Telehealth Versus Face-to-face Psychotherapy for Less Common Mental Health Conditions: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mental disorders are a leading cause of distress and disability worldwide. To meet patient demand, there is a need for increased access to high-quality, evidence-based mental health care. Telehealth has become well established in the treatment of illnesses, including mental health conditions.

OBJECTIVE

This study aims to conduct a robust evidence synthesis to assess whether there is evidence of differences between telehealth and face-to-face care for the management of less common mental and physical health conditions requiring psychotherapy.

METHODS

In this systematic review, we included randomized controlled trials comparing telehealth (telephone, video, or both) versus the face-to-face delivery of psychotherapy for less common mental health conditions and physical health conditions requiring psychotherapy. The psychotherapy delivered had to be comparable between the telehealth and face-to-face groups, and it had to be delivered by general practitioners, primary care nurses, or allied health staff (such as psychologists and counselors). Patient (symptom severity, overall improvement in psychological symptoms, and function), process (working alliance and client satisfaction), and financial (cost) outcomes were included.

RESULTS

A total of 12 randomized controlled trials were included, with 931 patients in aggregate; therapies included cognitive behavioral and family therapies delivered in populations encompassing addiction disorders, eating disorders, childhood mental health problems, and chronic conditions. Telehealth was delivered by video in 7 trials, by telephone in 3 trials, and by both in 1 trial, and the delivery mode was unclear in 1 trial. The risk of bias for the 12 trials was low or unclear for most domains, except for the lack of the blinding of participants, owing to the nature of the comparison. There were no significant differences in symptom severity between telehealth and face-to-face therapy immediately after treatment (standardized mean difference [SMD] 0.05, 95% CI -0.17 to 0.27) or at any other follow-up time point. Similarly, there were no significant differences immediately after treatment between telehealth and face-to-face care delivery on any of the other outcomes meta-analyzed, including overall improvement (SMD 0.00, 95% CI -0.40 to 0.39), function (SMD 0.13, 95% CI -0.16 to 0.42), working alliance client (SMD 0.11, 95% CI -0.34 to 0.57), working alliance therapist (SMD -0.16, 95% CI -0.91 to 0.59), and client satisfaction (SMD 0.12, 95% CI -0.30 to 0.53), or at any other time point (3, 6, and 12 months).

CONCLUSIONS

With regard to effectively treating less common mental health conditions and physical conditions requiring psychological support, there is insufficient evidence of a difference between psychotherapy delivered via telehealth and the same therapy delivered face-to-face. However, there was no includable evidence in this review for some serious mental health conditions, such as schizophrenia and bipolar disorders, and further high-quality research is needed to determine whether telehealth is a viable, equivalent treatment option for these conditions.

Urban-rural disparities in old-age mortality vary systematically with age: evidence from Germany and England & Wales

OBJECTIVES

Population aging - which tends to be more pronounced in rural than in urban areas - poses important challenges for facilitating equal opportunities for aging well and 'aging in place.' Unmet health care needs among the older rural population may result in poorer health and higher mortality, but the scientific evidence of a systematic rural mortality disadvantage at older ages is scarce. We argue that systematic urban-rural mortality differences by age may be found if the confounding effect of life expectancy is considered.

STUDY DESIGN

Nationwide population-based study.

METHODS

We draw on age- and sex-specific data for the population aged 60+ years in NUTS-3 regions in Germany (2016-2018) and LAU-1 regions in England & Wales (2017-2019). To account for the confounding effect of life expectancy, we compare age-specific mortality only across urban and rural regions with similar life expectancy levels. We quantify statistical uncertainty with bootstrapping.

RESULTS

The results show a remarkable shift from higher mortality in urban regions to higher mortality in rural regions with increasing age, when controlling for the confounding effect of life expectancy. That is, the urban mortality disadvantage is strongest for the population aged 60-79 years, whereas the pattern shifts toward a rural mortality disadvantage for the population aged 80 years and older. This pattern is present at all levels of life expectancy, for both sexes and in both countries.

CONCLUSION

The shift from urban to rural excess mortality over age suggests that regions may vary in their capability to respond to arising health issues across older ages. This systematic mortality disadvantage is of high public health relevance and should be considered in designing policies to reduce regional mortality disparities.

"No One Manages It; We Just Sign Them Up and Do It": A Whole System Analysis of Access to Healthcare in One Remote Australian Community

OBJECTIVE

To assess the accessibility, availability and utilisation of a comprehensive range of community-based healthcare services for Aboriginal people and describe contributing factors to providing effective healthcare services from the provider perspective.

SETTING

A remote community in New South Wales, Australia.

PARTICIPANTS

Aboriginal and non-Aboriginal health and education professionals performing various roles in healthcare provision in the community.

DESIGN

Case study.

METHODOLOGY

The study was co-designed with the community. A mixed-methods methodology was utilised. Data were gathered through structured interviews. Descriptive statistics were used to analyse the availability of 40 health services in the community, whilst quotations from the qualitative research were used to provide context for the quantitative findings.

RESULTS

Service availability was mapped for 40 primary, specialised, and allied health services. Three key themes emerged from the analysis: (1) there are instances of both underservicing and overservicing which give insight into systemic barriers to interagency cooperation; (2) nurses, community health workers, Aboriginal health workers, teachers, and administration staff have an invaluable role in healthcare and improving patient access to health services and could be better supported through further funding and opportunities for specialised training; and (3) visiting and telehealth services are critical components of the system that must be linked to existing community-led primary care services.

CONCLUSION

The study identified factors influencing service availability, accessibility and interagency cooperation in remote healthcare services and systems that can be used to guide future service and system planning and resourcing.

Can an Ecological Index of Deprivation Be Used at the Country Level? The Case of the French Version of the European Deprivation Index (F-EDI)

Most ecological indices of deprivation are constructed from census data at the national level, which raises questions about the relevance of their use, and their comparability across a country. We aimed to determine whether a national index can account for deprivation regardless of location characteristics. In Metropolitan France, 43,853 residential census block groups (IRIS) were divided into eight area types based on quality of life. We calculated score deprivation for each IRIS using the French version of the European Deprivation Index (F-EDI). We decomposed the score by calculating the contribution of each of its components by area type, and we assessed the impact of removing each component and recalculating the weights on the identification of deprived IRIS. The set of components most contributing to the score changed according to the area type, but the identification of deprived IRIS remained stable regardless of the component removed for recalculating the score. Not all components of the F-EDI are markers of deprivation according to location characteristics, but the multidimensional nature of the index ensures its robustness. Further research is needed to examine the limitations of using these indices depending on the purpose of the study, particularly in relation to the geographical grid used to calculate deprivation scores.

A novel telerehabilitation with an educational program for caregivers using telelecture is feasible for fall prevention in elderly people: A case series

BACKGROUND

The importance of fall prevention rehabilitations has been well recognized. Recently telerehabilitation was developed, however, there have been no reports on telerehabilitation with direct support from specialists for fall prevention among the elderly. We herein reported telerehabilitation by caregivers educated by our novel educational program.

METHODS

Caregivers were educated with our educational program using a telelecture system and supported telerehabilitation following instructions from rehabilitation specialists in our university using the telemedicine system every two to four weeks for three months. Caregivers were assessed with our original questionnaire before and after the telelecture. Participants were assessed by the Berg Balance Scale (BBS), Timed Up & Go test (TUG test), Hand-held dynamometer (HHD) and Mini-Mental State Examination (MMSE) before and after telerehabilitation. Wilcoxon's signed-rank test was used for the statistical analyses. A value of P<.05 was considered statistically significant.

RESULTS

Nine elderly people were enrolled. The mean age was 84.7 (78-90) years old and the sex ratio was 1:8 (males:females). The average number of telerehabilitation sessions was 4.7. The average score of nineteen caregivers before the lecture was 15.3, while that after the lecture was 18.3. Caregivers' understanding was significantly increased after the telelecture (P<.001). No adverse events occurred during the study period. The median values of the BBSs, TUG test, right and left HHD and MMSE before and after 3 months' telerehabilitation were 43 (95% confidence interval [CI]: 40.10, 49.01) and 49 (95% CI: 41.75, 50.91), 17.89 (95% CI: 15.51, 23.66) and 18.53 (95% CI: 14.56, 25.67), 7.95 (95% CI: 4.38, 10.14) and 11.55 (95% CI: 7.06, 13.55), 9.85 (95% CI: 6.79, 12.59) and 13.20 (95% CI: 7.96, 14.42), and 19 (95% CI: 12.34, 21.66) and 16 (95% CI: 10.81, 21.00), respectively. Although approximately half of the participants showed improvement in the BBS, TUG test, right and left HHD and MMSE, no significant changes were observed (P=.7239, P=.3446, P=.1023, P=.3538 and P=.8253, respectively).

CONCLUSIONS

Our telerehabilitation program exhibited significant effects in elderly people and improved the degree of understanding concerning rehabilitation among caregivers in facilities for elderly people.

Urban-Rural Disparity in the Incidence of Diagnosed Autism Spectrum Disorder in Taiwan: A 10-Year National Birth Cohort Follow-up Study

Autism spectrum disorder (ASD) is reportedly more prevalent in urban areas partly because of better accessibility and affordability to healthcare. With universal health insurance coverage in Taiwan, a previous study has shown no urban-rural disparity in the utilization rate of a child's preventive healthcare. Under this circumstance, we followed a birth cohort of 176,273 live births from 2006 to 2015 to detect the differences in ASD incidence between urbanicities. After adjusting for socioeconomic factors, children were 1.28 (95% confidence interval (CI): 1.13-1.44) and 1.54 (95% CI: 1.36-1.75) more likely to acquire ASD in satellite and urban areas compared with those in rural areas, respectively. A gradient association between parental educational attainment and ASD incidence was also noted. Greater ASD incidences in more urbanized areas and more advanced educated parents' children were detected under a circumstance with low barriers to healthcare.

The bounds of suicide talk: Implications for qualitative suicide research

Following the implementation of a provincial suicide prevention gatekeeper training initiative in western Canada between 2015 and 2018, we conducted a focused ethnography designed to capture the post-initiative context within one small community. Analyses of our field observations and interviews with community members suggest suicide prevention work is represented in multiple informal or coordinated actions to generate innovative pathways to provoke open conversations about suicide. Simultaneously, suicide talk is constrained and managed to limit vulnerability and exposure and adhere to community privacy norms. Further, parameters around suicide talk may be employed in efforts to construct the community and mental health care in livable ways. As the research process paralleled existing representations of suicide prevention work in the community, this paper explores our entanglement in the bounds of suicide talk during phases of recruitment, data collection and knowledge translation activities.

Relationships between management factors in dairy production systems and mental health of farm managers in Japan

To facilitate sustainable dairy farming, it is essential to assess and support the mental health of dairy farm workers, which is affected more than that of workers in other industries, as indicated by the relatively few studies to date. In addition, the limited investigations on mental health in dairy workers minimize the opportunities to suggest practical approaches of improvement of their mental health. Therefore, further data acquisition and analysis is required. In the present study, we undertook quantitative surveys on 17 management factors and administered a mental health questionnaire to 81 dairy farm managers (80 male, 1 female) in Hokkaido, northern Japan. The management factors were categorized into 3 groups: production input, production output, and facility indicator; mental health was evaluated based on the Center for Epidemiologic Studies Depression Scale (CES-D). Principal component analysis assigned the factors into 2 groups: intensiveness factors of dairy production systems (PC1: livestock care cost, fat- and protein-corrected milk, stocking density, medical consultation fee per unit time per animal unit, nonfamily wages, fertilizer and pesticide expenses, and net agricultural income ratio) and basic dairy management factors (PC2: net agricultural income ratio, quantity of concentrate feed, and milk quality variable). The depression symptoms of dairy farm managers were not significantly associated with PC1 and milking methods; however, they were significantly negatively associated with PC2, which integrated 3 management factors, including factors related to finances, feeding, and milk quality. According to the findings of the present study, the efforts needed for stable economic farm management, adequate feed supply, and milk quality maintenance may increase the depression levels of dairy farm managers and negatively affect their mental health. These findings could be the basis for future studies on the relationship between the mental health of farm managers and sustainable dairy farm management and production.

Geographical distribution of 3 allied health professions in South Australia: A summary of access and disadvantage

OBJECTIVE

To describe the distribution of 3 allied health professionals-occupational therapists, physiotherapists and podiatrists-in South Australia stratified by the Modified Monash Model and the Index of Relative Socio-Economic Disadvantage.

DESIGN

A descriptive data linkage cross-sectional study.

SETTING

The state of South Australia, Australia.

PARTICIPANTS AND MAIN OUTCOME MEASURES

Distribution of the 3 registered allied health professional groups stratified by Modified Monash Model and Index of Relative Socio-Economic Disadvantage.

RESULTS

The largest proportion of the 3 allied health professional groups (occupational therapists, physiotherapists and podiatrists) were found in areas classified as Modified Monash 1 and Modified Monash 2 (86.5%). The lowest proportion of allied health professionals were found in Modified Monash 7. The largest number of allied health professionals per 10 000 population was found in areas classified as Modified Monash 1 and Modified Monash 2. The lowest number of allied health professionals per 10 000 population was found in Modified Monash 7 areas. The largest number of allied health professionals per 10 000 population was found in areas with Index of Relative Socio-Economic Disadvantage quintile 2, while the lowest number of allied health professionals per 10 000 population was found in areas with Index of Relative Socio-Economic Disadvantage quintile 1.

CONCLUSIONS

The distribution of allied health professionals according to geographical remoteness, socio-economic disadvantage and per 10 000 population varies widely in South Australia. The number of allied health professionals per 10 000 population was lowest in rural and remote/very remote areas, explaining the typically poor access to allied health services for communities in these areas. The number of allied health professionals per 10 000 population according to Index of Relative Socio-Economic Disadvantage was variable within the context of both urban and rural areas.

Developing the geographic classification for health, a rural-urban classification for New Zealand health research and policy: A research protocol

INTRODUCTION

Rural-urban health inequities, exacerbated by deprivation and ethnicity, have been clearly described in the international literature. To date, the same inequities have not been as clearly demonstrated in Aotearoa New Zealand despite the lower socioeconomic status and higher proportion of Māori living in rural towns. This is ascribed by many health practitioners, academics and other informed stakeholders to be the result of the definitions of 'rural' used to produce statistics.

AIMS

To outline a protocol to produce a 'fit-for-health purpose' rural-urban classification for analysing national health data. The classification will be designed to determine the magnitude of health inequities that have been obscured by use of inappropriate rural-urban taxonomies.

METHODS

This protocol paper outlines our proposed mixed-methods approach to developing a novel Geographic Classification for Health. In phase 1, an agreed set of community attributes will be used to modify the new Statistics New Zealand Urban Accessibility Classification into a more appropriate classification of rurality for health contexts. The Geographic Classification for Health will then be further developed in an iterative process with stakeholders including rural health researchers and members of the National Rural Health Advisory Group, who have a comprehensive 'on the ground' understanding of Aotearoa New Zealand's rural communities and their attendant health services. This protocol also proposes validating the Geographic Classification for Health using general practice enrolment data. In phase 2, the resulting Geographic Classification for Health will be applied to routinely collected data from the Ministry of Health. This will enable current levels of rural-urban inequity in health service access and outcomes to be accurately assessed and give an indication of the extent to which older classifications were masking inequities.

Challenges in current nursing home care in rural Germany and how they can be reduced by telehealth - an exploratory qualitative pre-post study

Background

Telemedical care of nursing home residents in Germany, especially in rural areas, is limited to a few pilot projects and is rarely implemented as part of standard care. The possible merits of implementing video consultations in longer-term nursing care currently lack supporting evidence. In particular, there is little documentation of experiences and knowledge about the effects and potential benefits of the implementation in presently existing structures. The goal was to assess the effect of implementing medical video consultations into nursing home care addressing the following research questions:

How is medical care currently provided to nursing home residents, and where do problems in its implementation arise?

How can video consultations be used to reduce difficulties arising in everyday care?

How does implementation of video consultations impact day-to-day nursing home care delivery?

Methods

Twenty-one guided interviews (pre-implementation n = 13; post-implementation n = 8) were conducted with a total of 13 participants (physicians, nurses and medical technical assistants). Narratives were analysed using qualitative content analysis. The results were contrasted in a pre-post analysis.

Results

Challenges described by the participants before implementation included a requirement for additional organisational and administrative efforts, interruptions in the daily care routine or delayed treatments, and risk for loss of patient-relevant information due to process diversity. After implementation, communication was facilitated upon introduction of assigned time slots for video consultations. Clinical information was less likely to be lost, additional work was spared, and medication and therapeutic and assistive devices were provided more quickly.

Conclusions

Telehealth cannot replace physical, in-person visits, but does offer an alternative form of service delivery when properly integrated into existing structures. Our results suggest that the use of video consultations in nursing homes can reduce the burden and additional workload, and increase the efficiency of care provision for nursing home residents. Video consultations can complement in-person visits to nursing homes, especially to address the shortage of medical specialists in rural areas in Germany. To promote implementation and acceptance of video consultation in nursing homes, we need to increase awareness of its benefits and undertake further evaluation of video consultations in nursing home care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06950-y.

Exploring the influence of rural residence on uptake of organized cancer screening - A systematic review of international literature

Lower screening uptake could impact cancer survival in rural areas. This systematic review sought studies comparing rural/urban uptake of colorectal, cervical and breast cancer screening in high income countries. Relevant studies (n = 50) were identified systematically by searching Medline, EMBASE and CINAHL. Narrative synthesis found that screening uptake for all three cancers was generally lower in rural areas. In meta-analysis, colorectal cancer screening uptake (OR 0.66, 95 % CI = 0.50-0.87, I² = 85 %) was significantly lower for rural dwellers than their urban counterparts. The meta-analysis found no relationship between uptake of breast cancer screening and rural versus urban residency (OR 0.93, 95 % CI = 0.80-1.09, I² = 86 %). However, it is important to note the limitation of the significant statistical heterogeneity found which demonstrates the lack of consistency between the few studies eligible for inclusion in the meta-analyses. Cancer screening uptake is apparently lower for rural dwellers which may contribute to poorer survival. National screening programmes should consider geography in planning.

The impact of distance on post-ICU disability

BACKGROUND

Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.

OBJECTIVES

The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.

METHODS

This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received >24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU: <50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p < 0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.

RESULTS

A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living <50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.

Suicide in rural Australia: A retrospective study of mental health problems, health-seeking and service utilisation

BACKGROUND

Suicide rates are higher in rural Australia than in major cities, although the factors contributing to this are not well understood. This study highlights trends in suicide and examines the prevalence of mental health problems and service utilisation of non-Indigenous Australians by geographic remoteness in rural Australia.

METHODS

A retrospective study of National Coronial Information System data of intentional self-harm deaths in rural New South Wales, Queensland, South Australia and Tasmania for 2010-2015 from the National Coronial Information System.

RESULTS

There were 3163 closed cases of intentional self-harm deaths by non-Indigenous Australians for the period 2010-2015. The suicide rate of 12.7 deaths per 100,000 persons was 11% higher than the national Australian rate and increased with remoteness. Among people who died by suicide, up to 56% had a diagnosed mental illness, and a further 24% had undiagnosed symptoms. Reported diagnoses of mental illness decreased with remoteness, as did treatment for mental illness, particularly in men. The most reported diagnoses were mood disorders (70%), psychotic disorders (9%) and anxiety disorders (8%). In the six weeks before suicide, 22% of cases had visited any type of health service at least once, and 6% had visited two or more services. Medication alone accounted for 76% of all cases treated.

CONCLUSIONS

Higher suicide rates in rural areas, which increase with remoteness, may be attributable to decreasing diagnosis and treatment of mental disorders, particularly in men. Less availability of mental health specialists coupled with socio-demographic factors within more remote areas may contribute to lower mental health diagnoses and treatment. Despite an emphasis on improving health-seeking and service accessibility in rural Australia, research is needed to determine factors related to the under-utilisation of services and treatment by specific groups vulnerable to death by suicide.

Informing telehealth service delivery for cardiovascular disease management: exploring the perceptions of rural health professionals

Objective To explore the perceptions of rural health professionals who use telehealth services for cardiovascular health care, including the potential role of telehealth in enhancing services for this patient group. Methods Semi-structured interviews were conducted with ten rural health professionals across a range of disciplines, including medicine, nursing and allied health. All study participants were based in the same rural region in New South Wales, Australia. Results Participant responses emphasised the importance of including rural communities in ongoing dialogue to enhance telehealth services for cardiovascular care. Divergent expectations about the purpose of telehealth and unresolved technology issues were identified as factors to be addressed. Rural health professionals highlighted the importance of all stakeholders coming together to overcome barriers and enhance telehealth services in a collaborative manner. Conclusion This study contributes to an evolving understanding of how health professionals based in regional Australia experience telehealth services. Future telehealth research should proceed in collaboration with rural communities, supported by policy that actively facilitates the meaningful inclusion of rural stakeholders in telehealth dialogue. What is known about the topic? Telehealth is frequently discussed as a potential solution to overcome aspects of rural health, such as poor outcomes and limited access to services compared with metropolitan areas. In the context of telehealth and cardiovascular disease (CVD), research that focuses on rural communities is limited, particularly regarding the experiences of these communities with telehealth. What does this paper add? This paper offers insight into how telehealth is experienced by rural health professionals. The paper highlights divergent expectations of telehealth's purpose and unresolved technological issues as barriers to telehealth service delivery. It suggests telehealth services may be enhanced by collaborative approaches that engage multiple stakeholder groups. What are the implications for practitioners? The use and development of telehealth in rural communities requires a collaborative approach that considers the views of rural stakeholders in their specific contexts. To improve telehealth services for people living with CVD in rural communities, it is important that rural stakeholders have opportunities to engage with non-rural clinicians, telehealth developers and policy makers.

Child Farm-Related Injury in Australia: A Review of the Literature

Children on farms have been identified as a population vulnerable to injury. This review seeks to identify child farm-related injury rates in Australia and to determine the key hazards and contributing risk factors. This critical review utilised the PRISMA guidelines for database searching. Research from the year 2000 onward was included as well as earlier seminal texts. Reference lists were searched, and the relevant research material was explored. Our primary focus was on Australian peer-reviewed literature with international and grey literature examples included. Evidence suggests that there is limited Australian research focusing on child farm-related injuries. Child representation in farm-related injuries in Australia has remained consistent over time, and the key hazards causing these injuries have remained the same for over 20 years. The factors contributing to child rates of farm injury described in the literature include child development and exposure to dangerous environments, the risk-taking culture, multi-generational farming families, lack of supervision, child labour and lack of regulation, limited targeted farm safety programs, underuse of safe play areas, financial priorities and poor understanding and operationalisation of the hierarchy of control. It is well known that children experience injury on farms, and the key hazards that cause this have been clearly identified. However, the level of exposure to hazards and the typical attitudes, behaviours and actions of children and their parents around the farm that contribute to chid injury remain unexplored.

Trends in youth cannabis use across cannabis legalization: Data from the COMPASS prospective cohort study

Canada legalized recreational cannabis use for adults on October 17, 2018 with decision-makers emphasising the need to reduce cannabis use among youth. We sought to characterise trends of youth cannabis use before and after cannabis legalization by relying on a quasi-experimental design evaluating cannabis use among high school students in Alberta, British Columbia, Ontario, and Québec who participated in the COMPASS prospective cohort study. Overall trends in use were examined using a large repeat cross-sectional sample (n = 102,685) at two time points before legalization (16/17 and 17/18 school years) and one after (18/19 school year). Further differential changes in use among students affected by legalization were examined using three sequential four-year longitudinal cohorts (n = 5,400) of students as they progressed through high school. Youth cannabis use remains common with ever-use increasing from 30.5% in 2016/17 to 32.4% in 2018/19. In the repeat cross-sectional sample, the odds of ever use in the year following legalization were 1.05 times those of the preceding year (p = 0.0090). In the longitudinal sample, no significant differences in trends of cannabis use over time were found between cohorts for any of the three use frequency metrics. Therefore, it appears that cannabis legalization has not yet been followed by pronounced changes on youth cannabis use. High prevalence of youth cannabis use in this sample remains a concern. These data suggest that the Cannabis Act has not yet led to the reduction in youth cannabis use envisioned in its public health approach.

Experiences of older adults accessing specialized health care services in rural and remote areas: a qualitative systematic review

OBJECTIVE

The objective of this review was to synthesize the literature on the experiences of older adults accessing specialized health care services while living in remote or rural areas.

INTRODUCTION

Older persons with chronic illnesses often need specialized health care services. Those who live in remote or rural areas may have limited access to these specialized health care services, potentially leading to an increase in morbidity and mortality. Little is known about the experiences of older adults accessing specialized health care services while living in remote or rural areas.

INCLUSION CRITERIA

This review considered studies of persons 65 years and older who have self-identified as living in remote or rural areas. They will have, on at least one occasion, sought access in person to specialized health care services for a chronic condition such as cardiovascular disease, renal disease, diabetes, cancer, mental illness, or a major health concern beyond the scope of a primary care clinician, such as palliative care.

METHODS

The search strategy aimed to find both published and unpublished studies in English from 1980 onward. An initial limited search of MEDLINE and CINAHL was undertaken in February 2017, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. This informed the development of a search strategy, which was tailored for each information source. The search was first conducted in December 2018 and rerun in November 2019. The databases searched included CINAHL, PubMed, PsycINFO, and AgeLine. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and MedNar. Papers meeting the inclusion criteria were appraised by two independent reviewers for methodological quality. Data extraction was conducted according to the standardized data extraction tool from JBI. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Three papers were included in the review yielding a total of five findings and two categories. The categories were aggregated to form one synthesized finding: Distance often results in challenges accessing health care. For almost all older adults, the long distance to drive for specialized services was a barrier, especially for those living far out in the country, and led to delayed care. Lack of health education and peer support was also viewed as an issue. For one older adult, however, the distance was not seen as an issue; rather, it was viewed as an opportunity to enjoy time with family members. Participants noted that they had access to emergency care and, therefore, believed they were not putting their lives at risk by living in a rural area. The overall ConQual score was low.

CONCLUSION

We believe that the distance to travel to obtain specialized services, as well as living in an area without specialized services, impacted this population's experience of obtaining specialized health care as well as their health. The spectrum of findings for our synthesized finding suggests that this was the case for some people, but not all. We speculate that people who have chosen to live outside an urban area or have lived in a rural area for a prolonged period come to accept their access to health care, including the distance to travel for health care and their potential for this to impact their health. The findings also suggest the older adults have a range of experiences; for some, distance was an issue and for others, it was not an issue. Some participants found living in a rural area impacted their care while others did not.

Associations between measures of pediatric human resources and the under-five mortality rate: a nationwide study in China in 2014

BACKGROUND

To quantify the associations between the under-five mortality rate (U5MR) and measures of pediatric human resources, including pediatricians per thousand children (PPTC) and the geographical distribution of pediatricians.

METHODS

We analyzed data from a national survey in 2015-2016 in 2636 counties, accounting for 31 mainland provinces of China. We evaluated the associations between measures of pediatric human resources and the risk of a high U5MR (≥ 18 deaths per 1000 live births) using logistic regression and restricted cubic spline regression models with adjustments for potential confounders. PPTC and pediatricians per 10,000 km2 were categorized into quartiles. The highest quartiles were used as reference.

RESULTS

The median values of PPTC and pediatricians per 10,000 km2 were 0.35 (0.20-0.70) and 150 (50-500), respectively. Compared to the counties with the highest PPTC (≥ 0.7), those with the lowest PPTC (< 0.2) had a 52% higher risk of a high U5MR, with an L-shaped relationship. An inverted J-shaped relationship was found that the risk of a high U5MR was 3.74 [95% confidence interval (CI) 2.55-5.48], 3.07 (95% CI 2.11-4.47), and 2.25 times (95% CI 1.52-3.31) higher in counties with < 50, 50-149, and 150-499 pediatricians per 10,000 km2, respectively, than in counties with ≥ 500 physicians per 10,000 km2. The joint association analyses show a stronger association with the risk of a high U5MR in geographical pediatrician density than PPTC.

CONCLUSION

Both population and geographical pediatrician density should be considered when planning child health care services, even in areas with high numbers of PPTC.

Public perspectives on health improvement within a remote-rural island community

Background

Rural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health.

Objective

To identify and describe shared perspectives within a remote‐rural community on how to improve rural health.

Method

Using Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews.

Results

Sixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services.

Discussion and conclusions

Factors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice.

Public Contribution

Members of the public were involved in the development and piloting of the statement set.

Do people living in rural and urban locations experience differences in harm when admitted to hospital? A cross-sectional New Zealand general practice records review study

OBJECTIVE

Little is known about differences in hospital harm (injury, suffering, disability, disease or death arising from hospital care) when people from rural and urban locations require hospital care. This study aimed to assess whether hospital harm risk differed by patients' rural or urban location using general practice data.

DESIGN

Secondary analysis of a 3-year retrospective cross-sectional general practice records review study, designed with equal numbers of rural and urban patients and patients from small, medium and large practices. Hospital admissions, interhospital transfer and hospital harm were identified.

SETTING

New Zealand (NZ) general practice clinical records including hospital discharge data.

PARTICIPANTS

Randomly selected patient records from randomly selected general practices across NZ. Patient enrolment at rural and urban general practices defined patient location.

OUTCOMES

Admission and harm risk and rate ratios by rural-urban location were investigated using multivariable analyses adjusted for age, sex, ethnicity, deprivation, practice size. Preventable hospital harm, harm severity and harm associated with interhospital transfer were analysed.

RESULTS

Of 9076 patient records, 1561 patients (17%) experienced hospital admissions with no significant association between patient location and hospital admission (rural vs urban adjusted risk ratio (aRR) 0.98 (95% CI 0.83 to 1.17)). Of patients admitted to hospital, 172 (11%) experienced hospital harm. Rural location was not associated with increased hospital harm risk (aRR 1.01 (95% CI 0.97 to 1.05)) or rate of hospital harm per admission (adjusted incidence rate ratio 1.09 (95% CI 0.83 to 1.43)). Nearly half (45%) of hospital harms became apparent only after discharge. No urban patients required interhospital transfer, but 3% of rural patients did. Interhospital transfer was associated with over twice the risk of hospital harm (age-adjusted aRR 2.33 (95% CI 1.37 to 3.98), p=0.003).

CONCLUSIONS

Rural patient location was not associated with increased hospital harm. This provides reassurance for rural communities and health planners. The exception was patients needing interhospital transfer, where risk was more than doubled, warranting further research.

Nursing activities at clinics in rural areas in Japan: gaps between recognition of importance and implementation

This study determined the level of implementation and the importance placed on various nursing activities at clinics in rural areas of Japan in order to explore the achievement and perceived importance of implementing certain nursing roles and activities at such clinics. To identify these items, a questionnaire was administered to 40 nurses working in rural clinics. The results showed that activities related to “Basic Nursing Practice” and “Community Understanding” were recognized as important and were performed by almost all nurses. Some activities related to “Administration and Operation” and “Cooperation with Local Government” were recognized as important, but were not implemented, thereby hampering the continuum of care across the health system. These activities, which are related to collaboration with hospitals and local governments that support the clinics, included adjustment of staff inside and outside the facilities to guarantee the use of paid holidays, as well as collaboration with acute care, remote medical systems, and local governments during emergencies and for disaster preparation. Additional support for nurses in collaboration between clinics in rural areas, hospitals, and regional administrations that support the clinics remains a challenge to be addressed.

Occupational Safety and Health in a Community of Shellfish Divers: A Community-Based Participatory Approach

In artisanal fishing communities in Chile, the access to occupational safety and health (OSH) is limited by factors such as the informality of employment. Our objective was to analyze the working and health conditions of workers in a coastal town in Southern Chile, under a community-based participatory approach. We carried out two independent social dialogue workshops within the community. The first one (N of participants = 25) was aimed to identify the strengths, weaknesses and challenges for preventing decompression sickness among divers. The second workshop (N of participants = 10) was set to identify the work processes and to map the occupational risks during seafood harvesting and processing in the community. Community members' training for handling and preventing decompression sickness among divers, and the collaboration between a local health representative, stakeholders and authorities, were identified as contributing factors in reducing fatalities and sequels among divers in the past. Technology and safety on board the vessels, training of healthcare personnel in OSH, and access to health programs, were identified as remaining challenges. Through risk mapping, the participants identified the relationship between working and health conditions in the community, reinforcing the necessity of improving access to health and social security. The community participation in identifying and analyzing working and health conditions could be the first step for a strategy to address OSH through primary health care in rural communities. Community empowerment and involvement in action plans, training on basic OSH for health care workers, and public policies are required.

Building Mental Health Capacity: Exploring the Role of Adaptive Expertise in the ECHO Virtual Learning Model

INTRODUCTION

With the proliferation of virtual learning programs during the COVID-19 pandemic, there is increased need to understand learner experiences and impact on developing expertise. Project Extension for Community Healthcare Outcomes (Project ECHO®) is an established hub-and-spoke tele-education model aimed at building capacity and expertise in primary care providers. Our qualitative study explored how learning experiences within an ECHO mental health care program supported provider learning and ability to solve complex clinical problems.

METHODS

We sampled ECHO sessions across a 34-week cycle and analyzed audio transcribed data. Two individuals coded participant interactions during 2-hour recorded sessions using an iterative, constant comparative methodology.

RESULTS

The authors identified four key mechanisms of learning in ECHO: (1) fostering participants' productive struggle with cases, (2) development of an integrated understanding, (3) collaborative reformulation of cases, and (4) generation of conceptual solutions based on a new understanding. Throughout the ECHO sessions, learning was observed to be multidirectional from both the hub-to-spoke and between spoke sites.

DISCUSSION

Despite the widespread implementation of Project ECHO and other virtual learning models, a paucity of research has focused on mechanisms of virtual learning within these models. Our study demonstrated a bidirectional exchange of knowledge between hub specialist teams and primary care provider spokes that aligned with the development of adaptive expertise through specific learning experiences in Project ECHO. Moreover, the ECHO structure may further support the development of adaptive expertise to better prepare participants to address patients' complex mental health needs.

Key elements of effective postgraduate GP educational environments: a mixed methods study

OBJECTIVES

Evidence in the literature suggests that satisfaction with postgraduate general practice (GP) training is associated with the quality of the educational environment. This study aimed to examine GP registrars' level of satisfaction with a distributed model of training in a regional educational environment and investigate the relationship between satisfaction and academic performance.

STUDY DESIGN

A longitudinal 3-year study was conducted among GP registrars at James Cook University using a sequential explanatory mixed methods research design. GP registrars' satisfaction was obtained using the scan of postgraduate educational environment domains tool. A focus group discussion was conducted to explore GP registrars' perceptions of satisfaction with the educational environment.

SETTING

James Cook University General Practice Training (JCU GPT) programme.

PARTICIPANTS

Six hundred and fifty one (651) GP registrars enrolled between 2016 and 2018 at JCU GPT programme.

RESULTS

651 registrars completed the satisfaction survey between 2016 and 2018. Overall, 92% of the registrars were satisfied with the educational training environment. Registrars who had become fellows reported higher satisfaction levels compared with those who were still in training (mean=4.39 vs 4.20, p=0.001). However, academic performance had no impact on level of satisfaction with the educational environment. Similarly, practice location did not influence registrars' satisfaction rates. Four themes (rich rural/remote educational environment, supportive learning environment, readiness to continue with rural practice and practice culture) emerged from the thematic data analysis.

CONCLUSION

A clinical learning environment that focuses on and supports individual learning needs is vital for effective postgraduate medical training. This study suggests that JCU GPT programme's distributed model fostered a satisfying and supportive training environment with rich educational experiences that enhance retention of GP registrars in rural/remote North Queensland, Australia. The findings of this study may be applicable to other settings with similar training models.

Geographic variation in health system performance in rural areas of New South Wales, Australia

OBJECTIVES

(i) To quantify geographic variation in selected health system performance indicators across local government areas of rural New South Wales and (ii) to compare relationships between sociodemographic factors and health system performance indicators across the regions.

DESIGN

Ecological study.

SETTING

Rural New South Wales communities.

PARTICIPANTS

Eighty-nine local government areas in rural areas comprising 47 inner regional, 33 outer regional, 6 remote and 3 very remote areas.

MAIN OUTCOME MEASURES

Deaths from avoidable causes, public hospital admissions for potentially preventable conditions, screening program participation, immunisation coverage.

RESULTS

The largest geographic variation between rural areas of New South Wales was seen for avoidable mortality and potentially preventable hospital admissions. The average annual avoidable age-standardised mortality rate (2013-2017) ranged from 78.1 per 100 000 population to 493.7 per 100 000 population and the age-standardised rate of potentially preventable hospitalisations (2016-2017) ranged from 1491 to 5797 per 100 000 population. Approximately three quarters of local government areas had bowel and breast cancer screening participation rates equivalent to or better than the overall New South Wales rate; however, only 34% of local government areas met the New South Wales rate for cervical cancer screening. The least variation was seen for immunisation coverage; Byron had the lowest immunisation coverage for all 3 ages. The most common explanations for variation between rural local government areas in New South Wales were remoteness and socioeconomic characteristics.

CONCLUSIONS

The analysis of health system performance indicators reveals differences among New South Wales rural local government areas. The results highlight specific areas that might benefit from targeted intervention to improve inequities particularly for avoidable mortality and potentially preventable hospitalisations.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia.

STUDY DESIGN

Rapid review of articles published between January 2000 and May 2020.

DATA SOURCES

We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries.

DATA SYNTHESIS

Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding.

CONCLUSION

Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries.

STUDY DESIGN

We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references.

DATA SOURCES

We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence.

DATA SYNTHESIS

Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle.

CONCLUSION

There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia.

STUDY DESIGN

Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews.

DATA SOURCES

We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria.

DATA SYNTHESIS

Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma.

CONCLUSION

We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities.

STUDY DESIGN

Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km² .

DATA SOURCES

We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway.

DATA SYNTHESIS

We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3).

CONCLUSION

Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce.

STUDY DESIGN

We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool.

DATA SOURCES

We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites.

DATA SYNTHESIS

During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool.

CONCLUSION

We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings.

STUDY DESIGN

Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards.

DATA SOURCES

English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar.

DATA SYNTHESIS

Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation.

CONCLUSION

Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Child Injury Prevention: It Is Time to Address the Determinants of Health

Injuries, although almost entirely preventable, accounted for more than 4 [...].

Impact of In-hospital and Outreach models for regional P.A.R.T.Y. Program participants

OBJECTIVE

This retrospective observational study aimed to compare the impact of the Prevent Alcohol and Risk-Related Trauma Youth (P.A.R.T.Y.) Program when delivered as In-hospital or Outreach models to rural and regional students.

METHODS

The study population were consented participants from regional areas between 2013 and 2017 who completed pre-programme, immediately post-programme and 3-5 months post-programme surveys. Responses from the metropolitan In-hospital programme participants and regional Outreach programme participants were analysed within groups across the three time points. The primary outcome variable was a change in self-reported perception of driving after drinking alcohol. Secondary outcome variables were designating a safe driver after drinking, perception of risk of injury if not wearing a seatbelt, risks of injury if undertaking physical risk-taking activities and likelihood of the programme changing perceptions.

RESULTS

There were 1314 participants invited to participate and 547 (42%) sets of complete surveys were received, of whom 296 (54%) were Outreach participants. Pre-programme, a significantly lower proportion of Outreach participants reported 'definitely not' to driving after drinking (84% vs 91%), and perceived a 'definite' likelihood of sustaining injury if not wearing a seatbelt (57% vs 66%). Outreach participants displayed improvements in likelihood to drive after drinking alcohol immediately post-programme and on follow up (P = 0.028). Responses to all other secondary outcome measures demonstrated some improvement.

CONCLUSIONS

Although demographically similar, baseline perceptions toward alcohol, risk-taking and injury differed between groups. Improvements in perception were demonstrated across both models. These findings support P.A.R.T.Y. as an injury prevention initiative for regional youth.

Leveraging 31 Million Google Street View Images to Characterize Built Environments and Examine County Health Outcomes

OBJECTIVES

Built environments can affect health, but data in many geographic areas are limited. We used a big data source to create national indicators of neighborhood quality and assess their associations with health.

METHODS

We leveraged computer vision and Google Street View images accessed from December 15, 2017, through July 17, 2018, to detect features of the built environment (presence of a crosswalk, non-single-family home, single-lane roads, and visible utility wires) for 2916 US counties. We used multivariate linear regression models to determine associations between features of the built environment and county-level health outcomes (prevalence of adult obesity, prevalence of diabetes, physical inactivity, frequent physical and mental distress, poor or fair self-rated health, and premature death [in years of potential life lost]).

RESULTS

Compared with counties with the least number of crosswalks, counties with the most crosswalks were associated with decreases of 1.3%, 2.7%, and 1.3% of adult obesity, physical inactivity, and fair or poor self-rated health, respectively, and 477 fewer years of potential life lost before age 75 (per 100 000 population). The presence of non-single-family homes was associated with lower levels of all health outcomes except for premature death. The presence of single-lane roads was associated with an increase in physical inactivity, frequent physical distress, and fair or poor self-rated health. Visible utility wires were associated with increases in adult obesity, diabetes, physical and mental distress, and fair or poor self-rated health.

CONCLUSIONS

The use of computer vision and big data image sources makes possible national studies of the built environment's effects on health, producing data and results that may inform national and local decision-making.

Influence of the definition of rurality on geographic differences in HIV outcomes in British Columbia: a retrospective cohort analysis

BACKGROUND

Improving rural health is often identified as a priority area for research and policy in Canada. We examined how findings on HIV outcomes (virologic suppression) can vary depending on the definition of rurality used.

METHODS

We performed retrospective cohort analyses using the Comparative Outcomes and Service Utilization Trends study population-based cohort of adults (age ≥ 19 yr) living with HIV in British Columbia between Apr. 1, 2012, and Mar. 31, 2013. We performed univariate logistic regression analyses using the following geographic variables to predict HIV virologic suppression: rurality defined by forward sortation area, by Statistical Area Classification and by health authority. We mapped suppression using geographic information systems.

RESULTS

Virologic suppression was observed in 5605 (65.2%) of 8598 participants. In univariate analysis, rurality defined by Statistical Area Classification (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.65-0.82), but not by forward sortation area, was associated with lower odds of suppression. When we examined suppression by health authority, Northern Health had the lowest odds of suppression (OR 0.46, 95% CI 0.36-0.58 compared to Vancouver Coastal Health). Geographic information systems mapping showed poorer suppression in northern areas.

INTERPRETATION

Health outcome findings can vary depending on the definition of the geographic variable. When including geographic variables, researchers should carefully consider variable definitions and whether other classification systems, such as north-south, are more appropriate than rurality for their analysis.

Health literacy in rural and urban populations: A systematic review

OBJECTIVE

This review assessed whether health literacy differences exist between rural and urban populations and whether rurality is a determinant.

METHODS

Eight online databases were searched using the keywords "health literacy", "rural" and "urban", and related terms. Peer-reviewed original research comparing health literacy levels between rural and urban populations were evaluated for strength of evidence. A narrative synthesis summarised the results of included studies.

RESULTS

Nineteen articles met inclusion criteria and were of sufficient methodological quality for data extraction. The majority of studies found that urban populations had higher health literacy than rural populations. Differences were more likely to be found in developing than developed countries. Studies that performed covariate analysis indicated that rurality may not be a significant determinant of health literacy.

CONCLUSION

Evidence suggests that rurality alone does not explain rural-urban health literacy differences and that sociodemographic factors play important roles.

PRACTICE IMPLICATIONS

These findings could be used to help inform the development of evidence-based interventions specifically for rural populations, at both health policy and clinical levels; for example, by tackling healthcare access challenges. The findings also provide a lens through which to consider efforts to reduce rural-urban health outcome disparities.

Rural-Urban Disparities in Cardiovascular Disease Mortality Among Middle-Age Men in China

Rural-urban health disparities are still poorly understood, due to a considerable gap in knowledge, while a looming heart disease and stroke epidemic in China has caused global concern. This report attempts to fill in the knowledge gaps to examine if rural-urban disparities in heart disease and stroke mortality have widened, which population cohorts have experienced the greatest mortality growth and disparities, and if rurality still matters in China. Age-specific data from 2002 to 2016 published in the China Health Yearbooks were analyzed with the Joinpoint Regression Program. The results reveal that China faces a fast growing cardiovascular disease epidemic with widening rural-urban disparities. Rural death rates have grown higher than urban rates along with fast rising rural mortality, and the fastest increasing rates are found among rural men in younger age groups. These findings inspire further research into the causes of the disparities.

Associations between socioeconomic status and place of residence with survival after aneurysmal subarachnoid haemorrhage

OBJECTIVES

This study aims to understand early (< 24 h post ictus) and late (up to 12 months) survival post aneurysmal subarachnoid haemorrhage (aSAH), with a focus on rurality and socioeconomic status.

METHODS

A statewide population-based cohort of aSAH cases in Tasmania, Australia, was established from 2010-2014 utilising multiple overlapping sources. Clinical data were collected from medical records and the Tasmanian Death Registry, with area-level rurality and socioeconomic status geocoded to participants' residential address.

RESULTS

From a cohort of 237 (70% women, 36% disadvantaged, 38% rural) individuals over a 5-year period, 12-month mortality was 52.3% with 54.0% of these deaths occurring within 24 h post ictus. In univariable analysis of 12-month survival, outcome was not influenced by socioeconomic status but rural geographical location was associated with a non-significant increase in death (HR 1.22 95% CI 0.85-1.75) along with hypertension (HR 1.78 95% CI 1.07-2.98) and hypercholesterolemia (HR 1.70 95% CI 0.99-2.91). Multivariable analysis demonstrated a statistically significant increase in death to 12 months after aSAH for both hypertension (HR 1.81 95% CI 1.08-3.03) and hypercholesterolemia (HR 1.71 95% CI 1.00-2.94) but not socioeconomic status or geographic location.

CONCLUSION

We found high early death in this population-based aSAH Australian population. Survival to 12 months after aSAH was not related to either geographical location or socioeconomic status but modifiable risk factors increased the risk of death. This article is protected by copyright. All rights reserved.

Rural-urban differences in the mental health of perinatal women: a UK-based cross-sectional study

BACKGROUND

International data suggest that living in a rural area is associated with an increased risk of perinatal mental illness. This study tested the association between rurality and risk for two mental illnesses prevalent in perinatal women - depression and anxiety.

METHODS

Using a cross-sectional design, antenatal and postnatal women were approached by healthcare professionals and through other networks in a county in Northern England (UK). After providing informed consent, women completed a questionnaire where they indicated their postcode (used to determine rural-urban status) and completed three outcome measures: the Edinburgh Postnatal Depression Scale (EPDS), the Whooley questions (depression measure), and the Generalised Anxiety Disorder 2-item (GAD-2). Logistic regression models were developed, both unadjusted and adjusted for potential confounders, including socioeconomic status, social support and perinatal stage.

RESULTS

Two hundred ninety-five participants provided valid data. Women in rural areas (n = 130) were mostly comparable to their urban counterparts (n = 165). Risk for depression and/or anxiety was found to be higher in the rural group across all models: unadjusted OR 1.67 (0.42) 95% CI 1.03 to 2.72, p = .038. This difference though indicative did not reach statistical significance after adjusting for socioeconomic status and perinatal stage (OR 1.57 (0.40), 95% CI 0.95 to 2.58, p = .078), and for social support (OR 1.65 (0.46), 95% CI 0.96 to 2.84, p = .070).

CONCLUSIONS

Data suggested that women in rural areas were at higher risk of depression and anxiety than their urban counterparts. Further work should be undertaken to corroborate these findings and investigate the underlying factors. This will help inform future interventions and the allocation of perinatal services to where they are most needed.

Women's ideal and real expectations of postnatal care during their first pregnancy: An online survey in England

BACKGROUND

There are many studies of women's experiences of care during the postnatal period, however little is known about women's expectations of postnatal care.

OBJECTIVE

This study explores first-time pregnant women's expectations, both ideal and real life, of postnatal care in England.

DESIGN

a descriptive, cross-sectional online survey design was used. The questionnaire took approximately 10 minutes to complete and was developed specifically for this survey. It included an informed consent section, socio-demographic questions and closed tick-box questions on where they had received information on postnatal care, and real and ideal expectations of postnatal care in hospital/birth centre and at home.

SETTING

The survey was hosted on the National Perinatal Epidemiology Unit website and advertised through a number of third sector and commercial organisations in 2017.

PARTICIPANTS

Women who were pregnant, had not given birth before, were aged 16 years and over, and living in England were eligible to participate.

ANALYSIS

Survey data were analysed using descriptive statistics and, where appropriate, chi square test using SPSS Version 23. Data from open ended questions were analysed by two researchers separately then codes and themes were discussed until consensus was reached.

RESULTS

283 women responded to the survey of whom 200 were eligible and included in the analysis. Most had received information on postnatal care from multiple sources, with pregnancy classes and midwives being most common. Most expected to stay one day or less in hospital or birth centre after normal delivery. Real life expectations were lower than ideal expectations, and hospital/birth centre real life expectations were higher than home real life expectations for physical health advice/checks and information/help with feeding. Categories developed from the open text answers were 'Respect, compassion and individualised care at a vulnerable time', 'The ward environment', 'Feeling ready for hospital discharge' and 'Help to find support in the community'.

KEY CONCLUSIONS

Women in this survey had high ideal world expectations of their postnatal care but in real life expected more focus on checking on their health and that of their baby and on giving information about the new challenges of how to breastfeed and look after a baby. While women valued checks of their health and that of their baby, ideally they wanted easy access to reassurance that they were feeding and looking after their baby well, that they were 'doing it right', and that what was happening to them was normal.

IMPLICATIONS FOR PRACTICE

As well as the necessary checks in the immediate postpartum period, consideration also needs to be given to the best way to meet the informational and support needs of women to optimise their wellbeing and transition to parenthood. A number of resources are used by women that could be enhanced to inform expectations of postnatal care and to provide valuable information to support their postnatal care.

Prevalence and correlates of youth poly-substance use in the COMPASS study

BACKGROUND AND AIMS

Youth poly-substance use, associated with long-term negative health and social outcomes, is of increasing concern following the rise of e-cigarette vaping and cannabis legalization in Canada. This work aimed to investigate current evidence on correlates of this behaviour to inform effective prevention and harm reduction programming.

DESIGN

Cross-sectional sample taking part in a cohort study.

SETTING

Canadian high schools (AB, BC, ON, QC) PARTICIPANTS: 74,501 Canadian high school students who completed the COMPASS student questionnaire in 2018/2019.

MEASUREMENTS

Self-report data on use of five substances (alcohol, cigarettes, e-cigarettes, cannabis, and opioids) alongside demographic factors, social and school support, and mental health-related measures.

RESULTS

Of the 39% of youth who reported current substance use, 53% reported using two or more. E-cigarette vaping was most prevalent (28%) and most often combined with other substances. Feeling supported by friends and having no problem with seeking help at school were associated with higher levels of poly-substance use. Family support, school connectedness, and school support to resist drugs decreased the risk of substance co-use.

CONCLUSIONS

The evidence presented here suggests that interventions for youth poly-substance use should rely on joint efforts between parents, schools, and communities to focus on structural factors rather than problematizing the individual.

Geospatial Analyses of Pain Intensity and Opioid Unit Doses Prescribed on the Day of Discharge Following Orthopedic Surgery

OBJECTIVE

Inappropriate opioid prescribing after surgery contributes to opioid use disorder and risk of opioid overdose. In this cross-sectional analysis of orthopedic surgical patients, we examined the role of patient location on postoperative pain intensity and opioids prescribed on hospital discharge.

METHODS

We used geospatial analyses to characterize spatial patterns of mean pain intensity on the day of discharge (PiDoD) and opioid units prescribed on the day of discharge (OuPoD), as well as the effect of regional social deprivation on these outcomes.

RESULTS

At a 500-km radius from the surgery site, the Global Moran's I for PiDoD (2.71 × 10-3, variance = 1.67 × 10-6, P = 0.012) and OuPoD (2.19 × 10-3, SD = 1.87, variance = 1.66 × 10-6, P = 0.03) suggested significant spatial autocorrelation within each outcome. Local indicators of spatial autocorrelation, including local Moran's I, Local Indicator of Spatial Autocorrelation cluster maps, and Getis-Ord Gi* statistics, further demonstrated significant, specific regions of clustering both OuPoD and PiDoD. These spatial patterns were associated with spatial regions of area deprivation.

CONCLUSIONS

Our results suggest that the outcomes of pain intensity and opioid doses prescribed exhibit varying degrees of clustering of patient locations of residence, at both global and local levels. This indicates that a given patient's pain intensity on discharge is related to the pain intensity of nearby individuals. Similar interpretations exist for OuPoD, although the relative locations of hot spots of opioids dispensed in a geographic area appear to differ from those of hot spots of pain intensity on discharge.

End-of-Life Cancer Care Resource Utilisation in Rural Versus Urban Settings: A Systematic Review

BACKGROUND

Despite the advances in End-of-life (EOL) cancer care, disparities remain in the accessibility and utilisation of EOL cancer care resources. Often explained by socio-demographic factors, geographic variation exists in the availability and provision of EOL cancer care services among EOL cancer decedents across urban versus rural settings. This systematic review aims to synthesise mortality follow-back studies on the patterns of EOL cancer care resource use for adults (>18 years) during end-of-life cancer care.

METHODS

Five databases were searched and data analysed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria involved; a) original research; b) quantitative studies; c) English language; d) palliative care related service use in adults (>18 years) with any malignancy excluding non-melanoma skin cancers; e) exclusive end of life focus; f) urban-rural focus. Narrative reviews and discussions were excluded.

RESULTS

24 studies met the inclusion criteria. End-of-life cancer care service utilisation patterns varied by rurality and treatment intent. Rurality was strongly associated with higher rates of Emergency Department (ED) visits and hospitalisations and lower rates of hospice care. The largest inequities between urban and rural health service utilisation patterns were explained by individual level factors including age, gender, proximity to service and survival time from cancer diagnosis.

CONCLUSIONS

Rurality is an important predictor for poorer outcomes in end-of-life cancer care. Findings suggest that addressing the disparities in the urban-rural continuum is critical for efficient and equitable palliative cancer care. Further research is needed to understand barriers to service access and usage to achieve optimal EOL care for all cancer patient populations.

Health literacy and related health behaviour: a community-based cross-sectional study from a developing country

Objectives

The concept of health literacy (HL) is globally evolving, and understanding its nature and impact is essential for disease prevention and treatment. Therefore, we aimed in this study to assess level of HL and predictors of inadequate HL in Jordanian population as an example case of a developing country.

Method

This cross-sectional study was conducted in a public tertiary hospital and community pharmacies in Jordan. All respondents answered a questionnaire, which included demographic data, Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), Short Test of Functional HL in Adults (S-TOFHLA), and All Aspects of HL Scale (AAHLS). Chi-square test and logistic regression analysis were conducted to determine the relationship and significant predictors for HL.

Key findings

Among 310 participants, REALM-R showed that around 27.1% had limited HL. Similar findings with S-TOFHLA and AAHLS were shown with a mean score 25.6 out of 35 (SD = 3.54, Range = 16–33) for AAHLS. Functional and critical HL were comparably low. Education level, age, living area and chronic conditions were significant predictors of HL (P &lt; 0.05).

Conclusions

Health literacy was inadequate among Jordanians. Further research is required to assess the effect of inadequate HL on healthcare access and health outcomes. Health education programmes are required to improve HL particularly for patients with chronic diseases.

Introducing mobile fracture prevention services with DXA in Northern Scotland: a comparative study of three rural communities

Mobile fracture prevention services, with DXA, significantly improved access to care for those at high risk of fracture living in rural areas. Introduction of mobile services facilitated access to fracture liaison services and development of integrated of care pathways across community- and secondary-based care.

INTRODUCTION

The ageing population is growing faster in rural areas, yet most fracture prevention services are located in urban areas. As part of a wider study, evaluating the introduction of mobile fracture prevention services, we focus on whether mobile services improve access to care for those at highest risk of fracture.

METHODS

Services outcomes were assessed against the Royal Osteoporosis Society clinical standards for fracture liaison services. This included standardised, age-specific referral rates, FRAX 10-year probability of major osteoporotic and hip fracture of referrals, pre- and post-introduction of the mobile service across two island and one rural mainland sites. This was compared with referrals from a similar rural mainland region with local access to a comprehensive service.

RESULTS

Greatest impact occurred in areas with most limited service provision at baseline. Mean age of patients referred increased from 59 to 68 years (CI 6.8-10.1, p < 0.001). Referral rates increased from 2.8 to 5.4 per 1000 population between 2011 and 2018, with a 5-fold rise in those ≥ 75 years (0.4 to 2.0 per 1000). Mean FRAX 10-year risk of major osteoporotic fracture increased from 12.7 to 17.7% (CI 3.2-5.7, p < 0.001). Mean hip fracture risk probability increased from 3.0 to 5.7% (CI 2.0-3.4, p < 0.001). However, referral rates from the mobile sites remained lower than the comparator site.

CONCLUSIONS

Mobile fracture prevention services, including DXA, greatly improved uptake amongst high-risk individuals. Mobile services facilitated development of integrated of care pathways, including fracture liaison services, across community- and secondary-based care.

Non-prescription medicines may contribute to non-adherence to prescription medicines in people living with chronic health conditions

BACKGROUND

Non-adherence to prescribed medicines is linked to adverse health outcomes in people living with chronic health conditions (CHCs). Multiple factors are known to contribute to non-adherence to medicines including polypharmacy, demographic features and disease and health systems. Both non-prescription and prescription medicines contribute to polypharmacy; however, there is limited data on the influence of non-prescription medicines to non-adherence.

AIM

Therefore, the aim of the study was to investigate the influence of non-prescription medicines to non-adherence in an Australian population.

METHODS

Data from the 2016 National Survey of a random sample of Australian adult residents were utilised in this study to investigate factors associated with non-adherence. Descriptive statistics, χ² , regression and generalised linear models were used to assess the relationships between variables of interest. Narrative response and comments were used to provide further insight.

RESULTS

This study recruited 1217 participants to explore factors associated with non-adherence to medicines. Weak but statistically significant correlations were identified showing the number of CHCs, patient's age, number of prescription medicines, number of non-prescription medicines and total number of medicines associated with non-adherence.

DISCUSSION

The findings suggest that people living with CHCs and taking multiple medicines, including non-prescription medicines, are likely to be non-adherent to prescription medicines. This study shows the possible involvement of non-prescription medicines in contributing to non-adherence in an Australian population and suggests that future studies with a broader demographic are warranted.

The Importance of Place of Residence on Hospitalized Outcomes for Severely Injured Trauma Patients: A Trauma Registry Analysis

PURPOSE

Socioecological factors are understudied in relation to trauma patients' outcomes. This study investigated the association of neighborhood socioeconomic disadvantage (SED) and remoteness of residence on acute length of hospital stay days (ALSD) and inpatient mortality.

METHODS

A retrospective cohort study was conducted on adults hospitalized for major trauma in a Level 1 trauma center in southeast Queensland from 2014 to 2017. Neighborhood SED and remoteness indices were linked to individual patient variables. Step-wise multivariable negative binomial regression and proportional hazards regression analyses were undertaken, adjusting for injury and patient factors. Outcomes were ALSD and inpatient mortality.

FINDINGS

We analyzed 1,025 patients. Statistically significant increased hazard of inpatient mortality was found for older age (HR 3.53, 95% CI: 1.77-7.11), injury severity (HR 5.27, 95% CI: 2.78-10.02), remoteness of injury location (HR 1.75, 95% CI: 1.06-2.09), and mechanisms related to intentional self-harm or assault (HR 2.72, 95% CI: 1.48-5.03,). Excess mortality risk was apparent for rural patients sustaining less severe injuries (HR 4.20, 95% CI: 1.35-13.10). Increased risk for longer ALSD was evident for older age (RR 1.35, 95% CI: 1.07-1.71), head injury (RR 1.39, 95% CI: 1.19-1.62), extremity injuries (RR 1.82, 95% CI: 1.55-2.14), and higher injury severity scores (ISS) (RR 1.51, 95%: CI: 1.29-1.76).

CONCLUSIONS

Severely injured rural trauma patients are more likely to be socioeconomically disadvantaged and sustain injuries predisposing them to worse hospital outcomes. Further research is needed to understand more about care pathways and factors influencing the severity, mechanism and clinical consequences of rural-based traumatic injuries.

Impact of geography on Scottish cancer diagnoses in primary care: Results from a national cancer diagnosis audit

BACKGROUND

A recent meta-analysis of global research found cancer patients living in rural locations are 5% less likely to survive than their urban counterparts, a survival disadvantage that has never been satisfactorily explained.

AIMS

[1] To describe and compare primary-care involvement in the diagnosis of cancer between rural and urban patients in Scotland. [2] To compare the length of key diagnostic pathway intervals between rural and urban cancer patients in Scotland.

METHODS

Participating GPs in the Scottish National Cancer Audit of cancer diagnosis (2017) collected data from primary-care medical records on the diagnostic pathway of patients diagnosed in 2014. Residential postcodes designated the patients as rural or urban dwellers. Key cancer diagnostic pathway intervals (primary, diagnostic, secondary, and treatment) were compared using binary logistic regression. Descriptive analysis included comparison of patient characteristics, and routes to diagnosis.

RESULTS

73 Scottish general practices provided data on 1,905 cancer diagnoses. Rural patients did not have higher odds of prolonged diagnostic intervals compared to urban patients but were significantly more likely to have had a cancer alarm feature at presentation and three or more primary-care consultations prior to referral. Rural GPs were significantly more likely to perceive an avoidable delay in their patient's diagnostic pathway.

CONCLUSION

There was no evidence that rural patients were more likely to be subject to prolonged cancer diagnostic delays than urban patients. Rural patients may experience primary care differently in the lead-up to a cancer diagnosis. The effect on outcome is probably negligible, but further research is required to confirm this.

Efficacy and Acceptability of My Care Hub Mobile App to Support Self-Management in Australians with Type 1 or Type 2 Diabetes

The aim of this study was to evaluate the preliminary efficacy and user acceptance of My Care Hub (MCH) mobile app-developed to provide evidenced-based support and education on diabetes self-management (DSM). Using a mixed-methods design, the efficacy and acceptability of MCH were measured among people with type 1 or type 2 diabetes after three weeks of intervention. The primary outcome measure was level of involvement with DSM, while the mediating factors were skills and self-efficacy for DSM. Telephone interviews were conducted to elucidate information on perceptions of the app's impact on participants' DSM and interest in future use. Statistically significant improvements were observed between pre- and post-intervention measures: DSM activities (4.55 ± 1.14 vs. 5.35 ± 0.84; p = 0.001); skills (7.10 ± 1.99 vs. 7.90 ± 1.67; p = 0.04); and self-efficacy (7.33 ±1.83 vs. 8.07 ± 1.54; p = 0.03). Multivariate analysis showed that self-efficacy had the strongest, though not significant influence on DSM. Interview findings revealed that the app reinforced knowledge and provided motivation to participate in DSM activities. The study suggested a positive impact of MCH on DSM and acceptability by patients. To confirm these promising results, further large scale and long-term studies are required.

Integrating care: the work of diabetes care technicians in an integrated care initiative

Background

As diabetes prevalence rises world-wide, the arrangement of clinics and care packages is increasingly debated by health care professionals (HCPs), health service researchers, patient groups and policy makers. ‘Integrated care’, while representing a range of approaches, has been positioned as a promising solution with potential to benefit patients and health systems. This is particularly the case in rural populations which are often removed from centres of specialist care. The social arrangements within diabetes integrated care initiatives are understudied but are of particular importance to those implementing such initiatives. In this paper we explore the ‘work’ of integration through an analysis of the role played by Health Care Assistants (HCAs) who were specially trained in aspects of diabetes care and given the title ‘Diabetes Care Technician’ (DCT).

Methods

Using thematic analysis of interview (n = 55) and observation data (n = 40), we look at: how the role of DCTs was understood by patients and other HCPs, as well as the DCTs; and explore what DCTs did within the integrated care initiative.

Results

Our findings suggested that the DCTs saw their role as part of a hierarchy, providing links between members of the integrated team, and explaining and validating clinical decisions. Patients characterised DCTs as friends and advisors who provided continuity. Other HCPs perceived the DCTs as supportive, providing long-term monitoring and doing a different job to conventional HCAs. We found that DCTs had to navigate local terrain (social, ethical and physical), engage in significant conversation and negotiate treatment plans created through integrated care. The analysis suggests that relationships between patients and the DCTs were strong, had the quality of friendship and mitigated loneliness.

Conclusions

DCTs played multidimensional roles in the integrated care initiative that required great social and emotional skill. Building friendships with patients was central to their work, which mitigated loneliness and facilitated the care they provided.

Prevalence of Parent Reported Health Conditions Among 0- to 17-Year-Olds in Rural United States: National Survey of Children's Health, 2016-2017

PURPOSE

This study's purpose was to determine the prevalence of physical, mental, and developmental health conditions among US children and assess the association with urban versus rural residence.

METHODS

Bivariate/multivariable analyses were conducted with cross-sectional data for children aged 0-17 years (N = 71,811) from the 2016-2017 National Survey of Children's Health. Prevalence estimates of excellent/very good health were derived from parents' qualitative judgments. Parent-reported health conditions were aggregated by condition type (physical, mental, developmental). Prevalence was determined for condition type and severity. Adjusted risk ratios assessed the effect of residence on having physical, mental, or developmental conditions.

RESULTS

Among rural children in the general population, we found lower crude rates of excellent/very good overall health and higher rates of ≥1 physical condition(s) and ≥1 mental condition(s), as well as these 2 conditions in combination with ≥1 developmental condition(s). Rural children in the general population were also more likely to have physical and mental conditions that parents rated as moderate/severe in unadjusted analyses. To a lesser extent, these differences held true for the children with special health care needs. Risk ratios for rural residence were largely nonsignificant in adjusted analyses.

CONCLUSIONS

While rural children had lower crude rates of parent-reported excellent/very good health and higher crude rates of parent-reported or doctor-diagnosed physical and mental health conditions compared to urban children, the same pattern of urban-rural differentials was not evident in the adjusted analyses. Compositional and contextual differences in the urban/rural populations suggest that social determinants of health may have accounted for rate disparities in child health conditions.