty-one percent of graduates practice in rural areas, 28% practice in areas with high proportions of minority population (high minority areas), and 35% practice in federally designated medically underserved areas. Graduation from high school in a rural census tract was associated with rural practice (P ,.01). Of those practicing in a rural site, 32% graduated from a rural high school, as compared with 11% of nonrural practitioners. Graduation from high school in a census tract with a higher proportion of minorities was associated with practice in a proportionally high minority community (P =.01). For those practicing in a high-minority setting, the median minority percentage of the high school census tract was 31%, compared with 16% for people not practicing in a high minority area. No characteristics of the high school census tract were predictive of practice in a medically underserved area.
Conclusion: Census data from the residency graduate's high school predicted rural practice and practice in a proportionally high minority community, but not in a federally designated medically underserved area.

Where a Cancer Patient Dies: The Effect of Rural Residency
Frederick I. Burge, Beverley Lawson, Grace Johnston


Context: Surveys indicate 50% to 80% of cancer patients would choose to die at home if possible, although far fewer actually do. In Nova Scotia (NS), cancer deaths occurring out-of-hospital increased from 19.8% in 1992 to 30.2% in 1997. The impact of rural residency on this trend has not been studied.
Purpose: To determine the association between dying of cancer in a rural locale and the likelihood of it being an out-of-hospital death.
Methods: Secondary analysis of linked population-based administrative health data files. Subjects were all Nova Scotians who died of cancer from 1992 to 1997. Measures included location of death, dichotomized as a hospital death or an out-of-hospital death; and urban-rural residency, using an enumeration area urban-rural indicator created from postal code information adjusted for individual characteristics.
Results: Of the 13,652 total cancer deaths, 6,171 occurred in rural NS, of which 1,471 (23.8%) died out-of-hospital. Out-of-hospital deaths in rural NS increased from 16.2% in 1992 to just over 27% in 1997. Compared with urban cancer patients, the adjusted odds of an out-of-hospital death in rural NS was lower (adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.95).
Conclusions: There was an increasing trend during the 1990s for cancer patients to die out-of-hospital. Compared with their urban counterparts, patients in rural areas were less likely to do so. Those with cancer living in the rural setting who wish to die at home may face unique challenges.

Urban, Rural, and Regional Variations in Physical Activity
Sarah Levin Martin, Gregory J. Kirkner, Kelly Mayo, Charles E. Matthews, J. Larry Durstine; James R. Hebert


Purpose: There is some speculation about geographic differences in physical activity (PA) levels. We examined the prevalence of physical inactivity (PIA) and whether US citizens met the recommended levels of PA across the United States. In addition, the association between PIA/PA and degree of urbanization in the 4 main US regions (Northeast, Midwest, South, and West) was determined.
Methods: Participants were 178,161 respondents to the 2000 Behavioral Risk Factor Surveillance System (BRFSS). Data from 49 states and the District of Columbia were included (excluding Alaska). States were categorized by urban status according to the US Department of Agriculture. Physical activity variables were those commonly used in national surveillance systems (PIA Πno leisure-time PA; and PA Πmeeting a PA recommendation).
Results: Nationally, PA levels were higher in urban areas than in rural areas; correspondingly, PIA levels were higher in rural areas than in urban areas. Regionally, the urban-rural differences were most striking in the South and were, in fact, often absent in other regions. Demographic factors appeared to modify the association.
Conclusion: The association between PA and degree of urbanization is evident and robust in the South but cannot be generalized to all regions of the United States. For the most part, the Midwest and the Northeast do not experience any relationship between PA and urbanization, whereas, in the West, the trend appears to be opposite of that observed in the South.

HIV in Predominantly Rural Areas of the United States
H. Irene Hall, Jianmin Li, Matthew T. McKenna


Background: The burden of HIV/AIDS has not been described for certain rural areas of the United States (Appalachia, the Southeast Region, the Mississippi Delta, and the US-Mexico Border), where barriers to receiving HIV services include rural residence, poverty, unemployment, and lack of education.
Methods: We used data from Centers for Disease Control and Prevention (CDC) HIV/AIDS Reporting System to determine the rates of HIV (data from 29 states) and AIDS diagnoses (data from 50 states and the District of Columbia) in 2000 for the 4 regions by demographic and residential (rural and economic indicators of county of residence) characteristics.
Results: The rate of HIV diagnoses in 2000 was lower in rural areas (7.3 per 100,000) than in suburban (8.6 per 100,000) or urban areas (22.7 per 100,000). The highest race-adjusted rate was observed for the US-Mexico Border (21.1 per 100,000), followed by the Mississippi Delta (17.3 per 100,000), Southeast Region (14.7 per 100,000), and Appalachia (10.4 per 100,000). Heterosexually acquired HIV was more common in the Southeast Region and the Mississippi Delta than elsewhere. The Mississippi Delta had the highest proportion of HIV diagnoses among young people aged 13-24 years (18.4%). More than three quarters of people diagnosed with HIV in the Mississippi Delta and the Southeast Region were black, and diagnosis rates were higher among blacks and Hispanics than whites in all regions. The distribution of demographic and residential characteristics among people with AIDS was similar to that of all people with a diagnosis of HIV.
Conclusion: Strategies are needed to reach the populations of these areas to reduce transmission of HIV.

Dental Decay in Southern Illinois Migrant and Seasonal Farmworkers: An Analysis of Clinical Data
Sherri M. Lukes, Bret Simon


Context: Migrant and seasonal farmworkers are a population at risk for oral health problems. Data on the oral health conditions of migrant and seasonal farmworkers' permanent teeth are particularly lacking.
Purpose: To document the relative rates of treated and untreated dental decay in a sample of southern Illinois migrant and seasonal farmworkers who had sought care at a farmworker health center dental clinic.
Methods: Existing migrant health dental clinic records from 1995-2002 were reviewed. Final sample size was 650. Data for decayed, missing, and filled tooth surfaces were recorded using both anatomical recording and treatment notes.
Findings: Sixty-nine percent of migrant farmworkers had at least 1 decayed (untreated) tooth surface, and more than half had 3 or more decayed surfaces.
Conclusions: Results indicate that untreated dental decay is significant among migrant and seasonal farmworkers who seek care at this dental clinic. Recommendations include addressing barriers to care, improved monitoring of dental health conditions, and further research to better document the treatment needs of this population.

Teenage Pregnancy in the Texas Panhandle
Rosa Galvez-Myles, Thomas D. Myles


Purpose: This study compares rural and small-city teenage and adult pregnancies, with respect to complication rates and pregnancy outcomes.
Methods: Chart review of Medicaid patients (513 teenage [under 20 years] and 174 adult controls [ages 25-34]) delivered (excluding multiple gestation) in Amarillo, Texas, from January 1999 to April 2001. Demographic data collected included maternal race, gravidity, parity, smoking status, drug usage, presence of antenatally diagnosed sexually transmitted disease(s), county type (rural vs small city) and number of prenatal visits. Outcomes included mode of delivery, primary cesarean section rates, preterm birth (,34 or ,37 weeks), birth weight, birth weight ,2,500 g, preeclampsia, total maternal weight gain, hemoglobin changes after delivery, Apgar scores, and neonatal intensive care unit admissions. Statistical comparisons between groups were made for a number of factors and outcomes (P,.05).
Results: Teenagers did not have a significantly higher frequency of either illicit drug or tobacco usage, but teenagers _17 years had a greater incidence of sexually transmitted diseases (19.8% vs 10.4%, P,.008) and preeclampsia (7.1% vs 2.3%, P,.025, odds ratio 3.2 [1.1 to 9.9]) when compared with adults. The total weight gain was highest for teens _17 years (36.4 pounds vs adults: 28.2, P,.001). The primary cesarean section rate was higher in adults (all teens 18.5% vs adults 38.6%, P,.001). County rurality had no impact on any of the observed findings or variables tested.
Conclusions: Young teenagers have a higher incidence of sexually transmitted diseases and preeclampsia and also gain significantly more weight with pregnancy than young adults. However, the pregnancy outcomes were no different for rural vs small city teens.

Factors Associated With Incidence of ''Inappropriate'' Ambulance Transport in
Rural Areas in Cases of Moderate to Severe Head Injury in Children
Dmitri Poltavski, Kyle Muus


Context: Ambulance transport of pediatric trauma patients to designated trauma centers in cases of moderate and severe injury is not always performed, which has been shown to result in poor treatment outcomes. Determination of factors involved in inappropriate patient transport, especially in rural areas, remains an important avenue of research.
Purpose: To identify factors involved in ambulance transport of pediatric patients sustaining moderate-to-severe head injury to nondesignated trauma centers in rural North Dakota. Method: Emergency medical service ambulance records for North Dakota from 1995 to 2000 were used. One hundred fifty-six cases of pediatric head injuries with Glasgow Coma Scale scores _12 and transported by rural ambulance squads were selected. A logistic regression analysis was conducted to identify a set of significant predictors of cases of inappropriate deliveries to acute care facilities with no trauma-center designation of any level (II-V).
Results: Greater distance (mean Π19.96 miles) to the nearest trauma center and shorter distance traveled by the ambulance squad to the receiving facility (mean Π19.07 miles) corresponded to higher probabilities of mistriage, especially when a child was Native American (16 times more likely) and the transportation was conducted in the winter (9 times more likely).
Conclusions: Timely delivery of pediatric trauma patients to designated trauma centers is encumbered in the winter, particularly in Native American communities, because of the greater traveling distances, which could be counteracted by better mobilization of available resources aimed at administration of optimal trauma care.

Rural generalist nurses' perceptions of the effectiveness of their therapeutic interventions for patients with mental illness
Chanelle Clark, Elizabeth Parker, Trish Gould

Objective: To explore generalist nurses' perceptions of their efficacy in caring for mentally ill clients in rural and remote settings, and their educational needs in the area of mental health care.
Design: A self-administered questionnaire adapted from the Mental Health Problems Perception Questionnaire; a Likert scale used to rate the perceptions of nursing staff of their own ability to adequately treat and care for patients experiencing mental illness.
Setting: The Roma and Charleville Health Service Districts, Queensland, Australia.
Subjects: Nurses (Registered Nurses, Assistants in Nursing and Enrolled Nurses) in the Roma and Charleville health service districts (n = 163).
Main outcome measures: Generalist nurses' perceptions regarding their therapeutic commitment, role competency and role support.
Results: Seventy per cent of respondents indicated that limited knowledge of mental health problems was an issue preventing nursing staff in rural and remote settings from providing optimum care to patients with mental illness. Twenty-nine per cent of respondents indicated that they had never received or undertaken training or education in relation to the care, treatment or assessment of patients with mental illness.
Conclusion: Rural nurses do not feel competent, nor adequately supported, to deal with patients with mental health problems. In addition, the nurses' education and ongoing training do not adequately prepare them for this sphere.

Perception of causes of malaria and treatment-seeking behaviour of nursing mothers in a rural community
Comfort A. Ibidapo

Objective: Maternal health care workers' recognition of malaria, its transmission and treatment of children's fever at community level.
Design: Randomised sampling of households with children of 0 5 years.
Setting: Rural community in a forest zone.
Subjects: Fifty-five households at Ijegemo village, Ogun state, Nigeria were sampled and questionnaires administered to 200 mothers/care workers of children within the age group 0 5 years. Blood smears were obtained from finger pricks and level of parasitemia with malaria parasites determined for each child.
Main outcome measures: Interactions with the women during the survey empowered them with accurate knowledge of malaria recognition, transmission and management of children's fever at the community level.
Results: Forty per cent of the respondents did not know the exact cause of malaria, 20% attributed the cause to sunlight, 16.5% to mosquitoes, 12.5% to poor hygiene, 4% to palm oil intake, 4% to blood shortage and 6% to a hot body. Of respondents 85.5% identified stagnant water as breeding site of mosquitoes but could not correlate it with the occurrence of malaria fever. Herbal concoction was the first treatment action. Some of these herbs are listed in the text. Plasmodium falciparum alone was identified in all blood smears. Children at two to three years of age were recorded with the highest percentage (67.5%) of parasite-positive cases with a mean value of 1237.04 ± 2113.19.
Conclusion: This study highlights a critical need for targeting health messages towards poorly educated women in order to empower them with the knowledge and resources to recognise and manage their children's health problems.

Factors associated with rural doctors' intention to continue a rural career: A survey of 3072 doctors in Japan
Masatoshi Matsumoto, Masanobu Okayama, Kazuo Inoue, Eiji Kajii

Objective: To show the relationship between the personal and educational backgrounds of rural doctors and their intention to continue a rural career.
Design: Nationwide postal survey.
Setting: Public clinics or hospitals in municipalities that are classified as 'rural' by the national government.
Subjects: A total of 4896 doctors working for 828 public clinics and hospitals.
Measurements: A questionnaire was mailed. The questionnaire inquired about the subject's age, sex, hometown, exposure to rural practice in undergraduate education, postgraduate training, continuing medical education, current position and affiliation status with a medical school, as well as his or her intention to continue a rural career.
Results: Response rate was 64%; 26% answered that they intended to continue a rural career. Postgraduate training in general internal medicine, general surgery, anaesthesiology, paediatrics and gastroenterology were positively related with the intention to continue a rural career (odds ratio = 2.045, 1.59, 1.30, 1.48, 1.38). Rural background, undergraduate exposure to rural practice, multispecialty-rotation in postgraduate training and current administrative position had positive correlations with the intention to continue in logistic regression analysis (odds ratio = 1.80, 2.47, 1.54, 2.17). Affiliation with a medical school department was negatively related with the intention to continue (odds ratio = 0.45).
Conclusion: In addition to the rural background of physicians, some undergraduate and postgraduate factors were independently associated with the intention to continue a rural career.

Teaching clinical pathology by flexible delivery in rural sites
Richard Hays, Jan Veitch, Alfred Lam

Objective: To evaluate the implementation of a clinical pathology and clinical skills course designed for delivery at several distributed sites, including a mandatory eight-week placement in small remote communities.
Design: All students in the first cohort for the course were invited to complete questionnaires rating the value of their learning experiences and the impact of relying on resources delivered by information technology. Forty-one of 63 students responded.
Results: Formal lectures and resources provided at the main campus were most highly valued by the students. Patient presentations in the rural and remote communities were better examples of clinical pathology than those encountered in urban hospitals, and the rural tutors were regarded very highly for their support of student learning. Delivery of resource materials in remote sites was not as successful as planned, due to difficulties with bandwidth and download speeds. Student academic performance appeared unrelated to location of learning.
Conclusion: Students were able to achieve learning objectives for the course, relying on a richer patient mix, campus-based core sessions and information technology-based resources. Curriculum planners should be encouraged to further devolve learning in traditionally campus-based content to rural and remote communities, but only after careful planning and resource allocation to support learning in rural teaching sites.

Overseas-trained doctors in Australia: Community integration and their intention to stay in a rural community
Gil-Soo Han, John S. Humphreys

Objective: The aim of this study was to identify the factors that influence foreign doctors' community integration and examine how these affect their intention to stay in the rural community.
Design: Qualitative study using life-history perspective.
Setting: Rural communities throughout Victoria.
Participants: Fifty-seven overseas-trained doctors (OTDs) working throughout rural Victoria, Australia.
Main outcome measures: Key factors of community integration influencing OTDs' decision to stay in or leave a rural community.
Results: Maintaining cultural and religious values, as well as relationships to their respective ethnic communities is important to OTDs. While they do not expect excessive support from the community they appreciated the cultures of welcoming or 'embracing differences'. Supportive communication and supervisory support positively influence OTDs' appreciation of what the rural community can offer them and how they might overcome any difficulties that they face with their rural practice and life.
Conclusion: As well as ensuring that OTDs' professional needs are met, the importance of a supportive environment within the clinic and community awareness of the OTDs' needs should not be underestimated as influences on an OTD's retention in a rural community.

The diabetes experiences of Aboriginal people living in a rural Canadian community
Sylvia S. Barton, Nancy Anderson, Harvey V. Thommasen

Objective: To optimise participation with Aboriginal people by sharing experiences of living with the challenges of diabetes in rural south-western Canada, and how these could be addressed.
Design: Qualitative content analysis of semi-structured and conversational interviews.
Setting: Diabetes health services in the Bella Coola Valley, British Columbia, Canada.
Subjects: Eight Nuxalk Nation participants, five women and three men, living with type 2 diabetes, were interviewed. Four of these participants, three women and one man, were engaged in six follow-up conversational interviews.
Main outcome measures: The descriptive research explored experiences of Nuxalk people living with the challenges of diabetes, and how these could inform diabetes health services in culturally specific ways.
Results: Challenges included understanding the connections between (i) diabetes and western or traditional medicines; (ii) dietary changes, exercise and weight loss; (iii) how health professionals communicate and the relevance of what is said; (iv) having many life choices and the responsibility to choose; and (v) a belief in living day by day and an awareness of life cycles that may need to be broken.
Conclusion: The study substantiated the fundamental necessity for diabetes health services to be inclusive of Aboriginal perspectives.

Strongyloidiasis: A review of the evidence for Australian practitioners
Fay H. Johnston, Peter S. Morris, Richard Speare, James McCarthy, Bart Currie, Dan Ewald, Wendy Page, Karen Dempsey

Objective: To summarise the available evidence concerning the prevalence, clinical manifestations, diagnosis and management of strongyloidiasis in Northern Australia.
Methods: We searched Medline, Clinical Evidence and the Cochrane Library using MeSH terms and text words 'strongyloides OR strongyloidiasis'. For Australian studies we included text words '(parasite* OR parasitic OR helminth*) AND Australia*'. We examined references contained in retrieved studies or identified from direct contact with researchers. Studies consistent with our objective that described their methods were eligible for inclusion.
Results: The prevalence in some tropical Aboriginal communities is high. Infection can be asymptomatic, cause a range of clinical syndromes or death. It may become chronic. Infected patients are at risk of developing severe disseminated disease particularly with immune compromise. There is little information about the relative frequency of different clinical outcomes. Available diagnostic tools are imperfect. Stool examination has a low sensitivity. Serology may have a low specificity in high prevalence populations and has not been evaluated in Aboriginal populations. Antihelmintic drugs are relatively safe and effective. Community programs based on treatment of stool-positive cases have been associated with a reduced prevalence of strongyloidiasis. We found no studies examining alternative public health interventions.
Conclusion: There is a high prevalence in many Aboriginal communities. Strongyloides infection should be excluded prior to commencing immunosuppressive therapies in patients from endemic areas. Further studies examining the public health impact of strongyloidiasis, the role of the enzyme-linked immuno-sorbent assay serological test and population-based approaches to management of the disease in endemically infected Australian populations are needed.