Showing papers in "Journal of Rural Health in 1988"

Patterns of travel for rural individuals hospitalized in New York State: relationships between distance, destination, and case mix.

Abstract: : The travel patterns of individuals living in rural areas of New York State who were discharged from short-term general hospitals in New York State in 1983 are examined. Counties are used as the geographical unit, and rural individuals who cross geographic boundaries to obtain inpatient hospital care are compared with those who receive such care in their own geographic area. Hospitals serving the rural population of New York are classified into three types: urban, consisting of all hospitals located in MSAs; rural referral centers; and other rural hospitals. Next, the rural patients who are admitted to each of these three types of hospitals are characterized in terms of distance traveled, case mix, length of stay, and age. Individuals who travel beyond the counties adjacent to their county of residence had a higher case mix index but were less likely to be more than 75 years old. Distance traveled and the expected cost of care were strongly positively related for patients admitted to urban and rural referral center hospitals, but were only weakly related for other rural hospitals. Finally, comparisons of rural patients in these three types of hospitals were performed adjusting for DRG mix, a comparison which is relevant to hospital reimbursements under the Medicare Prospective Payment System. Using several measures of illness severity, rural patients in urban hospitals and rural referral center hospitals were more severely ill than rural patients in other rural hospitals after adjusting for DRG mix. We conclude that somewhat higher payments to urban hospitals and rural referral center hospitals in New York are justified based on the more severely ill patients which they treat.

Residence differences in the health status of elders.

Abstract: : Using data from the 1984 Supplement on Aging to the National Health Interview Survey, this study examined residential differences on a selected group of health status measures among persons 65 years of age and older (N = 11,497). Mean values on indicators of health and impairment for each of the residence categories were examined before and after adjusting for distributional differences in background and demographic characteristics which are associated with both health and residence. Three important conclusions emerged from the analysis: (1) health status does not vary with residence in a unitary fashion; (2) the relationship between residence and health status does not appear to fall along a straightforward rural-urban continuum; and (3) there is both diversity in, and a general patterning of, the significant relationships between health and residence with the extremes of health status located in the rural categories.

Organizational characteristics, occupational stress, and depression in rural emergency medical technicians.

Abstract: : A model of organizational characteristics, occupational stress and mental health in emergency medical technicians (EMTs) is developed and tested. Supervisor behavior and work group support are used as predictors of negative role perception. Negative role perception is specified as intervening between the organizational variables and occupational stress. Occupational stress is hypothesized to directly influence depression. Data collected from 250 EMTs is used in a structural equation analysis to estimate model parameters. The sample is mostly male (74%), white (94%), and married (68%). Results suggest that there is a direct relationship between perceived occupational stress and increased depression. Role perception is a critical intervening variable between supervisor behavior, work group support, and occupational stress. The findings suggest that EMTs are more satisfied when supervisory practices result in an environment which encourages open expression and group problem solving. This work environment leads to more supportive relationships among squad members, reduced role ambiguity, and decreased occupational stress and depression.

Necessary conditions for supporting a general surgeon in rural areas.

Abstract: : Loss of a general surgeon in a rural community can alter the referral patterns, the image and utilization of the local hospital, and even the market share of local primary care physicians. Prior research has not defined the necessary and/or sufficient conditions for a rural county to be able to support a local general surgeon. Based upon empirical analysis of 96 rural Missouri counties and the limited literature available on rural surgeons and physician referral rates, a first approximation of those conditions are offered. We conclude that a rural county with a hospital, a population base of more than 15,000 people, and at least 11 potential referring physicians has sufficient conditions to enable it to support a local general surgeon. Among those rural Missouri counties not meeting the above conditions but having a general surgeon in 1984, we estimate that 8 to 10 potential referring physicians appear to be the minimum necessary condition for supporting a rural general surgeon through patient referral. From those conclusions, we argue that any rural hospital currently without a surgeon should re-examine its situation. To prepare for a competitive future, such a hospital should take every opportunity to expand the referral base necessary to support a full-time local surgeon rather than place long-term reliance upon itinerant general surgeons.

Stress on the Farm: A Test of the life‐Events Perspective Among Iowa Farm Operators

Abstract: : Although a great deal is known about the nature and severity of the recent financial crisis in agriculture, there has been little systematic study of the social and psychological effects of this crisis upon farm operators and their families. Using data from a statewide sample of Iowa farmers, this study tests some hypotheses about correlates of psychological stress. The findings suggest that many farm operators find their situations to be stressful and that such stress is related to the severity of their financial problems. In addition, the life-events perspective is examined in its utility to explain how adverse economic changes impact psychological well-being.

The rural hospital project: conceptual background and current status.

Abstract: : Rural hospitals are confronting continuing and increasing threats to their inability. A demonstration project for the Washington-Alaska-Montana-Idaho region to address the problems of the rural hospital and health system is described. The assumptions underlying the project are that the rural hospital represents the most important component of the rural health care system, and the role of the rural hospital must be defined in relation to the broad health care needs of the population it serves. However, since the elements of community health services are also interdependent, a comprehensive approach to addressing the broad array of problems which besiege rural health services has been developed. The phases of this comprehensive health services development model are described. This approach is having a substantial impact on the ability of community health care leaders to work together, identify important problems, and initiate a range of interventions, with results that are encouraging for the future of the rural hospital and health care system.

Health Promotion for the Rural Elderly

Abstract: : There has been increased interest in developing health promotion programs for the rural elderly as a means to foster successful aging. The present study describes one such program and identifies rural and urban differences in health promotion activities. Data corne from the California Preventive Health Cane for the Aging Program (PHCAP) which is one of the oldest and largest such programs in the United States. A sample of over 5,000 PHCAP clients was draum from rural, semi-rural and urban projects. Though the rural and urban clients differed significantly with respect to demographic characteristics, differences in health promotion practices were relatively minor. However, the health promotion practices of semi-rural residents differed considerably from that in rural projects. Though less disabled, semi-rural clients received a greater scope of health promotion activities than rural clients. The authors discuss possible site, practitioner and client factors which may bave accounted for rural health promotion activities being more restricted. Regardless of Project site, the California PHCAP detected many health problems and a majority of clients were referred to other health professionals for treatment.

Rural‐Urban Differences in Access to Iowa Child Health Services*

Abstract: : Indicators of access, utilization, and quality of available child health services as well as health status were obtained through a telephone survey of Iowa households with children under age six. These indicators were compared for rural-urban subsamples within an AFDC sample drawn from Iowa Department of Human Service files (N=637), and within poverty (N=129) and nonpoverty groups (N=631) drawn from the population of all households in the state with children under age six. About 55 percent of all households studied were rural. Rural households were generally larger than urban households, more likely to be intact maritally, white, and earning a living from farming. The findings support the hypothesis that place of residence has an impact on access, utilization, and quality of child health services over and above family income, although not always to the disadvantage of rural children. Typical problems for rural children, irrespective of income, were access to pediatric care, greater travel time to providers, and discontinuity of well care and sick care. Rural children in all income groups had lower seat belt use than urban children; they were also less likely to have well visits and their providers showed less attentiveness to behavioral and developmental issues at these visits. Rural residency exacerbated problems in access to care for low income children, who were less likely to be eligible for AFDC/ Medicaid than their urban counterparts. Medicaid coverage, however, did not eliminate rural-urban differences in receiving desired medical care.

The Community Health Worker: Forty years of experience of an integrated primary rural health care system in Brazil

Abstract: This article presents one aspect of a highly successful, but surprisingly little known, rural health program in Brazil. Information on the selection, training, supervision, productivity, coverage, costs, and quality of care of their Visitadoras, a type of Community Health Worker, should be of utility to rural health planners and managers in other countries.

Impact of Medicare's prospective payment system and the farm crisis on the health care of the elderly: a case study.

Abstract: : The spectrum of health care for the rural elderly has been negatively affected by recent changes in Medicare reimbursement policies and by the farm crisis. This case study examined the effects of these changes on the ability of rural hospitals, the aging network, and caregivers to provide adequate and continuous care to the elderly. In this case study, three gaps in services were found: a lack of programs designed to meet the needs of terminally ill patients and their families; a lack of education during the crucial transitional period between hospital discharge and home; and a lack of services and programs for the chronically-ill older adult. More studies are needed to determine if similar service gaps will be found in other rural communities. If so, public attention should be focused on possible solutions.

Toward a Rural Health Corps Concept: Lessons from the Dominican Republic*

Abstract: In recent years, primary health care services have expanded rapidly in rural Latin America. However, these services are characterized in many countries of the region by inefficiency and low quality. Research on rural health services in the Dominican Republic identifies the compulsory year of rural service required of graduating medical students (known as pasantia in some countries and medicatura rural in others) as one of the main causes for these problems. Conflicting roles assigned to rural health promoters by the ministry of health and by rural residents are another contributing factor. The manner in which these characteristics of the rural health system reduce the productivity of health resources and the quality of care is discussed. The authors suggest that the organization of a rural health corps could resolve the main flaws inherent in the use of the pasantia and strengthen the work of the promoters.

Differences in need among the rural and urban aged: statistical versus practical significance.

Abstract: Needs assessment data from two states are analyzed to determine if there are differences between rural and urban older persons. Five different definitions of "rural" are utilized. A test of statistical significance is used to determine if differences exist and a measure of association is used to determine how strong the relationships are between residence and need. It is concluded that, with the exception of one rural definition within one state, there are residential differences in need. However, those differences are so small as to have limited practical significance in the public policy arena.

Use of a State-Level Pharmaceutical Assistance Program Among Urban and Rural Elders

Abstract: : A number of state-level pharmaceutical assistance programs have been established as a result of the growing recognition of the role of Pharmaceuticals in the long-term care of the elderly. However, existing research does not provide a coherent expectation for patterns of use by rural and urban elderly. The data for this analysis are drawn from a larger study of the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE). PACE provides prescription medicines for elderly who meet income requirements. The research project was designed to assess the characteristics of PACE program participants and non-participants on a wide range of issues. Chi-square analysis and regression models were used to assess the association between rural and urban residence and access to the PACE Program. The results indicate that rural/urban status of the elderly is not a significant predictor of the use of PACE. Other traditional variables (e.g., health self-rating and physician visits) did predict difference in the pattern of use.

Small hospital obstetrics: is small beautiful?

Abstract: : The number of deliveries in small Canadian hospitals over the last 15 years was reviewed. The two provinces with the highest percentage of deliveries in small hospitals had similar patterns of Perinatal Mortality Rates to the two provinces with the lowest percentage of small hospital deliveries. Birthweight specific mortality rates for newborns weighing greater than 2,500 grams was lower in small hospitals compared to larger hospitals in the provinces of Ontario, Newfoundland and Saskatchewan for 1985. In Ontario, for the year 1985, even when corrected for perinatal transfers and the home address of the mother, there were no significant differences in perinatal mortality between those hospitals with less than 400 births, those between 401 and 2,999 births and those with 3,000 or more births. Within the present Canadian system of perinatal regionalization, small hospital obstetrics is safe.

Impact of Federal Primary Health Care Policy in Rural Areas: Empirical Evidence from the Literature*

Abstract: This review examines the equity, efficiency and effectiveness of federal rural primary care policy as documented by the existing literature. The focus is on the Community Health Center and National Health Service Corps programs which have constituted the major components of the policy. The literature relating to the policy is limited in the number of studies available and in the quality of the research. The available evidence indicates that the policy is associated with an improvement in the distribution of health resources between rural and urban areas,and among rural areas. There is also partial evidence that the policy has been cost-efficient. For federally subsidized practices,the cost of delivering a similar quality of health care is shown to be up to 50 percent less in rural than in urban areas. Rural private practitioners, though, may be more cost-efficient than federally subsidized rural practitioners, at least under certain conditions which have yet to be fully delineated. Program effectiveness is the least well documented, but the literature does suggest that the policy has had a positive effect on the health status of rural populations. Substantially more research on the efficiency, and particular the effectiveness, of federal rural primary care policy is required for the development of a rational basis for the policy.

Social Networks and Depression Among the Elderly: Metropolitan/Nonmetropolitan Comparisons*

Abstract: : Contradictory findings have been reported about depression in the elderly living in metropolitan and nonmetropolitan regions of the United States. Additionally, the extent to which the same sets of variables are predictive of depression among the elderly living in metropolitan and nonmetropolitan environments is unknown. We examined these issues using the Center for Epidemiologic Studies Depression Scale (CES-D) and a national sample of elderly respondents. Findings indicated no differences in the average depression scores of metropolitan and nonmetropolitan elderly. Differences were observed in the social network variables found to be predictive of depression within each subgroup. Among the metropolitan elderly, intimate social relations were found to be independently associated with depression, while secondary social attachments were related to depression among the nonmetropolitan elderly. An examination of the buffering effect of social ties upon the relationship between stress and depression revealed that a simple additive model may not be adequate to describe the association between social network elements and depression among the elderly.

Social Supports of the Rural Widowed Elderly

Abstract: : A brief demographic profile of rural aging in Canada is provided along with an overview of Canadian research findings on the rural aged in general. The findings from a study of 152 widowed residents of two urban and two rural communities in southern Ontario, Canada, are reported. Three measures of social support were used: i.e., perceived support, patterns of support, and preferred sources of support. The data indicate many more similarities than differences in the social support patterns of this sample of rural and urban widowed elders. Where differences did emerge, the rural widowed reported higher levels of frequency of contact with support members. The rural elderly, however, also had lower socio-economic status and had been widowed for a shorter period of time. Thus, some of the differences between the support patterns of the rural and urban widowed were accounted for by background differences, rather than by residential location per se. Despite these findings, the respondents perceived that living in a rural area was an advantage in widowhood.

Neuquen, Argentina: Provincial Health Policies and Their Results*

Abstract: A case study of the creation and implementation of a four-tier, integrated system of health care services in a sparsely populated, rural province in Argentina is described and discussed. Begun in 1970 in a diverse geographical area with a tradition of poor health status and inadequate health care resources, the provincial government set out to develop the human, physical and technological resources needed to provide a system of preventive and curative services appropriate to the health care needs of its residents. Innovative programs included training in management techniques, and epidemiological perspective of high risk, an emphasis on personnel development through a rural general medicine residency and an expanded nursing program as well as programs to attack infectious diseases, poor sanitation and dental problems were all developed in response to the distinctive features of the physical and social environment of the province. Improvements in traditional health indicators are reviewed and attributed to the program and administrative structures that were developed.

The Need to Train Physicians for Rural Primary Health Care in Latin America: Some Family Medicine Experiences*

Abstract: Training strategies to prepare physicians for rural primary care generally have not been a feature of medical education in Latin America. The emergence of family medicine as a specialty discipline has resulted in a number of primary care educational initiatives which are designed to give students or residents the knowledge and skills necessary to practice in rural settings. Specific programs in Mexico, Colombia, Chile, and Argentina are identified and discussed. These programs were selected because they raise a number of educational and manpower planning issues which teachers of family medicine and rural primary care need to address if the long-term viability of these programs is to be achieved. These issues include: the role of the community as an educational laboratory, the supervision of community-based learning experiences, the development of strong clinical and community health promotion skills, the reinforcement of positive primary care learning throughout training, and the development of rural health role models. Manpower planning issues to be addressed include: developing a more precise identity for the primary care physician, a re-examination of the pasantia or year of required community service, developing closer ties between the medical schools and the Ministries of Health and other institutional employers of physicians, and encouraging successful programs to share their experiences with others.

Rural hospital nursing as an elective.

Abstract: : A rural hospital elective in a diploma nursing program is described. A need and opportunity for this unique practicum was identified in a Canadian province where one-third of the acute care beds are in hospitals of under 100 beds, located primarily in towns outside of metropolitan areas. The six week course offers students 35 hours of classroom content focusing on rural health care concepts plus a 150 hour practicum in one of three participating hospitals. The course is seen as unique in that it focuses on rural health care and is offered within the context of a diploma nursing program. Vive student outcomes are identified: awareness of the differences between rural and urban health care; integration of knowledge and experience from previous nursing courses as it relates to the rural context; increasing understanding of how rural population groups affect health care delivery; awareness of rural employment opportunities; and, preparation for the graduate role. A shared vision and collaborative effort on the part of the School of Nursing, the rural hospitals and the host communities has been necessary to establish and maintain such a course.

Rural Health Care in Bolivia

Abstract: Eighty percent of Bolivians live in rural areas. However, because of a lack of resources and an urban / curative health sector orientation, rural primary health care services are woefully inadequate. Consequently, Bolivia has the worst health conditions of any of the Latin American countries. The broader factors which underlie Bolivia's poor health conditions, such as the low standard of living and impediments to socioeconomic development, are reviewed. Rural primary health programs are hampered by a lack of local support, overdependence on central and distant Ministry of Health supervisory staff, a lack of strong national political support for rural primary health care programs, the absence of public sector support for social programs, and a lack of appropriately trained health providers who are comfortable in the rural sociocultural mileu of community-oriented primary health care. The experience of Andean Rural Health Care is briefly described, and the potential contribution of private organizations working with local communities and with the Ministry of Health is addressed. The most viable option for improving rural primary health care in Bolivia is the census-based community-oriented approach.