Showing papers in "Journal of Rural Health in 2002"

Rural health care providers in the United States

Abstract: One of the most recalcitrant problems of the rural health landscape is the uneven distribution and relative shortage of medical care providers. Despite considerable efforts by federal and state governments over the past three decades to address these problems, rural provider distribution and shortage issues have persisted. The purpose of this article is to identify the challenges for rural health research and policy regarding health provider supply in the first decade of the 21st century. While the emphasis in this article is on physicians, workforce concerns pertaining to nurses, nurse practitioners, and physician assistants are briefly described. Physician supply, geographic and specialty distribution, age, gender, quality of care, recruitment and retention, training, productivity and income, reimbursement and managed care, federal and state ameliorative programs, safety net, and telehealth are discussed. Also highlighted are issues concerning rural health care workforce research, methods, and data as well as a series of policy-relevant questions. Solutions to rural health personnel problems can only be successfully addressed through multifaceted approaches. No vision of the future of rural health can come to fruition if it does not promote stable, rewarding, and fulfilling professional and personal lives for rural health care providers.

Food security and perceptions of health status: a preliminary study in rural Appalachia.

Abstract: Food insecurity is estimated to affect about 10% of the United States population. Rural areas experience even higher rates and intensity of food security problems related to poverty, food access, and higher food costs. Reports of the relationship between household food security and health status, however, are limited. This report examines the relationship between household food security and measures of functional health status in a rural Appalachian sample. A comprehensive health status survey was completed by 1,006 individuals seen either in a clinical (n = 605) or nonclinical (n = 401) community setting. The survey included the USDA Food Security Core Module, the SF-36, and demographic and health care access questions. Household food insecurity was reported by 23% of respondents. Food insecure respondents reported significantly poorerfunctional status on all SF-36 scales compared tofood secure respondents (all p < 0.05). After adjusting for demographic and access variables in a multiple regression analysis, food insecurity remained a significant independent predictor of responses for each SF-36 scale. Generalizability of results are limited by the convenience sampling methods and geographic region in which the study was conducted. In this preliminary study, even minimal levels of food insecurity are related to self-reported levels of health status as measured by the SF-36 spectrum. Health professionals must be able to identify individuals at risk for food insufficiency; policy makers must develop more effective programs for alleviating the basic causes of food insecurity.

Chronic disease and injury in an agricultural county: The Keokuk County Rural Health Cohort Study.

Abstract: The Keokuk County Rural Health Study (KCRHS) was designed as a 20-year, prospective cohort study focusing on chronic disease and injury in an agricultural southeastern Iowa county. The goals of the KCRHS are to prospectively describe, measure, and analyze prevalent rural and agriculturally related adverse health outcomes and their respective risk factors and to provide the basis for future community-based intervention programs to reduce disease and injury incidence. Methods of data collection included in-person interviews, medical screenings, and environmental assessments of homes and farms. All households studied were rural; comparisons were made among farm, rural nonfarm, and town households, between men and women, and between smokers and nonsmokers. The present paper reports selected adult baseline data from Round 1 of this study. Residents of farm households were somewhat younger and better educated than residents of rural nonfarm and town households; smoked less; were more likely to have ridden an all-terrain vehicle; and were more likely to report firearms in the home. Eighty-nine percent of the men and 66% of the women engaged in farming or did so in the past. Men more often reported hearing loss, were more often overweight and obese, more often reported an injury, less often reported asthma, and less often saw a medical practitioner. Women reported poorer emotional health and higher rates of depression symptoms. The KCRHS has identified several modifiable health outcomes and risk factors as candidates for further analysis and targets for community-based prevention and intervention programs.

The health effects of rural-urban residence and concentrated poverty.

Abstract: This research quantifies the extent to which excess morbidity in rural areas is associated with individual characteristics, county income, and neighborhood poverty. Census geographic codes were assigned to people 25 to 64 years old (n = 176,930) from the National Health Interview Survey, 1989 to 1991, in order to link individuals to the U.S. Department of Agriculture's county urban-rural classification scheme and to 1990 county per capita income and poverty concentration in Census tracts. General health status and limitation of activity were analyzed in logistic and multinomial logit models. Residents of rural counties were at greater risk for health problems compared to residents of metropolitan and central core counties. In adjusted models, the health disadvantage of rural areas was partly explained by differences in population composition. The residual rural disadvantage was concentrated in people with less than a high school education. Tract poverty and county per capita income were also important independent predictors of morbidity. The results of this study suggest that special attention should be paid to improving education in disadvantaged places and to better understanding the ways in which economic growth and its benefits are distributed.

Rural hospitals: Trends, challenges, and a future research and policy analysis agenda

Abstract: Previous reviews of the status of rural hospitals conclude that rural hospitals play a major role in ensuring the provision of health services in rural areas, are an essential part of the social and economic identity of rural communities, have had mixed success in their ability to respond to environmental threats, and are very sensitive to public policies due, in part, to their small size. The evolving hospital paradigm in the United States and a turbulent economic and health care environment have created an uncertain future for the rural hospital. Hospitals are being forced to shift their emphasis from filling acute inpatient care beds to providing a more diversified set of services through linkages with other institutions and provider groups. This presents challenges for rural hospitals, which often serve as the foundation for health care delivery in rural communities yet struggle to Overcome the effects of troubled local economies, shortages of health professionals, and public policy inequities. This article reviews key trends and challenges facing rural hospitals from the perspective of their structure and organization, financial sustainability, quality of care provided, and strategic linkages with other entities. It concludes with the presentation of a research and policy analysis agenda that addresses the feasibility of the role of the rural hospital as the hub or coordinator of the rural health care delivery system, the fiscal viability of the rural hospital in the post-Balanced Budget Act period, strategies for measuring and improving the qualify of care provided by rural hospitals, and the structure and value of horizontal and vertical linkages of rural hospitals.

Variations in Rural AIDS Epidemiology and Service Delivery Models in the United States

Abstract: This article reviews AIDS surveillance data and the rural health literature to summarize what is known about the rural AIDS epidemic, characteristics of rural environments that affect HIV service delivery, and approaches that rural areas are using to address the health and support service needs of HIV-positive residents. During 1999, nonmetropolitan (non-MSA) adult/adolescent AIDS rates were highest in the South (11 per 100,000) and Northeast (9 per 100,000). The South had the highest non-MSA proportion of adult/adolescent AIDS cases (12%), followed by the North Central region (9%), the West (4%), and the Northeast (3%). Variations in rural HIV/AIDS epidemiologic patterns and the demographic, socio-economic, and cultural characteristics of rural environments are likely to require different levels of resource investment and different methods of organizing and delivering HIV services. Currently, many HIV-positive rural residents are traveling to metropolitan areas for medical care because of concerns about confidentiality or a lack of confidence in the HIV management capabilities of local physicians. Rural communities are attempting to address these problems by developing the HIV care capacity of existing clinics, building local networks of physicians with HIV management experience, and cultivating "shared care" arrangements with urban-based specialists.

Rural Long‐term Care: What Do We Need to Know to Improve Policy and Programs?

Abstract: This article examines what is known and what we need to know about rural long-term care populations and the formal and informal service systems that support their long-term care needs. The article provides a framework for identifying some of the critical policy and research questions concerning the financing and delivery of rural long-term care that merit the attention of health services researchers and policymakers. It documents differences in the demographic and health characteristics of the rural and urban elderly and in the availability, organization, and use of health and long-term care services in rural areas that have significant implications for long-term care policy and programs. With this background in mind, the author discusses specific topics and questions relevant to long-term care policy and program improvements for rural communities and people: (a) the changing role of the rural nursing home; (b) residential care alternatives in rural areas; (c) health personnel and rural long-term care; (d) the quality of rural long-term care; (e) innovations in long-term care financing and service delivery; (f) use of technology in rural long-term care; and (g) the effects of Medicaid and Medicare policy changes on the rural long-term care system.

Pharmacy services in rural areas: is the problem geographic access or financial access?

Abstract: Access to pharmacy services is an important rural health policy issue but limited research has been conducted on it. This article describes rural retail pharmacies in Minnesota, North Dakota, and South Dakota, including their organizational characteristics, staffing, services provided, and planned future changes; examines the availability of pharmacy services and pharmacy closures in rural areas of these three states; and briefly discusses policy issues that affect the delivery of pharmacy services in rural areas. Study data came from a phone survey of 537 rural pharmacies, an analysis of pharmacy licensure data, and phone interviews with clinic, public health, and social services staff in rural communities with potential pharmacy access problems. Using a standard of 20 miles to the nearest pharmacy, most rural residents of these three states currently have adequate geographic access to pharmacy services. However, rural pharmacists and clinic, public health, and social services staff rate financial access to pharmacy services for the elderly and the uninsured as a major problem. Key policy issues that will affect future access to pharmacy services in rural areas include pharmacy staffing and relief coverage; alternative methods of providing pharmacy services; thefinancial viability of rural pharmacies; and the potential impact of a Medicare prescription benefit on rural consumers and rural pharmacies.

Distribution of services and supports for people with traumatic brain injury in rural and urban Missouri.

Abstract: New paradigms of disability suggest that many variables interact to influence the community functioning of people with traumatic brain injury (TBI), including injury severity and social, psychological, and environmental factors. Unfortunately, the majority of TBI outcome research to date has primarily focused on injury severity variables (e.g., neuroradiologic findings, loss of consciousness, posttraumatic amnesia) to the exclusion of environmental variables. Limited environmental resources such as rehabilitation professionals, facilities, and services may be significant barriers that affect outcome for people with TBI, particularly for those in rural areas. Using data from Missouri, where 32% of the population lives in rural counties, this study researched the availability of rehabilitation resources for individuals with TBI, with an emphasis on differences between rural and urban areas. Data indicated that there is a scarcity of rehabilitation professionals (i.e., physiatrists, mental health providers, rehabilitation therapists),facilities (i.e., hospitals offering comprehensive rehabilitation therapies), and services (i.e., support groups) in rural areas of the study state. The results suggest that (1) future rehabilitation researchers need to evaluate the impact of accessibility to rehabilitation services and resources on the outcome of people with TBI and (2) TBI health policy administrators need to consider how to increase rehabilitation resources for people with TBI in rural areas, including the use of rural-based training programs, rural debt-forgiveness training programs, and telehealth systems.

Where to seek care: an examination of people in rural areas with HIV/AIDS.

Abstract: Though HIV/AIDS has spread to rural areas, little empirical evidence is available on where patients living in these areas receive care. This article presents estimates of rural residents in care for HIV/AIDS, their demographic and health-related characteristics, information about whether they receive care in a rural or urban setting, and data on the drug therapies prescribed. The estimates come from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults receiving care in the contiguous United States. Regardless of the definition used--enrollment site, usual source of HIV care, or site of most recent hospitalization--almost three quarters of rural residents with HIV/AIDS obtained their health care in urban areas. The authors find that differences in the demographic characteristics of those using urban vs. rural care do not drive the decision on where to obtain care, with the primary difference being that people with a rural provider tend to be older. Rural residents with an urban usual source of HIV care incurred significant inconvenience in obtaining care--the majority said their care was not conveniently located, they had substantially longer mean travel times, and over 25% had put off obtaining care in the past 6 months because they did not have a way to get to their provider. Given the considerable burden this places on a chronically ill population,further research is needed to explore how provider supply and provider experience affect the decision to travel for care and how quality of care is affected.

Developing policies responsive to barriers to health care among rural residents: what do we need to know?

Abstract: A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies have grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.

Not raising a "bubble kid": farm parents' attitudes and practices regarding the employment, training and supervision of their children.

Abstract: This article explores farm parents' attitudes and practices regarding the employment, training and supervision of their children among a sample of 24 farm couples from southeastern Washington state. The goal was to gain a greater understanding of parental attitudes and practices in order to devise appropriate and meaningful efforts to improve the safety of children and adolescents involved in farm work. Demographic data regarding the farm families and their farm safety practices were collected through a short questionnaire, and parental attitudes and practices regarding the employment, training and supervision of their children were explored through open-ended, semi-structured interviews. The results suggest that farm parents have developed a logical and consistent set of beliefs and attitudes regarding the employment, training, and supervision of their children that is based in part on the belief that farm work is highly beneficial to their children's development. Safety interventions to reduce childhood farm injuries will have to acknowledge farm work as important and beneficial for children in order to maintain legitimacy and credibility. Nevertheless, because farm parents' practices regarding their children's employment reflect cultural beliefs and values regarding children and child-rearing, some recommended safety guidelines will be difficult to implement.

A national call to action: CDC's 2001 Urban and Rural Health Chartbook.

Abstract: It remains to be seen if Congress will recognize the CDC report as a national call to action, or whether future CDC reports will simply record the ongoing health disparities of rural America. Regardless of the Congressional outcome in 2002, the CDC report clearly succeeds in moving the national debate on rural concerns beyond the political rhetoric and into a data-driven debate.

Primary care practice management in rural and urban Veterans Health Administration settings.

Abstract: Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care. The authors used survey and administrative data from 1999 from the Veterans Health Administration (VHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally. Rural VHA hospitals were smaller, less likely to be academically affiliated, and had fewer integrated specialty care services. Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services. However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals. Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received. Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones. This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings. Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings.

Quality of Diets Consumed by Older Rural Adults

Abstract: Older adults residing in rural communities are at risk for low dietary quality because of a variety of social, physical and environmental circumstances. Minority elders are at additional risk because of poorer health status and lower socioeconomic status. This study evaluated the food group intake of 130 older (>70 years) African American (34%), European American (36%), and Native American (30%) residents of two rural communities in central North Carolina. An interviewer-administered food frequency questionnaire was used to measure dietary intake. Food items were classified into food groups similar to the United States Department of Agriculture (USDA) Food Guide Pyramid and the National Cancer Institutes 5 A Day for Better Health program. None of the survey participants met minimum intake recommendations and most over-consumed fats, oils, sweets and snacks. African Americans and Native Americans consumed fewer servings of meats, fruits and vegetables, and fats, oils, sweets and snacks than European Americans. African American men consumed the fewest servings of fruits and vegetables of all gender/ethnic groups. Consumption of fats, oils and sweets was greatest among those 85 years and older and was more common among denture users. National strategies to educate the public about the importance of consuming a varied diet based on the recommendations presented in national nutrition education campaigns may not be reaching older adults in rural communities, particularly minority group members.

Access to dental care services for Medicaid children: variations by urban/rural categories in Illinois.

Abstract: Poor oral health status and limited access to dental care have been recognized as problems for children from Medicaid and low-income families. However, little is known about dental access for Medicaid-enrolled children in rural areas. This study examines differences between rural and urban counties in dental utilization rates of Illinois children enrolled in either Medicaid or the Children's Health Insurance Program. How the overall dentist supply, the dentist Medicaid participation rate, and county level sociodemographic factors relate to Medicaid dental utilization are examined. Illinois counties were aggregated into four urban/rural categories. Descriptive analysis showed lower utilization rates in the rural categories (25 and 27%) compared with the metropolitan categories (35 and 31%). Rural areas had a substantially lower supply of dentists, and consequently a lower supply of dentists participating in Medicaid, despite the substantially higher Medicaid participation rate of dentists in the rural categories (45 and 51%) than in the metropolitan categories (22 and 32%). However, regression results indicated no significant relationship between the rate of utilization of Medicaid-enrolled children and rural status after controlling for several dental supply and population factors. The most important factors relating to Medicaid-enrolled children's dental utilization, regardless of urban or rural status, were the proportion of children enrolled in Medicaid and the participating dentist to population ratio. Without the high participation rate of dentists in rural areas, access to oral health care for rural children enrolled in Medicaid would have been worse. Policy makers should focus on maintaining high rural dentist participation rates as well as addressing future supply problems that may exacerbate difficulties with access in rural areas.

Hispanic farmworker interpretations of green tobacco sickness.

Abstract: This paper describes the explanatory model of green tobacco sickness (GTS) held by migrant and seasonal farmworkers in North Carolina and compares it with a research-based biobehavioral model. GTS is a form of acute nicotine poisoning that affects individuals who work in wet tobacco fields. It is characterized by nausea, vomiting, headache, and dizziness. There are no standard diagnostic criteria for GTS; clinicians must diagnose it based on a combination of symptoms and exposure risk. GTS resembles pesticide poisoning, but treatment is quite different. Many farmworkers in tobacco today are Spanish-speaking immigrants from Mexico with limited experience in tobacco work. In-depth interviews about GTS were conducted with 23 Hispanic farmworkers in central North Carolina to explore their understanding of the problem. Workers generally attributed the symptoms to other aspects of working in tobacco, such as pesticides or heat, rather than nicotine. They cited many of the same risk factors identified in the biobehavioral model, such as wet work conditions and inexperience with tobacco work. Prevention and treatment include a combination of exposure avoidance and common medications. The symptoms of most importance to farmworkers were insomnia and anorexia, both of which impaired the ability to work. This jeopardized their income, as well as their work security. If health care providers understand the explanatory model held by farmworkers, they will be more effective at diagnosing and treating GTS and be better prepared to teach patients how to prevent future episodes.

Disparities in mammography screening in rural areas: analysis of county differences in North Carolina.

Abstract: The extent to which targeted mammography programs have impacted women in rural areas is not well defined. We investigated mammography screening rates among 843 women age 50 and over from a population-based sample in four predominantly rural eastern North Carolina counties. We examined age, race, education level, county of residence, health insurance, and the self-reported completion of mammography in the past year using contingency tables and logistic regression. African American females aged 65 years or older had the lowest reported mammography rates (42%), while white females aged 50 to 64 had the highest rates (58%). Uninsured women and those with less education were less likely to have received a mammogram. Logistic regression demonstrated that age, education, and health insurance were significant predictors of mammography completion. A county-level analysis revealed that three counties had similar rates and one county had substantially lower rates. A higher-than-expected rate of screening-mammography completion among African American women was noted in one predominantly rural county served by a breast cancer screening program. Logistic regression analysis confirmed that county was a significant predictor for mammography completion. In separate regressions run by race, county remained a significant predictor for African American women but not for white women. Differences in mammography screening appear to persist in some predominantly rural areas and are related to age, race, education, and health insurance. Programs that target hard-to-reach women with efforts tailored specifically to their needs may be effective in reducing persistent racial differences.

Colorectal cancer incidence and mortality in Texas 1990-1992: a comparison of rural classifications.

Abstract: Although cancer incidence and mortality rates are known to be higher in urban populations, more unstaged tumors and later staged cancer are diagnosed in rural populations. Most investigators have used a dichotomous definition of urban and rural in studying these populations, and they have not considered whether a more detailed categorization of rural areas could influence their findings. The objective of this study was to evaluate colorectal cancer incidence and mortality rates in Texas from 1990 to 1992 by using a dichotomous definition (Metropolitan Area vs. Nonmetropolitan Area [MA/non-MA]) and two, more detailed rural classifications (the Rural-Urban Continuum Code [RUCC] and the Urban Influence Code [UICI). Cancer data were obtained from the Texas Cancer Registry for 1990 to 1992 and supplemented with data from the Texas State Department of Vital Statistics (mortality), the U.S. Census Bureau (age, gender, race) and the Area Resource File (rural and urban definitions). Incidence and mortality rates, age-adjusted to the 1970 U.S. standard population, were calculated for non-Hispanic White, African American, and Hispanic males and females. Results revealed a nonlinear relationship between rural category and colorectal cancer incidence or mortality for all races. Applying the MA definition yielded rates in the middle of the ranges obtained with using RUCC or UIC classifications and most closely reflected the result for non-Hispanic Whites using the more detailed scales. Our results suggest that a dichotomous definition of rural and urban may mask important variation in colorectal cancer incidence and mortality rates within rural areas.

Behavioral health: setting the rural health research agenda.

Abstract: This article seeks to identify current research priorities in the area of rural behavioral health. The method for accomplishing this task begins by identifying several domains where policy has a potential to effect improvements in access or quality but has been hampered by lack of empirical knowledge. In each domain a synthesis of current research summarizes what is known and draws attention to knowledge gaps. Research questions in each domain are proposed. The policy domains are theoretically based, using a conceptual model of access to health care, with a focus on illness level (prevalence), enabling factors (the delivery system, organization and financing, the promise of telemedicine), and predisposing factors (special populations, beliefs, values, stigma).

Telehealth: An Assessment of Growth and Distribution

Abstract: Telemedicine uses telecommunications technologies to deliver health care to populations located at some distance from health care providers. Telehealth is a somewhat broader term that includes non-clinical applications (such as education). This article draws on data from a nationwide survey of telehealth networks that assesses the extent and character of telemedicine activity. Although statistics point to increased utilization, the distribution of growth has been skewed toward a few applications and it is not clear that rural areas would derive substantial benefit in the absence of federal subsidy. Reported barriers to building sustainable programs often seem to reflect concerns of large hospitals and health care systems rather than constraints faced by rural organizational and individual network members. The potential role of government in addressing barriers is discussed.

Community Entry in Conducting Rural Focus Groups: Process, Legitimacy, and Lessons Learned

Abstract: This article explores the value of community collaboration in a qualitative study of diabetes. In 1999, the Appalachian Diabetes Coalition of West Virginia University's Prevention Research Center employed a statewide effort to conduct focus groups in West Virginia to elicit cultural perspectives on diabetes and its management. The success of this research depended on community participation at many levels, particularly because of the rural, often geographically isolated community structure of the state. The researchers' entry into small communities and the involvement of local residents in focus groups was possible with the collaboration of the West Virginia Rural Health Education Partnerships program and the West Virginia University Extension Service, both of which played primary roles as community gatekeepers in helping the research team access and involve rural areas. This collaboration reinforced the value of a two-tiered approach in enlisting local resources. These relationships resulted in beneficial outcomes to all partners. Researchers benefited by gaining entry to communities, and the community organizations benefited by gaining a better understanding of the diabetic population to assist in planning programs. Working with well-established community groups with strong community ties is crucial when gaining entry for research and interventions. The identification and involvement of trusted, accessible members of rural communities gives research local legitimacy, ensures adequate participation and effective data collection, and permits entry into remote communities.

Rural‐Urban Home Health Care Differences Before the Balanced Budget Act of 1997

Abstract: This study arose from concerns that home health care may be more difficult to provide to rural than urban elderly patients (because of geographic barriers, personnel shortages, and other factors) and may therefore be less effective in terms of patient outcomes. Case mix, home health care service use, and outcomes (primarily discharge status) were analyzed for a national random sample of 3,869 rural and urban elderly home health patients. Longitudinal data covered the period from home health admission to discharge or 120 days (whichever occurred first). Primary data collection instruments were designed to obtain longitudinal patient-level health status data; agency records and Medicare data provided service use information. (The study did not address access but focused on services and outcomes after admission to home health care.) Two-group statistical tests and multivariate analyses were employed to assess rural-urban differences. The major findings were that, after adjustment for rural-urban case mix and agency differences, rural compared to urban patients received fewer home health services and attained less favorable discharge outcomes. For example, the rural patients had a higher case mix adjusted hospitalization rate. Because the study data pertain to 1995 through 1996, the results provide a baseline for future analyses of possibly different rural compared to urban effects of the Balanced Budget Act of 1997, which resulted in major changes in Medicare payment for home health care.

Developing, implementing, and evaluating a treatment protocol for rural substance abusers.

Abstract: Substance abuse is a significant social and public health problem facing rural Americans. However, most treatment protocols have been developed in urban areas. This article describes the development, implementation, and evaluation of an innovative substance abuse treatment designed with the collaboration of rural professionals and consumers specifically for rural clients and delivered by rural clinicians. Results of the process evaluation of Structured Behavioral Outpatient Rural Therapy (SBORT) produced findings about the experiences of participating clients, clinicians, and program directors. Most clients perceived SBORT as a helpful learning process that used multiple treatment strategies and presented an alternative to 12-step programs. Clients also reported that treatment was stressful even when beneficial, and that clinician support was critical for remaining in treatment. Most clinicians found that SBORT challenged their "old" treatment frameworks, was demanding to learn and adopt, and that the training and supervision involved in the project implementation helped remedy rural isolation from the treatment community. Interestingly, agency approach to program implementation strongly influenced clinician responses to the innovation. Agency program directors' appraisals of SBORT included observations that the therapy was viable because of its rural-specific design and that most staff were able to adapt to the changes demanded by the manualized protocol. All three groups reported that they saw the emphasis and acceptance of motivation as an emergent process as important to the treatment. This project highlighted the challenge and importance of testing rural substance abuse treatment protocols in naturalistic settings.

Cervical Cancer Risk as a Predictor of Pap Smear Use in Rural North Carolina

Abstract: Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer-related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross-sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk-appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High-risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low-risk status was the absence of all factors. A high-risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low-risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk-appropriate screening guidelines. Low-risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.

The reported value of rural internal medicine residency electives and factors that influence rural career choice.

Abstract: This study examines how rural electives affect medical residents' opinions about rural practice and which factors encourage or discourage choice of rural practice. Participants in a one- to two-month rural elective and a matched group of randomly selected nonparticipants were surveyed. Seventy percent of the elective participants (n = 58) and 61 % of the matched nonparticipants (n = 51) completed the questionnaire. The groups' responses to scaled response measures and open-ended questions were analyzed using, chi-square and Mann-Whitney U tests. A majority of participants stated that the elective was a beneficial experience (n = 36), and participants' interest in rural practice increased significantly after the elective. Elective participants were more likely than nonparticipants to see breadth of practice, continuity of care, quality of life in rural areas, and experiences with mentors as encouraging rural practice. Elective participation did not demonstrably increase rural career choice, although this finding may be attributable to small sample size. Respondents identified means to encourage rural practice, as well as barriers to rural practice: Elective participants suggested that electives may be more effective if they occurred earlier in medical training, lasted for longer periods of time, and addressed the needs of spouses or partners. Generalizability is limited by several factors, including small sample size and the possibility of pre-existing differences between elective participants and nonparticipants.

Quality of care in the rural context: a proposed research agenda.

Abstract: The quality of health care provided in rural areas is critical to rural patients and providers and will shape the future evolution of the rural health care system. Past research has focused almost exclusively on disease-specific comparisons of the quality of care rendered in rural as compared with urban areas, which ignores the fact that it is the functioning of the entire system of care that determines whether or not rural residents receive high quality care. Future research should focus on the functioning of the entire rural system of care. To accomplish this objective, we suggest investments in the following areas: the creation of a national database that collects information on the process and outcome of care delivered to rural populations, the incorporation of human factors research into our research agenda, greater emphasis on the importance of sociodemographic and cultural issues to the quality of care, and a shift to a focus on populations as opposed to individuals.

Veterinarian perception of the intentional misuse of veterinary medications in humans: a preliminary survey of Idaho-licensed practitioners.

Abstract: The intentional administration of veterinary medications to humans is a form of medication misuse that has not been systematically studied. Veterinarians are the health practitioner group most likely to have knowledge about this problem and to be approached by the public for advice. For this preliminary study, questionnaires were mailed to 1,077 veterinarians registered with the Idaho Board of Veterinary Medicine regarding their knowledge and perceptions of this type of misuse; 392 (36.4%) completed surveys were returned. The most frequently reported veterinary medications misused in humans were analgesic, anti-inflammatory medications, anti-arthritis medications, or both; systemic antibiotics, topical anti-infectives; and topical corticosteroids. People involved with rodeo, horse racing, and health care; rural area residents; and those lacking health insurance were perceived to be the groups most likely to misuse veterinary drugs. Veterinarians rated the following as likely reasons for misuse: having an independent self-sufficient attitude, convenient availability of veterinary medications, lower cost, and belief that veterinary medications are stronger than comparable human medications. Human misuse of veterinary drugs may be more common than many health practitioners realize. Limitations of this study include the response rate, sampling of veterinarians licensed in only one rural state, and reliance on veterinarians' recall of relevant instances of misuse and their perceptions of groups most likely to misuse these drugs and why. These limitations make it difficult to determine if the problem is being under- or over-represented relative to the general population. However, regardless of the magnitude of the problem in the rural population, the general population, or both, the potential for harm is great. Patients with risk factors for this form of misuse should be questioned by their physician in a nonthreatening manner to detect use of veterinary medications and to provide an opportunity to inform them of the risks.

An outreach intervention for older rural African Americans.

Abstract: This article describes the process, approaches, and selected outcomes of a rural care management outreach intervention for older African Americans in South Carolina. The model is a community-academic partnership between a federally qualified community health center, a rural health clinic, and the Medical University of South Carolina. Its aim is to improve access to and utilization of health care and social services to enhance the quality of life of older African Americans. This is being accomplished by using paid, trained outreach workers (called geriatric coordinators), who function as advocates in linking clients to needed health and social services through activities such as arranging transportation to health care, rescheduling missed medical appointments, providing health promotion, and making referrals to public benefits and indigent drug programs. Outcomes demonstrated that the use of geriatric coordinators as care managers is a feasible way of increasing quality of life for older African Americans. The most notable outcome showed that 54% of clients who were eligible but not receiving benefits prior to this intervention were signed on for programs such as Supplemental Security Income, Specified Low-Income Medicare Beneficiary (SLMB), Qualified Medicare Beneficiary (QMB), disability, railroad pensions, and Veterans Administration benefits. Health centers realized an increase in reimbursable services and new clients. Increased capacity for older adult services is being accomplished through geriatric-coordinator-directed collaborations with social service agencies and participation in community events and committees.