Journal Search - issue 1, 2006

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Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in rural health journals worldwide.

Alcohol drinking habits and community perspectives on alcohol abuse in the Bella Coola Valley
Harvey V Thommasen, Neil Hanlon, Carol Thommasen, William Zhang

Introduction: This study surveyed the residents of the rural and remote communities in the Bella Coola Valley, British Columbia, on their alcohol drinking habits and on their opinions as to which of a list of health issues were the most important considerations for the well-being of the community.
Methods: People aged 17 years and older living in the Bella Coola Valley were asked to complete a detailed Health and Quality of Life Survey during the period August 2001 to May 2002. This included two separate mailouts. Alcohol drinking habits; and ratings on whether or not people believed that alcohol abuse, drug abuse, family violence, unemployment, sexual abuse and racial discrimination were surveyed.
Results: A total of 674 adults age 17 years and older (39% response rate) completed an 11-page questionnaire. Results from the survey indicate that unemployment, alcohol abuse and drug abuse are seen as the most important community health problems by the majority of residents. Eighty-eight percent of respondents agree or strongly agree that unemployment is a problem; for alcohol abuse it was 83%, for drug abuse 77%, for both family violence and sexual abuse 58%, and for racial discrimination it was 53%. Patterns of drinking habits vary considerably between Aboriginal peoples and non-Aboriginal people. More Aboriginal respondents abstained from drinking alcoholic beverages (54%) than non-Aboriginal respondents (22%). Among the Aboriginal peoples who did drink alcohol, there were relatively more heavy drinkers (36%) compared with non-Aboriginal people (7%). There were more heavy drinkers among men than among women.
Conclusion: Patterns of drinking habits vary between men and women and between Aboriginal and non-Aboriginal people. The majority of residents agree that alcohol is a problem in these communities. Unemployment, drug abuse, family violence, sexual abuse and racial discrimination are also believed to be important issues for the Bella Coola Valley. This information should be used to set priorities for future health and wellness programs.

Review of salaried physician visits in a rural remote community - Bella Coola Valley
Harvey V. Thommasen, Janet Tatlock, Rhonda Elliott, William Zhang, Sam Sheps

Introduction: The current study quantifies visits to salaried physicians working in a geographically remote health care facility in British Columbia in 2001.
Methods: A retrospective chart review was conducted of patients residing in the Bella Coola Valley and attending the Bella Coola General Hospital/Medical Clinic (BCGH/Medical Clinic) in 2001. Visits to family physicians at this clinic, visits to the BCGH emergency department, hospital admissions, smoking rates and chronic disease prevalence rates were quantified.
Results: An estimated 2378 patients made 7747 BCGH/Medical Clinic family physician visits, and 4474 "other" visits in 2001. These "other" visits included emergency department visits (n = 1736), hospital admissions (n = 245) and prescription visits (n = 2252). Twenty-six percent (n = 622) of the population did not see a family physician at all in 2001, and 15% of the population accounted for 52% of all visits. Women had a higher number of visits than men; pregnant women had a higher number of visits than non-pregnant women, and the Aboriginal population saw family physicians more often than did non-Aboriginal people (p < 0.001). Those who had a chronic illness (e.g., diabetes) saw family physicians more frequently than did people who did not have that particular chronic illness (p < 0.01). The Aboriginal population used the BCGH/Medical Clinic and emergency department more frequently than did the non-Aboriginal population. BCGH/Medical Clinic physicians had an average of 75 patient visits per week. An additional 22 "visits" per week were for writing prescription refills with the patient not present.
Conclusion: Older people, people with chronic disease, women and Aboriginal peoples more frequently visited the family physicians. Salaried physicians working in geographically isolated communities appeared to behave in ways that minimized contact (e.g., used the phone, wrote prescriptions without patient being present) and maximized time efficiency for both themselves and their patients.

Self-management of chronic conditions: implications for rural physicians of a demonstration project Down Under
Erica Bell, Peter Orpin

Objectives: This paper describes the outcomes achieved for clients of a demonstration project in self-management in one of Australia's most rural and remote states.
Methods: Client survey data obtained over a maximum of 18 months from 264 clients in 3 sites across Tasmania were analyzed using standard descriptive techniques. These data provided demographic information as well as client self-assessments of health and well-being, and health-related behaviours. Tests of significance were conducted on differences in client health data over a maximum of 4 data collection times.
Results: In relation to demographic factors, these data show low education, employment and income levels in an aged population. There were gender differences in project participation (many more females than males), and relatively low levels of completion of the self-management course by those who were not married and who were living with their families. Statistically significant improvements in health dimensions were obtained for those clients attending the self-management course (where p values < 0.05): in the areas of distress, symptoms and depression. Data also show significant declines over time in client ratings of exercise behaviours and cognitive self-management strategies.
Conclusions: The effects of barriers to self-management of chronic conditions (lack of formal education, age-related physical frailty, and poverty) are likely to be multiplied in areas showing a paucity of health professionals and related health infrastructure. The data for gender and living arrangements suggest the importance of tailoring self-management programs to meet the needs of specific community sub-groups. Declining ratings are one of the least explored areas of self-management research, yet they point to the importance of sustaining interventions in rural communities. Rural physicians apprised of the issues in implementing successful self-management programs in rural contexts can be an important resource for more isolated communities wanting to achieve workable programs with sustainable gains.

Surgical site infection rates at the Pontiac Health Care Centre, a rural community hospital
Runi Chattopadhyay, Sevag Zaroukian, Earle Potvin

Introduction: The prevalence of surgical site infections (SSIs) at the Pontiac Health Care Centre, a rural hospital, was compared with rates obtained by large multicentre studies. Postoperative nosocomial infection (NI) rates were also calculated.
Methods: A review of all surgical interventions involving an incision, excluding ophthalmological procedures, performed between October 2001 and March 2003 (n = 831) was undertaken. Various clinical parameters were recorded. Infection rates were calculated. Data were analyzed using either the χ2 or Student's t test.
Results: The overall SSI rate was 5.54%: 3.50% in clean cases (C), 6.77% in clean-contaminated cases (CC), and 14.58% in contaminated or dirty cases (D). The postoperative NI rate was 6.62% (C, 3.68%; CC, 9.90%; D, 16.67%). The mean duration of surgery was significantly higher among patients with SSIs and with NIs than those without infections for CC (133 ± 95 v. 78 ± 60 min, p < 0.05, and 129 ± 82 v. 77 ± 60 min, p < 0.001 respectively) and D (130 ± 96 v. 82 ± 62 min, p < 0.001, and 136 ± 92 v. 80 ± 60 min, p < 0.001 respectively). There were significantly higher SSI and NI rates among patients with combined American Society of Anesthesiologists (ASA) scores II and III than those with ASA score I in D (χ2 = 5.06 and χ2 = 6.34 respectively). There was also significantly higher SSI and NI rates among patients with combined Comorbidity Scale score 1-6 than those with no comorbid factors in CC (χ2 = 4.14 and χ2 = 4.42 repectively) and D (not significant and χ2 = 4.04 respectively).
Conclusion: SSI rates at the Pontiac Health Care Centre were comparable to multicentre rates. Wound contamination category, type of surgery, duration of surgery, ASA score and Comorbidity Scale score were associated with SSI and NI rates. Studies have shown that examining NI rates decreases these rates by raising awareness; thus, we suggest that rural hospitals implement protocols to survey their postoperative NI rates.

Family Decision-Making for Nursing Home Residents With Dementia: Rural-Urban Differences
Charles E Gessert, Barbara A. Elliott, Cynthia Peden-McAlpine

Context: Research has demonstrated substantial differences between end-of-life care in rural and urban settings. As the end of life approaches, rural elders are less likely to be hospitalized, to be placed in an intensive care unit, or to have a feeding tube, compared to their urban counterparts. These differences cannot be fully explained by rural-urban differences in access to medical services.
Purpose: To describe and understand rural-urban differences in attitudes toward death and in end-of-life decision making.
Methods: Eight focus groups were convened in rural and urban Minnesota nursing homes. The 38 focus group participants were family members of nursing home residents with severe cognitive impairment.
Findings: Most rural focus group participants voiced unqualified acceptance of death and placed few conditions on death, beyond their hope that it would be quick and peaceful. Urban respondents presented a wider range of attitudes toward death, from unambiguous acceptance of immediate death to evident discomfort with welcoming death under any circumstances. These rural-urban differences had practical implications. Rural respondents were much less likely to endorse interventions that would impede death, compared to their urban counterparts.
Conclusions: Rural respondents tended to express confidence in natural forces; death was seen as neutral or beneficent. Resistance to the approach of death was more characteristic of urban respondents, some of whom insisted upon aggressive medical care in advanced dementia.

Social and Emotional Impacts of Farmwork Injuries: An Exploratory Study
SM Robertson, Dennis J Murphy, Lisa A Davis

Context: The physical hazards of farming have been extensively studied and reported upon. Far less studied are the social and emotional impacts of farmwork injuries and deaths.
Purpose: To investigate and document broad but targeted issues regarding the impact on individuals, families, and communities of farmwork injuries and fatalities of farmer leaders.
Methods: Ten incidents of farmwork injuries with disabilities or fatalities in Pennsylvania were used for a collective case study. Data were collected through a total of 47 interview sessions with 66 individuals including next of kin, other family members, injured persons, and community members. Thematic analysis was used to identify themes and issues in this descriptive study.
Findings: Community members missed the rich, broad, and comprehensive skills, abilities, and perspectives that farmers brought to community service. Participants expressed that the community assistance and support provided to injured persons and families benefited not only the injured persons and their families and farms but also the community members. Participants reported emotional anguish and loss as well as positive transformations and consequences. As expressed by participants, God and religion play an important role in their beliefs regarding the occurrence and outcome of farmwork injury incidents.
Conclusions: Social and emotional impacts on individuals, families, and communities are varied and multileveled. The role that religion and storytelling play in the process of dealing with serious injury incidents raises questions regarding agricultural injury prevention.

Rural Illinois Hospital Chief Executive Officers' Perceptions of Provider Shortages and Issues in Rural Recruitment and Retention
Michael Glasser, Karen Peters, Martin MacDowell

Background: It is important to assess rural health professions workforce needs and identify variables in recruitment and retention of rural health professionals.
Purpose: This study examined the perspectives of rural hospital chief executive officers (CEOs) regarding workforce needs and their views of factors in the recruitment and retention process.
Methods: A survey was mailed to CEOs of 28 Illinois rural hospitals, in towns ranging from 3,396 to 33,530 in population size. The survey addressed CEO perceptions of number of physicians needed by specialty, need for other health professionals, and variables important to recruitment and retention.
Findings: Twenty-two CEOs (79%) responded to the survey. Eighty-six percent indicated a physician shortage in the community, with 64% reporting the need for family physicians. CEOs also indicated the need for physicians in obstetrics-gynecology, general and orthopedic surgery, general internal medicine, cardiology, and psychiatry. In terms of needs for other health professionals, most often mentioned were registered nurses (91%), pharmacists (64%), and nurses' aides (46%). Related to recruitment and retention, most often mentioned by the CEOs was community attractiveness in general, followed by practice and physician career opportunities.
Conclusions: CEOs offer 1 important perspective on health professions needs, recruitment, and retention in rural communities. While expressing a range of opinions, rural hospital CEOs clearly indicate the need for more primary care physicians, call for an increased capacity in nursing, and point to community development as a key factor in recruitment and retention.

Rural Residence and Hispanic Ethnicity: Doubly Disadvantaged for Diabetes?
Richelle J Koopman, Arch G Mainous III, Mark E Geesey

Context: Hispanics are at increased risk for diabetes, while rural residents have historically had decreased access to care.
Purpose: To determine whether living in a rural area and being Hispanic confers special risks for diagnosis and control of diabetes.
Methods: We analyzed the Third National Health and Nutrition Examination Survey (1988-1994). Hispanics and non-Hispanic white adults were classified according to rural/urban residence to create 4 ethnicity-residence groups. Investigated outcomes were previously diagnosed and undiagnosed diabetes. Among those with diagnosed diabetes, we investigated control of glucose, hypertension, and lipids.
Findings: The prevalence of diagnosed diabetes was greatest for rural residents, especially for rural Hispanics (8.2%) versus that for urban whites (4.6%), rural whites (6.5%), or urban Hispanics (4.5%), (P < .01). However, urban Hispanics were most likely to have undiagnosed diabetes at 3.7%, versus 2.3% of rural whites, 2.8% of urban whites, and 2.7% of rural Hispanics (P = .04). Among people with diagnosed diabetes, there was no difference in glycemic control between the 4 groups. Rural Hispanics with diagnosed diabetes had the greatest prevalence of elevated systolic blood pressure at 45%, compared to 37% of urban whites, 29% of rural whites, 28% of urban Hispanics (P = .01). In regression models controlling for potential confounders, there were no differences among urban and rural whites and Hispanics in the likelihood of undiagnosed diabetes or in glycemic control for those with diagnosed diabetes.
Conclusions: Initiatives that target Hispanic health, and especially diabetes, should acknowledge rural/urban Hispanic health differences.

Practice Locations of Graduates of Family Physician Residency and Nurse Practitioner Programs: Considerations Within the Context of Institutional Culture and Curricular Innovation Through Titles VII and VIII
Joellen B Edwards, Jim L Wilson, Bruce A Behringer, Patricia L Smith,1 Kaethe P Ferguson, Reid B Blackwelder, Joseph A Florence, Bruce Bennard, Fred Tudiver

Background: Studies have described the aggregate results of federal funding for health professions education at the national level, but analysis of the long-term impact of institutional participation in these programs has been limited.
Purpose: To describe and assess federally supported curricular innovations at East Tennessee State University designed to promote family medicine and nurse practitioner graduate interest in rural and underserved populations.
Methods: Descriptive analysis of a survey to determine practice locations of nurse practitioner graduates (1992-2002) and graduates of 3 family medicine residencies (1978-2002). Graduates' (N = 656) practice locations were documented using specific federal designations relating to health professions shortages and rurality.
Results: Overall, 83% of family medicine residency and 80% of nurse practitioner graduates selected practice locations in areas with medically underserved or health professions shortage designations; 48% of family physicians and 38% of nurse practitioners were in rural areas.
Conclusions: Graduates who study in an educational setting with a mission-driven commitment to rural and community health and who participate in curricular activities designed to increase their experience with rural and underserved populations choose, in high numbers, to care for these populations in their professional practice.

Posttraumatic Stress Disorder in Rural Primary Care: Improving Care for Mental Health Following Bioterrorism
Jennie CI Tsao, Aram Dobalian, Brenda A Wiens, Julius A Gylys, Garret D Evans

Context: Recent bioterrorist attacks have highlighted the critical need for health care organizations to prepare for future threats. Yet, relatively little attention has been paid to the mental health needs of rural communities in the wake of such events. A critical aspect of bioterrorism is emphasis on generating fear and uncertainty, thereby contributing to increased needs for mental health care, particularly for posttraumatic stress disorder, which has been estimated to occur in 28% of terrorism survivors.
Purpose: Prior experience with natural disasters suggests that first responders typically focus on immediate medical trauma or injury, leaving rural communities to struggle with the burden of unmet mental health needs both in the immediate aftermath and over the longer term. The purpose of the present article is to draw attention to the greater need to educate rural primary care providers who will be the frontline providers of mental health services following bioterrorism, given the limited availability of tertiary mental health care in rural communities.
Methods: We reviewed the literature related to bioterrorist events and mental health with an emphasis on rural communities.
Findings and Conclusions: Public health agencies should work with rural primary care providers and mental health professionals to develop educational interventions focused on posttraumatic stress disorder and other mental disorders, as well as algorithms for assessment, referral, and treatment of postevent psychological disorders and somatic complaints to ensure the availability, continuity, and delivery of quality mental health care for rural residents following bioterrorism and other public health emergencies.

Acute Stroke Care at Rural Hospitals in Idaho: Challenges in Expediting Stroke Care
James G Gebhardt, Thomas E Norris

Context: Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve.
Purpose: To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care.
Methods: Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care.
Findings: The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed.
Conclusions: Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays.

Cultural health beliefs in a rural family practice: A Malaysian perspective
Kamil M Arif, Khoo S Beng

Background: Understanding the sociocultural dimension of a patient's health beliefs is critical to a successful clinical encounter. Malaysia with its multi-ethnic population of Malay, Chinese and Indian still uses many forms of traditional health care in spite of a remarkably modern rural health service.
Objective: The objective of this paper is discuss traditional health care in the context of some of the cultural aspects of health beliefs, perceptions and practices in the different ethnic groups of the author's rural family practices. This helps to promote communication and cooperation between doctors and patients, improves clinical diagnosis and management, avoids cultural blind spots and unnecessary medical testing and leads to better adherence to treatment by patients.
Discussion: Includes traditional practices of 'hot and cold', notions of Yin-Yang and Ayurveda, cultural healing, alternative medicine, cultural perception of body structures and cultural practices in the context of women's health. Modern and traditional medical systems are potentially complementary rather than antagonistic. Ethnic and cultural considerations can be integrated further into the modern health delivery system to improve care and health outcomes.

Going home from hospital: The postdischarge experience of patients and carers in rural and remote Queensland
Chris Williams, Rosamund Thorpe, Nonie Harris, Hilary Dickinson, Chris Barrett, Francine Rorison

Objective: This paper reports on a study of the experiences of patients and carers discharged from the Townsville General Hospital into rural and remote communities in North Queensland.
Design: The findings presented in this paper are drawn from post-discharge in-depth, qualitative interviews of both patients and carers.
Results: The findings indicate the importance of examining the lived experience of both patients and carers in attempting to understand the impact of current discharge practices.
Conclusion: We conclude that carers are providing the bulk of post-discharge care of patients - a difficult role in which the difficulties are exacerbated when the patient or the carer or both is a long way from the home community.

Going country: Rural student placement factors associated with future rural employment in nursing and allied health
Denese Playford, Ann Larson, Belynda Wheatland

Objective: To measure the rate and predictors of health science graduates joining the rural health workforce following a rural placement.
Design: Longitudinal survey including the years immediately prior to and post graduation.
Setting: Western Australian health sciences graduates contacted by email and/or phone.
Participants: Allied health and nursing students from urban campuses of three Western Australian universities who had taken a rural placement in their final year of study between 2000 and 2003.
Main outcome measures: Location of employment six months or more after graduation.
Results: Of 429 participating allied health and nursing graduates, 25% had entered the rural workforce. Factors with a positive bivariate association with rural employment were: rural background, health discipline, self-reported value of placement, non-compulsory rural placement, and placements of four weeks or less. After controlling for rural background, the value and duration of the placement were significantly associated with rural employment.
Conclusions: This study augments previous work showing that any prior rural background is a significant predictor of rural work. Rural practitioners of both urban and rural origin who undertake voluntary rural placements are more likely to enter rural practice and consequently mandatory placements may not be helpful to increasing the rural workforce. The quality of a placement is a highly significant factor associated with future workplace choice, the details of which need to be further investigated.

Renal disease in the Aboriginal community of Woorabinda
Teresa J Hazel, Peter S Hill

Objective: An apparent increase in the incidence of end-stage renal disease had been observed in the Australian Aboriginal community of Woorabinda. This study documents the incidence of end-stage renal disease (ESRD) in Woorabinda, and correlates this with predictors of renal disease.
Design: The methodology included a retrospective audit of deaths from, and cases commencing treatment for ESRD between 1999 and 2001 in Woorabinda, and a cross-sectional study.
Participants: The 183 participants were Aboriginal residents over 15 years of age. Females numbered 102 (55.7%) and males 81 (44.3%).
Main outcome measure: The incidence of ESRD was comparable to other recognised high incidence Indigenous communities in Australia. This was corroborated by a high prevalence of predictors of renal disease.
Results: Audit: the year 2001 age- and sex-standardised incidence ratio for commencement of renal replacement therapy is 93.18 (95% CI, 25.34-238.53). Clinical Study: the prevalence of overt albuminuria was 7.6%; 11.7% had an albumin : creatinine ratio>3.4-33.9 g mol 1; 33.3% had microalbuminuria of ≥20 mg L 1; and 67.8% prevalence of proteinuria was found. The prevalence of diabetes was 18.6%, with another 13.2% having impaired fasting glucose. There was a 19.7% prevalence of hypertension. Of those with hypertension 22.2% had overt albuminuria.
Conclusions: Although Woorabinda was previously placed in a region of low end-stage renal disease incidence, further investigation has identified a high incidence of renal disease, not exclusively due to diabetes. The finding raises questions regarding the current trajectory of the epidemic in other Aboriginal and Torres Strait Islander communities.

Primary medical care workforce enumeration in rural and remote areas of Australia: Time for a new approach?
Robert W Pegram, John S Humphreys, Gordon Calcino

The rural and remote primary medical workforce continues to struggle to meet community needs. This paper looks at the strengths and weaknesses of the various datasets used to measure workforce. The analysis concludes that no current data set adequately describes workforce from a community need perspective. In particular, activity based data sets based on claims data do not capture issues such as service mix or the importance of issues outside activity collections, such as time on call. The paper calls for a new approach to workforce measurement based on a community needs model.

Collaboration and referral practices of general practitioners and community mental health workers in rural and remote Australia
Chris Lockhart

Design: Semistructured interviews.
Setting: Rural and remote health service region in Australia.
Participants: In total, 31 general practitioners and 14 mental health workers.
Results: Meaningful collaboration and referral practices between general practitioners and mental health workers are prevented by contradictory and ambiguous definitions involving professional roles and mental health. A pattern of negative collaboration was further magnified by the rural and remote context.
Conclusion: The implementation of Australia's National Mental Health Strategy faces serious problems in rural and remote area due to the negative collaboration and referral practices between general practitioners and mental health workers.

What do we mean by sustainable rural health services? Implications for rural health research
John S Humphreys, John Wakerman, Robert Wells

The concept of health service sustainability, endorsed by the Australian Health Ministers as a key dimension of the National Performance Framework, is particularly important in rural and remote communities. To date, however, few Australian studies have demonstrated how the real drivers of sustainability inter-relate or are translated into sustainable rural and remote health services. This article highlights the need for a systemic approach in which the integrated nature of sustainability components are recognised and evaluated in terms of access to rural and remote health services, quality of care and cost of provision.