Availability and quality of publicly available health workforce data sources in Australia: a scoping review protocol

INTRODUCTION

The health workforce is an integral component of the healthcare system. Comprehensive, high-quality data on the health workforce are essential to identifying gaps in health service provision, as well as informing future health workforce and health services planning, and health policy. While many data sources are used in Australia for these purposes, the quality of the data sources with respect to relevance, accessibility and accuracy is not clear.

METHODS AND ANALYSIS

This scoping review aims to identify and appraise publicly available data sources describing the Australian health workforce. The review will include any data source (eg, registry, administrative database and survey) or document reporting a data source (eg, journal article, report) on the Australian health workforce, which is publicly available and describes the characteristics of the workforce. The search will be conducted in 10 bibliographic databases and the grey literature using an iterative process. Screening of titles and abstracts will be undertaken by two investigators, independently, using Covidence software. Any disagreement between investigators will be resolved by a third investigator. Documents/data sources identified as potentially eligible will be retrieved in full text and reviewed following the same process. Data will be extracted using a customised data extraction tool. A customised appraisal tool will be used to assess the relevance, accessibility and accuracy of included data sources.

ETHICS AND DISSEMINATION

The scoping review is a secondary analysis of existing, publicly available data sources and does not require ethics approval. The findings of this scoping review will further our understanding of the quality and availability of data sources used for health workforce and health services planning in Australia. The results will be submitted for publication in peer-reviewed journals and presented at conferences targeted at health workforce and public health topics.

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Urban-rural and socioeconomic status: Impact on multimorbidity prevalence in hospitalized patients

OBJECTIVE

The aim of this study was to describe multimorbidity prevalence in hospitalized adults, by urban-rural area of residence and socioeconomic status (SES).

METHODS

Linked hospital episode data were used. Adults (≥18 years) admitted to hospital as an inpatient during 2014 in Grampian, Scotland, were included. Conditions were identified from admissions during the 5 years prior to the first admission in 2014. Multimorbidity was defined as ≥2 conditions and measured using Tonelli et al. based on International Classification of Diseases-10 coding (preselected list of 30 conditions). We used proportions and 95% confidence intervals (CIs) to summarize the prevalence of multimorbidity by age group, sex, urban-rural category and deprivation. The association between multimorbidity and patient characteristics was assessed using the χ 2 test.

RESULTS

Forty one thousand five hundred and forty-five patients were included (median age 62, 52.6% female). Overall, 27.4% (95% CI 27.0, 27.8) of patients were multimorbid. Multimorbidity prevalence was 28.8% (95% CI 28.1, 29.5) in large urban versus 22.0% (95% CI 20.9, 23.3) in remote rural areas and 28.7% (95% CI 27.2, 30.3) in the most deprived versus 26.0% (95% CI 25.2, 26.9) in the least deprived areas. This effect was consistent in all age groups, but not statistically significant in the age group 18-29 years. Multimorbidity increased with age but was similar for males and females.

CONCLUSION

Given the scarcity of research into the effect of urban-rural area and SES on multimorbidity prevalence among hospitalized patients, these findings should inform future research into new models of care, including the consideration of urban-rural area and SES.

Retention strategies and interventions for health workers in rural and remote areas: a systematic review protocol

OBJECTIVE

The objective of the current review is to examine the association between exposure to strategies or interventions to retain health workers in rural and remote areas of high-income countries and improved retention rates.

INTRODUCTION

Attracting and retaining sufficient healthcare staff to provide adequate services for residents of rural and remote areas is an international problem. High-income countries have specific challenges in staffing remote and rural areas; despite the majority of the population clustering in large cities, a significant number of communities are in rural, remote or frontier areas which may be perceived as less attractive locations in which to live and work.

INCLUSION CRITERIA

The review will consider studies that include health workers in high-income countries where participants have been exposed to interventions, support measures or incentive programs to increase retention or workforce length of employment or reduce turnover for health workers in rural and remote areas. Analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational study designs, and descriptive cross-sectional studies published from 2010 will be eligible for inclusion.

METHODS

We will use the JBI methodology for reviews of risk and etiology. A range of databases will be searched. Two reviewers will screen, critically appraise eligible articles, and extract data from included studies. Data synthesis will be conducted, where feasible, with RevMan 5.3.5. A random effects model will be used to conduct meta-analyses. We will assess the certainty of the findings using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

An Investigation of Short-Term Longitudinal Associations Between Handgrip Strength and Cardiovascular Disease Biomarkers Among Middle-Aged to Older Adults: A Project FRONTIER Study

The purpose of this study was to examine short-term longitudinal relationships between handgrip strength (HGS) and cardiovascular disease (CVD) biomarkers in middle-aged to older adults living in rural areas (N = 138). The association between HGS and CVD biomarkers was examined at baseline, with HGS as a predictor of the annual change in biomarkers, and in a parallel fashion between the annual change in HGS and CVD biomarkers over an average of 2.8 follow-up years. The results showed HGS to cross-sectionally associate with waist circumference and diastolic blood pressure at baseline, but HGS at baseline was not found to predict the annual change in any biomarker. The annual increase in HGS was significantly associated with favorable changes in high-density lipoprotein cholesterol, triglycerides, and systolic/diastolic blood pressures; yet, these associations varied by the baseline levels of biomarkers. The present findings suggest that improved muscle strength with aging is related to favorable changes in CVD biomarkers.

Social inclusion as a tool to improve rural health

Health inequalities between metropolitan and rural areas persist despite a range of interventions over recent years. Social inclusion is often linked to health outcomes, yet few studies examine social inclusion across different geographic areas. In this study, a set of indicators of social inclusion were drawn together and sourced data were aligned to these indicators, which are readily available to primary health practitioners and population health planners. Through this process, a useful framework that provides a nuanced understanding to guide primary health policy and practice has been produced. Using Victoria as an example, 11 domains of social inclusion were explored using population data across 79 local government areas. Analysis highlighted significant differences in several indicators, with rural and regional local government areas ranking higher on measures of social participation, trust and social resources. The use of a diversity of data sources provided information on the social, economic, and education issues of an area, along with relational factors such as safety, trust, community resources and civic participation. A social inclusion lens can inform action to address the rural-urban primary health divide by determining and exploring the social inclusion characteristics of communities.

The workforce outcomes of dental graduates from a metropolitan school 'Rural Clinical Placement Program' versus a 'Rural Clinical School'

INTRODUCTION

This study compares the workplace decisions from University of Sydney (USYD) dental graduates who participated in a 1-month voluntary Rural Clinical Placement Program (RCPP), USYD graduates who did not participate in the RCPP (non-RCPP), and with graduates who qualified from a dental Rural Clinical School (RCS) at Charles Sturt University (CSU).

METHODOLOGY

From mid-2015, USYD students who graduated between 2009 and 2013, and CSU graduates from 2013 to 2014, were requested to complete a telephone interview related to employment choices. For USYD, 135 interviews were completed (63% of contactable graduates) and for CSU, 39 interviews (68%). Mixed methods were applied to analyse the data.

RESULTS

For USYD, 33% of RCPP participants were working rurally compared with 18% of the non-RCPP, whilst 54% of CSU graduates were working rurally. For USYD, the self-reported influence of the RCPP on the graduates' employment decisions was a significant predictor of rural employment. For CSU, country of birth and employment status were weakly associated with rural employment. Across the three cohorts, key employment factors were as follows: job availability, family, personal relationships, good mentorship, clinical training, partner factor and lifestyle. In addition, both the RCPP and CSU graduates showed greater interest and awareness of rural employment than the non-RCPP.

CONCLUSION

The CSU RCS and USYD RCPP are leading to positive rural employment outcomes, and it is clear that the provision of a rural experience is influencing graduates to work rurally. Further investigation of the CSU program is required to fully assess its impact and to provide longitudinal workforce information.

Association of military life experiences and health indicators among military spouses

Background

The health and well-being of military spouses directly contribute to a robust military force by enabling the spouse to better support the active duty member’s career. In order to understand the overall health and well-being of military spouses, we assessed health indicators among military spouses using the Healthy People 2020 framework and examined associations of these health indicators with military experiences and psychosocial factors.

Methods

Using data from the Millennium Cohort Family Study, a U.S. Department of Defense-sponsored survey of 9872 spouses of service members with 2–5 years of military service, we examined attainment of Healthy People 2020 goals for spouses and service members, including healthy weight, exercise, sleep, and alcohol and tobacco use. Multivariable logistic regression models assessed associations of spouse health indicators with stressful military life experiences and social support, adjusting for demographics and military descriptors. The spousal survey was administered nationwide in 2011.

Results

The majority of military spouses met each health goal assessed. However, less than half met the healthy weight and the strength training goals. Reporting greater perceived family support from the military was associated with better behavioral health outcomes, while having no one to turn to for support was associated with poorer outcomes. Using the Healthy People 2020 objectives as a framework for identifying key health behaviors and benchmarks, this study identified factors, including military-specific experiences, that may contribute to physical health behaviors and outcomes among military spouses. With respect to demographic characteristics, the findings are consistent with other literature that women are more likely to refrain from risky substance use and that greater education is associated with better overall health outcomes.

Conclusions

Findings suggest that enhanced social and military support and tailored programming for military spouses may improve health outcomes and contribute to the well-being of military couples. Such programming could also bolster force readiness and retention.

Inequalities in elevated depressive symptoms in middle-aged and older adults by rural childhood residence: The important role of education

OBJECTIVES

To quantify inequalities in the prevalence of elevated depressive symptoms by rural childhood residence and the extent to which childhood socioeconomic conditions and educational attainment contribute to this disparity.

METHODS

We identified the prevalence of depressive symptoms among US-born adults ages 50 years and older in the 1998 to 2014 waves of the Health and Retirement Study (n = 16 022). We compared prevalence of elevated depressive symptoms (>4/8 symptoms) by rural versus nonrural childhood residence (self-report) and the extent to which own education mediated this disparity. We used generalized estimating equations and marginal standardization to calculate predicted probabilities of elevated depressive symptoms.

RESULTS

In age, race/ethnicity, and sex-adjusted models, rural childhood residence was associated with elevated depressive symptoms (OR = 1.20; 95% CI, 1.12-1.29; marginal predicted probability 10.5% for rural and 8.9% for nonrural childhood residence). Adjusting for US Census birth region and parental education attenuated this association (OR = 1.07; 95% CI, 0.99-1.15; marginal predicted probability 9.9% for rural and 9.3% for nonrural). After additional adjustment for own education, rural childhood residence was not associated with elevated depressive symptoms (OR = 0.94; 95% CI, 0.87-1.01; marginal predicted probability 9.2% for rural and 9.8% for nonrural).

CONCLUSIONS

Rural childhood residence was associated with elevated depressive symptoms in middle-aged and older adults; birth region, parental education, and own education appear to contribute to this disparity.

Community-based Disparities in the Treatment and Outcomes of Early-stage Non-small-cell Carcinoma

Introduction Lung cancer is the most common malignancy in men and women combined. It is also the leading cause of cancer-related deaths in the US. The objective of this study is to report the treatment and survival outcomes for early-stage non-small-cell lung carcinoma (NSCLC) when stratified by urban versus rural geography. Methods A dataset of 62,213 patients, all aged 60 years or above, with stage-1 NSCLC, who underwent treatment from 2004 to 2012 was retrieved from the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute (NCI). Patients were divided into metropolitan, urban, or rural (in descending order of population density) based on their location of cancer treatment using the US Rural-Urban Continuum Code Definitions for 2003. Patient characteristics were compared using the chi-square test, and survival statistics were calculated using the Kaplan-Meier estimator. Results Rural or urban stage-1 NSCLC patients are more likely to be white, young, male, poor, and uninsured or Medicaid-dependent. They generally have squamous histology and receive radiation therapy when compared to metropolitan counterparts [probability value (p): <0.0001]. Median overall survival was shorter for rural and urban patients than metropolitan patients (41, 41, and 52 months respectively; p: <0.0001). Conclusion Tertiary care centers in metropolitan areas continue to demonstrate superior outcomes in the treatment of stage-1 NSCLC. This is presumably due to the existing disparities in patient access to care. Rural and urban stage-1 NSCLC patients (who tend to be younger, poorer, and more likely to be treated with radiation than surgery) are likely to be disproportionately impacted by changes in health policy.

The "Total Worker Health" Concept: A Case Study in a Rural Workplace

OBJECTIVE

This case study was conducted to identify barriers of integration of health protection and health promotion in rural workplaces with tailored interventions that address the identified barriers.

METHODS

Data on a workplace's ability to integrate wellness programs and health protection programs were collected through a questionnaire along with a seven-question interview. Descriptive statistics were used to analyze the quantitative data. Qualitative measures were assessed using thematic analysis. Based off the results of the assessments, the company received tailored training sessions.

RESULTS

The largest hindrance to organizational support was time. However, improved knowledge about the need and importance of integration helped the participants to conceptualize and plan for more collaboration between departments.

CONCLUSIONS

New ways to increase integration at workplaces, especially rural workplaces are needed. More comprehensive interventions that include management are also needed.

Determining rural risk for aneurysmal subarachnoid hemorrhages: A structural equation modeling approach

An aneurysmal subarachnoid hemorrhage (aSAH) carries a high disability burden. The true impact of rurality as a predictor of outcome severity is unknown. Our aim is to clarify the relationship between the proposed explanations of regional and rural health disparities linked to severity of outcome following an aSAH. An initial literature search identified limited data directly linking geographical location, rurality, rural vulnerability, and aSAH. A further search noting parallels with ischemic stroke and acute myocardial infarct literature presented a number of diverse and interrelated predictors. This a priori knowledge informed the development of a conceptual framework that proposes the relationship between rurality and severity of outcome following an aSAH utilizing structural equation modeling. The presented conceptual framework explores a number of system, environmental, and modifiable risk factors. Socioeconomic characteristics, modifiable risk factors, and timely treatment that were identified as predictors of severity of outcome following an aSAH and within each of these defined predictors a number of contributing specific individual predictors are proposed. There are considerable gaps in the current knowledge pertaining to the impact of rurality on the severity of outcome following an aSAH. Absent from the literature is any investigation of the cumulative impact and multiplicity of risk factors associated with rurality. The proposed conceptual framework hypothesizes a number of relationships between both individual level and system level predictors, acknowledging that intervening predictors may mediate the effect of one variable on another.

Mobile Mammography Screening as an Opportunity to Increase Access of Rural Women to Breast Cancer Research Studies

Objectives

Rural women are underrepresented in cancer research. We hypothesized that providing access to a research study to rural, medically underserved women who were receiving their breast cancer screening using a mobile mammography unit would increase the representation of rural women in a cancer cohort study.

Design

This study is a cross-sectional study using a cohort of women who have been recruited to a breast cancer study in Arkansas.

Setting

Recruiters accompanied a mobile mammography unit, the MammoVan, to implement a novel method for reaching and recruiting underrepresented rural Arkansas women into the study. Participants include 5850 women recruited from 2010 through 2012 as part of the Arkansas Rural Community Health (ARCH) study.

Results

Participants recruited during their mammography screening on the MammoVan tended to be more rural, less educated, and more likely to be non-Hispanic than those recruited in other venues. A significant difference was not noted for race or age.

Conclusion

Collaboration with the MammoVan greatly aided the recruitment of rural participants. These strategies can facilitate the representation of this historically underserved and understudied rural population in future research studies.

Nature-Based Interventions for Mental Health Care: Social Network Analysis as a Tool to Map Social Farms and their Response to Social Inclusion and Community Engagement

Social farming represents a hybrid governance model in which public bodies, local communities, and economic actors act together to promote health and social inclusion in rural areas. Although relational variables are crucial to foster social farm performance, the relational system in which farms are embedded has still not been fully described. Using social network analysis, here we map the nature of the links of a selected sample of social farms operating in Northern Italy. We also explore possible network variations following specific actions taken to potentiate local social farming initiatives. The results show a certain degree of variability in terms of the extension and features of the examined networks. Overall, the actions taken appear to be significant to enlarge and diversify farms' networks. Social farming has the potential to provide important benefits to society and the environment and to contrast vulnerability in rural areas. Being able to create social and economic networks of local communities, social farming may also represent an innovative way to respond to the cultural shift from institutional psychiatry to community-based mental health care. This study emphasizes the critical role played by network facilitation in diversifying actors, promoting heterogeneous relationships, and, in turn, system complexity.

The Australian Aboriginal Birth Cohort study: socio-economic status at birth and cardiovascular risk factors to 25 years of age

OBJECTIVES

To determine whether socio-economic status at birth is associated with differences in risk factors for cardiovascular disease - body mass index (BMI), blood pressure, blood lipid levels - during the first 25 years of life.

DESIGN

Analysis of prospectively collected data.

SETTING, PARTICIPANTS

570 of 686 children born to Aboriginal mothers at the Royal Darwin Hospital during 1987-1990 and recruited for the Aboriginal Birth Cohort Study in the Northern Territory. Participants resided in 46 urban and remote communities across the NT. The analysed data were collected at three follow-ups: Wave 2 in 1998-2001 (570 participants; mean age, 11 years), Wave 3 in 2006-2008 (442 participants; mean age, 18 years), and Wave 4 in 2014-2016 (423 participants; mean age, 25 years).

MAIN OUTCOME MEASURES

Cardiovascular disease risk factors by study wave and three socio-economic measures at the time of birth: area-level Indigenous Relative Socioeconomic Outcomes (IRSEO) index score and location (urban, remote) of residence, and parity of mother.

RESULTS

Area-level IRSEO of residence at birth influenced BMI (P < 0.001), systolic blood pressure (P = 0.024), LDL-cholesterol (P = 0.010), and HDL-cholesterol levels (P < 0.001). Remoteness of residence at birth influenced BMI (P < 0.001), HDL-cholesterol (P < 0.001), and triglyceride levels (P = 0.043). Mother's parity at birth influenced BMI (P = 0.039).

CONCLUSIONS

Our longitudinal life course analyses indicate that area-level socio-economic factors at birth influence the prevalence of major cardiovascular disease risk factors among Indigenous Australians during childhood and early adulthood.

Regional variation of premature mortality in Ontario, Canada: a spatial analysis

BACKGROUND

Premature mortality is a meaningful indicator of both population health and health system performance, which varies by geography in Ontario. We used the Local Health Integration Network (LHIN) sub-regions to conduct a spatial analysis of premature mortality, adjusting for key population-level demographic and behavioural characteristics.

METHODS

We used linked vital statistics data to identify 163,920 adult premature deaths (deaths between ages 18 and 74) registered in Ontario between 2011 and 2015. We compared premature mortality rates, population demographics, and prevalence of health-relevant behaviours across 76 LHIN sub-regions. We used Bayesian hierarchical spatial models to quantify the contribution of these population characteristics to geographic disparities in premature mortality.

RESULTS

LHIN sub-region premature mortality rates ranged from 1.7 to 6.6 deaths per 1000 per year in males and 1.2 to 4.8 deaths per 1000 per year in females. Regions with higher premature mortality had fewer immigrants and higher prevalence of material deprivation, excess body weight, inadequate fruit and vegetable consumption, sedentary behaviour, and ever-smoked status. Adjusting for all variables eliminated close to 90% of geographic variation in premature mortality, but did not fully explain the spatial pattern of premature mortality in Ontario.

CONCLUSIONS

We conducted the first spatial analysis of mortality in Ontario, revealing large geographic variations. We demonstrate that well-known risk factors explain most of the observed variation in premature mortality. The result emphasizes the importance of population health efforts to reduce the burden of well-known risk factors to reduce variation in premature mortality.

Comparison of general and cardiac care-specific indices of spatial access in Australia

Objective

To identity differences between a general access index (Accessibility/ Remoteness Index of Australia; ARIA+) and a specific acute and aftercare cardiac services access index (Cardiac ARIA).

Research design and methods

Exploratory descriptive design. ARIA+ (2011) and Cardiac ARIA (2010) were compared using cross-tabulations (chi-square test for independence) and map visualisations. All Australian locations with ARIA+ and Cardiac ARIA values were included in the analysis (n = 20,223). The unit of analysis was Australian locations.

Results

Of the 20,223 locations, 2757 (14% of total) had the highest level of acute cardiac access coupled with the highest level of general access. There were 1029 locations with the poorest access (5% of total). Approximately two thirds of locations in Australia were classed as having the highest level of cardiac aftercare. Locations in Major Cities, Inner Regional Australia, and Outer Regional Australia accounted for approximately 98% of this category. There were significant associations between ARIA+ and Cardiac ARIA acute (χ² = 25250.73, df = 28, p<0.001, Cramer’s V = 0.559, p<0.001) and Cardiac ARIA aftercare (χ² = 17204.38, df = 16, Cramer’s V = 0.461, p<0.001).

Conclusions

Although there were significant associations between the indices, ARIA+ and Cardiac ARIA are not interchangeable. Systematic differences were apparent which can be attributed largely to the underlying specificity of the Cardiac ARIA (a time critical index that uses distance to the service of interest) compared to general accessibility quantified by the ARIA+ model (an index that uses distance to population centre). It is where the differences are located geographically that have a tangible impact upon the communities in these locations–i.e. peri-urban areas of the major capital cities, and around the more remote regional centres. There is a strong case for specific access models to be developed and updated to assist with efficient deployment of resources and targeted service provision. The reasoning behind the differences highlighted will be generalisable to any comparison between general and service-specific access models.

Hunting practices in northern Australia and their implication for disease transmission between community dogs and wild dogs

OBJECTIVE

This survey aimed to understand hunting practices involving domestic dogs in remote Indigenous communities in northern Australia and, in the context of disease transmission, describe the domestic-wild dog interface and intercommunity interactions of hunting dogs during hunting activities.

METHODS

A cross-sectional survey of 13 hunters from communities of the Northern Peninsula Area (NPA) of Queensland gathered information on demographics of hunters and hunting dogs, hunting practices and past encounters with wild dogs during hunting trips. Social networks that described the connections of hunters between NPA communities from hunting expeditions were developed.

RESULTS

Most hunters interviewed were not aware of any diseases that could be transmitted to dogs (n = 11) or humans (n = 9) from wild animals while hunting. More than half (n = 7) of the respondents had experienced at least one wild dog encounter during hunting in the year prior to the interview. A map of the relative risk of interactions between wild and hunting dogs during hunting trips allowed the identification of high-risk areas in the NPA; these areas are characterised by dense rainforests. The social networks at the community level resulted in relatively large density measures reflecting a high level of intercommunity connectedness.

CONCLUSIONS

This study contributes to our knowledge of Australian Indigenous hunting practices and supports the potential for disease transmission at the domestic-wild dog interface and intercommunity level through contacts between hunting dogs during hunting activities. Insights from this study also highlight the need for educational programs on disease management in Indigenous communities of northern Australia.

China's dusty lung crisis: Rural-urban health inequity as social and spatial injustice

This paper examines rural-urban inequities in dusty lung (pneumoconiosis) deaths in China from 2002 to 2016 and possible causes for such inequities in the framework of social and spatial justice. The research reveals alarming results that have not been reported before. Dusty lung death rates for rural men increased twice as fast as those among urban men. The rural rates were particularly higher among middle-aged men, but lower in older age groups, as compared to urban rates. There were dramatic increases in death rates from 2011 to 2016 particularly among rural men aged 40-49 years old, who were many times more likely to die from dusty lung than urban men of a similar age. Chinese rural male victims also die at a younger age, compared to men in any of the seven countries or regions included in the study. For example, rural Chinese men aged 35-59 years old were many times more likely to die from dusty lung than their American, German, Polish, and Spanish counterparts. A possible explanation for the high death rates among middle-aged rural Chinese men is the tendency for rural migrant workers to be employed in unhealthy and unsafe working conditions in decent decades. Other explanations for the severe spatial injustice include the Hukou (household registration) system and the development policies that prioritize economic growth and urban development over occupational health and safety. The paper demonstrates the usefulness and weakness of the social and spatial justice concepts in understanding health inequity. Therefore, it proposes new definitions and models of social justice and spatial justice that combine the competing distribution and capabilities approaches and highlight interactions among multiple attributes.

Association between area-level socioeconomic status, accessibility and diabetes-related hospitalisations: a cross-sectional analysis of data from Western Victoria, Australia

OBJECTIVE

Hospitalisation rates for many chronic conditions are higher in socioeconomically disadvantaged and less accessible areas. We aimed to map diabetes hospitalisation rates by local government area (LGA) across Western Victoria, Australia, and investigate their association with socioeconomic status (SES) and accessibility/remoteness.

DESIGN

Cross-sectional study METHODS: Data were acquired from the Victorian Admitted Episodes Dataset for all hospitalisations (public and private) with a diagnosis of type 1 or type 2 diabetes mellitus during 2011-2014. Crude and age-standardised hospitalisation rates (per 1000 population per year) were calculated by LGA for men, women and combined data. Associations between accessibility (Accessibility/Remoteness Index of Australia, ARIA), SES (Index of Relative Socioeconomic Advantage and Disadvantage, IRSAD) and diabetes hospitalisation were investigated using Poisson regression analyses.

RESULTS

Higher LGA-level accessibility and SES were associated with higher rates of type 1 and type 2 diabetes hospitalisation, overall and for each sex. For type 1 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men incidence rate ratio [IRR]=2.14, 95% CI 1.64 to 2.80; women IRR=2.45, 95% CI 1.87 to 3.19; combined IRR=2.30, 95% CI 1.69 to 3.13; all p<0.05). Higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.25, 95% CI 1.09 to 1.43; women IRR=1.32, 95% CI 1.16 to 1.51; combined IRR=1.23, 95% CI 1.07 to 1.42; all p<0.05). Similarly, for type 2 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men IRR=2.49, 95% CI 1.81 to 3.43; women IRR=2.34, 95% CI 1.69 to 3.25; combined IRR=2.32, 95% CI 1.66 to 3.25; all p<0.05) and higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.15, 95% CI 1.02 to 1.30; women IRR=1.14, 95% CI 1.01 to 1.28; combined IRR=1.13, 95% CI 1.00 to 1.27; all p<0.05).

CONCLUSION

Our observations could indicate self-motivated treatment seeking, and better specialist and hospital services availability in the advantaged and accessible areas in the study region. The determinants for such variations in hospitalisation rates, however, are multifaceted and warrant further research.

Spatiotemporal Analysis of Oklahoma Tobacco Helpline Registrations Using Geoimputation and Joinpoint Analysis

OBJECTIVE

Tobacco quitlines provide free smoking cessation telephone services to smokers interested in quitting tobacco. We aimed to explore spatial and temporal analyses of registrations to the Oklahoma Tobacco Helpline including those of any racial group and American Indians (AI) from January 1, 2006, to June 30, 2017. This will allow tribal and community organizations, such as the Oklahoma Tribal Epidemiology Center, to better implement and evaluate public health prevention efforts at a smaller geographic area using the larger geographic units that are publicly available.

DESIGN

Retrospective, descriptive study.

SETTING

Oklahoma.

PARTICIPANTS

Registrants to the Oklahoma Tobacco Helpline.

MAIN OUTCOME MEASURES

To evaluate the spatial distribution of Helpline participants using geoimputation methods and evaluate the presence of time trends measured through annual percent change (APC).

RESULTS

We observed increased density of participants in the major population centers, Oklahoma City and Tulsa. Density of AI registrations was higher in the rural areas of Oklahoma where there is a larger tribal presence compared with participants of any racial group. For all racial groups combined, we identified 3 significant trends increasing from July 2008 to March 2009 (APC: 10.9, 95% confidence interval [CI], 0.8-21.9), decreasing from March 2009 to May 2014 (APC: -0.8, 95% CI: -1.1 to -0.4), and increasing from May 2014 to June 2017 (APC: 0.8, 95% CI: 0.0-1.6). The number of AI registrations to the Helpline increased significantly from July 2008 to March 2009 (APC: 12.0, 95% CI: 2.0-22.9) and decreased from March 2009 to June 2014 (APC: -0.7, 95% CI: -1.0 to -0.3).

CONCLUSIONS

Results of this project will allow the Helpline to efficiently identify geographic areas to increase registrations and reduce commercial tobacco use among the AI population in Oklahoma through existing programs at the Oklahoma Tribal Epidemiology Center.

Prevalence and outcomes of overweight and obesity among pregnant women in rural Queensland

OBJECTIVE

To assess the prevalence of overweight and obese women in the antenatal and perinatal periods, in rural hospitals; and to evaluate neonatal and maternal outcomes, including transfer to larger birthing centres.

DESIGN

A retrospective clinical chart audit.

SETTING

Rural maternity services in five Queensland rural hospitals.

PARTICIPANTS

Data were collected from 250 women presenting to participating rural hospitals, with an estimated due date in 2016.

MAIN OUTCOME MEASURES

Obstetric and neonatal data, whether transfer occurred, mode of delivery and any complications, and neonatal outcomes including birth weight and complications were collected. Demographic information collected included maternal age, gravidity and parity, race, smoking status and pre-pregnancy body mass index. The main outcome measures of interest were birth weight, Caesarean rate, transfer rate and diagnosis of gestational diabetes in relation to the body mass index.

RESULTS

Over 50% of women were overweight or obese while entering pregnancy, with 5.2% of mothers in the morbidly obese category. There was an increase in the birth weight of mothers with a body mass index of more than 25. The increasing body mass index was associated with an increased likelihood of transfer, diagnosis of gestational diabetes, elective and, especially, emergency Caesareans performed at the hospital. Twenty-four percent of women continued to smoke throughout pregnancy.

CONCLUSION

A high prevalence of obesity was found in the rural obstetric population. As the body mass index increases, so too does birth weight, gestational diabetes, transfer rate and Caesarean section rate. The rates of smoking throughout pregnancy were higher than the average metropolitan rates. These findings have implications not just for rural hospital operation and resources, but also for preventive health activities in rural communities.

A Randomised Controlled Trial of an Information Communication Technology Delivered Intervention for Children with Autism Spectrum Disorder Living in Regional Australia

This exploratory randomised controlled trial tested the effectiveness of a tablet-based information communication technology early intervention application to augment existing therapy with the aim of improving visual motor, imitation, language and social skills in young children with ASD who reside in regional areas. Fifty-nine participants were recruited and randomised to either a therapy-as-usual group or intervention group. With the exception of the expressive language subscale on the Mullen Scales of Early Learning, no significant between-group differences were recorded for visual motor, imitation, receptive language and social skills of participants between baseline and post-intervention. When all participants were pooled and measured over time, improvements were shown in receptive and pragmatic language and social skills; these gains were maintained, thus suggesting skill acquisition.

Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States

OBJECTIVES

Trends over time in the United States show success in rebalancing long-term services and supports (LTSS) toward increased home- and community-based services (HCBS) relative to institutionalized care. However, the diffusion and utilization of HCBS may be inequitable across rural and urban residents. We sought to identify potential disparities in rural HCBS access and utilization, and to elucidate factors associated with these disparities.

DESIGN

We used qualitative interviews with key informants to explore and identify potential disparities and their associated supply-side factors.

SETTING AND PARTICIPANTS

We interviewed 3 groups of health care stakeholders (Medicaid administrators, service agency managers and staff, and patient advocates) from 14 states (n = 40).

MEASURES

Interviews were conducted using a semistructured interview guide, and data were thematically coded using a standardized codebook.

RESULTS

Stakeholders identified supply-side factors inhibiting rural HCBS access, including limited availability of LTSS providers, inadequate transportation services, telecommunications barriers, threats to business viability, and challenges to caregiving workforce recruitment and retention. Stakeholders perceived that rural persons have a greater reliance on informal caregiving supports, either as a cultural preference or as compensation for the dearth of HCBS.

CONCLUSIONS/IMPLICATIONS

LTSS rebalancing efforts that limit the institutional LTSS safety net may have unintended consequences in rural contexts if they do not account for supply-side barriers to HCBS. We identified supply-side factors that (1) inhibit beneficiaries' access to HCBS, (2) affect the adequacy and continuity of HCBS, and (3) potentially impact long-term business viability for HCBS providers. Spatial isolation of beneficiaries may contribute to a perceived lack of demand and reduce chances of funding for new services. Addressing these problems requires stakeholder collaboration and comprehensive policy approaches with attention to rural infrastructure.

Rural-urban residence and cancer survival in high-income countries: A systematic review

There is some evidence that place of residence is associated with cancer survival, but the findings are inconsistent, and the underlying mechanisms by which residential location might affect survival are not well understood. We conducted a systematic review of observational studies investigating the association of rural versus urban residence with cancer survival in high-income countries. We searched the Ovid Medline, EMBASE, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases up to May 31, 2016. Forty-five studies published between 1984 and 2016 were included. We extracted unadjusted and adjusted relative risk estimates with the corresponding 95% confidence intervals. Most studies reported worse survival for cancer patients living in rural areas than those in urban regions. The most consistent evidence, observed across several studies, was for colorectal, lung, and prostate cancer. Of the included studies, 18 did not account for socio-economic position. Lower survival for more disadvantaged patients is well documented; therefore, it could be beneficial for future research to take socio-economic factors into consideration when assessing rural/urban differences in cancer survival. Some studies cited differential stage at diagnosis and treatment modalities as major contributing factors to regional inequalities in cancer survival. Further research is needed to disentangle the mediating effects of these factors, which may help to establish effective interventions to improve survival for patients living outside major cities.

Youth Perspectives of Healthcare in Central Mexico: An Application of Massey's Critical Health Literacy Framework

Attention to health literacy is essential more now than ever given the recognition, attention, and resources being dedicated to addressing health disparities throughout the world. Unfortunately, health literacy research is scarce in many parts of the world, particularly among youth. Using focus group discussions with junior high school students (N = 98) in a rural town of Central Mexico, we sought to learn about their experiences utilizing healthcare services at a local health clinic. The themes that naturally emerged from focus group discussions aligned with Massey's framework on critical health literacy among US youth, and included problems navigating the health system, embarrassment speaking to doctors about sensitive issues, and minimal importance being placed on preventative care. This suggests that Massey's framework may be appropriate to use when seeking to understand and promote health literacy among youth in Mexico. Furthermore, the challenges faced by adolescent participants in this study suggest that additional research is needed to assess how youth in other areas of Mexico are faring in efforts to understand and access their new and evolving universal healthcare system.

Rural and metropolitan South Australian mental health workers' views about nurse prescribing: A thematic analysis

Almost one third of the South Australian population reside in regional locations, which are serviced by just 8% of the State's total psychiatrist workforce. Consequently, access to psychotropic medications in regional South Australia (SA) can be challenging. Granting prescribing rights to mental health nurses (MHNs) located in regional settings presents an opportunity to increase consumer access to psychotropic medications. The aim of the study was to understand the perspectives of mental health workers (MHWs) practising in regional and metropolitan settings towards MHN prescribing. The study adopted a qualitative approach. Seventeen MHWs participated in three focus groups, including two in regional SA and one in a metropolitan site within the State of SA. Participants reported difficulties in accessing medicines in regional areas. The regional focus groups indicated that MHN prescribing may help to release psychiatrists' time and provide quicker assessment and diagnosis. By contrast, the metropolitan focus group expressed reservations about MHN prescribing. Participants indicated that suitable governance structures supported by appropriate education programmes were a necessary prerequisite for MHN prescribing of psychotropic medications. MHN prescribing may help to mitigate the impact of psychiatrist shortages in regional South Australia and possibly in other areas of the world where recruitment is a challenge. The provision of adequate education and the establishment of a suitable governance and support framework are considered necessary steps to progress MHN prescribing.

Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials

The objective of this systematic literature review is to examine the impact of interventions to improve cardiovascular disease healthcare provided to people living in rural areas. Systematic electronic searches were conducted in Medline, CINAHL, Embase, Scopus, and Web of Knowledge in July 2018. We included clinical trials assessing the effectiveness of interventions to improve cardiovascular disease healthcare in rural areas. Study eligibility assessment, data extraction, and critical appraisal were undertaken by two reviewers independently. We identified 18 trials (18 interventions). They targeted myocardial infarction (five interventions), stroke (eight), and heart failure (five). All the interventions for myocardial infarction were based on organizational changes (e.g. implementation of mobile coronary units). They consistently reduced time to treatment and decreased mortality. All the interventions for heart failure were based on the provision of patient education. They consistently improved patient knowledge and self-care behaviour, but mortality reductions were reported in only some of the trials. Among the interventions for stroke, those based on the implementation of telemedicine (tele-stroke systems or tele-consultations) improved monitoring of stroke survivors; those based on new or enhanced rehabilitation services did not consistently improve mortality or physical function; whereas educational interventions effectively improved patient knowledge and behavioural outcomes. In conclusion, a number of different strategies (based on enhancing structures and providing patient education) have been proposed to improve cardiovascular disease healthcare in rural areas. Although available evidence show that these interventions can improve healthcare processes, their impact on mortality and other important health outcomes still remains to be established.

Web-based videoconferencing for rural palliative care consultation with elderly patients at home

PURPOSE

Providing specialized palliative care support to elderly patients in rural areas can be challenging. The purpose of this study was to gain a preliminary understanding of the experience of using mobile web-based videoconferencing (WBVC) for conducting in-home palliative care consults with elderly rural patients with life-limiting illness.

METHODS

This was a descriptive, exploratory, proof-of-concept study with a convenience sample of 10 WBVC visits. A palliative care clinical nurse specialist (PC-CNS), in the home with the patient/family and home care nurse (HC-N), used a laptop computer with webcam and speakerphone to connect to a distant palliative care physician consultant (PC-MD) over a secure Internet connection. Data was collected using questionnaires, interviews, and focus groups.

RESULTS

Analysis of qualitative data revealed four themes: communication, logistics, technical issues, and trust. Participants reported they were comfortable discussing concerns by WBVC and felt it was an acceptable and convenient way to address needs. Audiovisual quality was not ideal but was adequate for communication. Use of WBVC improved access and saved time and travel. Fears were expressed about lack of security of information transmitted over the Internet.

CONCLUSIONS

Using WBVC for in-home palliative care consults could be an acceptable, effective, feasible, and efficient way to provide timely support to elderly rural patients and their families. Having a health care provider in the home during the WBVC is beneficial. WBVC visits have advantages over telephone calls, but limitations compared to in-person visits, suggesting they be an alternative but not replacement for in-person consultations.

Cancer Patients' Utilization of Tertiary Hospitals in Seoul Before and After the Benefit Expansion Policy

Objectives

The aim of this study was to investigate cancer patients’ utilization of tertiary hospitals in Seoul before and after the benefit expansion policy implemented in 2013.

Methods

This was a before-and-after study using claims data of the Korean National Health Insurance Service from 2011 to 2016. The unit of analysis was inpatient episodes, and inpatient episodes involving a malignant neoplasm (International Classification of Diseases, Tenth Revision codes: C00-C97) were included in this study. The total sample (n=5 565 076) was divided into incident cases and prevalent cases according to medical use due to cancer in prior years. The tertiary hospitals in Seoul were divided into two groups (the five largest hospitals and the other tertiary hospitals in Seoul).

Results

The proportions of the incident and prevalent episodes occurring in tertiary hospitals in Seoul were 34.9% and 37.2%, respectively, of which more than 70% occurred in the five largest hospitals in Seoul. Utilization of tertiary hospitals in Seoul was higher for inpatient episodes involving cancer surgery, patients with a higher income, patients living in areas close to Seoul, and patients living in areas without a metropolitan city. The utilization of the five largest hospitals increased by 2 percentage points after the policy went into effect.

Conclusions

The utilization of tertiary hospitals in Seoul was concentrated among the five largest hospitals. Future research is necessary to identify the consequences of this utilization pattern.

Preferences for rural specialist health care in the treatment of Parkinson's disease: exploring the role of community-based nursing specialists

People living with Parkinson’s disease (PWPD) in rural areas have limited access to local condition-specific care. This paper examines the healthcare preferences of PWPD living in rural areas and how a community-driven initiative to employ a movement disorder nurse (MDN) functioned to address barriers to health services access. A qualitative design facilitated an understanding of how interactions with the health system shaped PWPD and their carer’s experiences of living in a regional community. A total of 42 semi-structured interviews were conducted 6–9 months apart; 19 interviews with PWPD and 23 dyadic interviews. The findings support the contention that specialist care can be effectively delivered through allied health professionals in some settings. In particular, having access to a specialist MDN can cushion the effects of living with Parkinson’s disease in regional and rural areas where continuity of care and access to timely support is often difficult for people to find. The quality of social support provided by the MDN may increase people’s ability to cope in the face of an unpredictable disease course. This is consistent with prior research, which identified that a specialist nurse or allied health services for people living with chronic conditions is enhances quality of life.

Diet Quality in a Weight Gain Prevention Trial of Reproductive Aged Women: A Secondary Analysis of a Cluster Randomized Controlled Trial

Reproductive-aged women are at high risk for obesity development. Limited research exploring weight gain prevention initiatives and associated modifiable risk factors, including diet quality exists. In a secondary analysis of a 12 month, cluster randomized controlled trial for weight gain prevention in reproductive-aged women, we evaluated change in diet quality, macronutrient and micronutrient intake, predictors of change and associations with weight change at follow-up. Forty-one rural towns in Victoria, Australia were randomized to a healthy lifestyle intervention (n = 21) or control (n = 20). Women aged 18⁻50, of any body mass index and without conditions known to affect weight, were recruited. Diet quality was assessed by the Dietary Guideline Index (DGI) and energy, macronutrient, and micronutrient intake as well as anthropometrics (weight; kg) were measured at baseline and 12 months. Results were adjusted for group (intervention/control), town cluster, and baseline values of interest. Of 409 women with matched data at baseline and follow-up, 220 women were included for final analysis after accounting for plausible energy intake. At 12 months, diet quality had improved by 6.2% following the intervention, compared to no change observed in the controls (p < 0.001). Significant association was found between a change in weight and a change in diet quality score over time β -0.66 (95%CI -1.2, -0.12) p = 0.02. The percentage of energy from protein (%) 0.009 (95%CI 0.002, 0.15) p = 0.01 and glycemic index -1.2 (95%CI -2.1, -0.24) p = 0.02 were also improved following the intervention, compared to the control group. Overall, a low-intensity lifestyle intervention effectively improves diet quality, with associated weight gain preventions, in women of reproductive age.

Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

BACKGROUND AND AIMS

Canada's large geographic area and low population density pose challenges in access to specialized health care for remote and rural residents. We compared health services use, surgical rate, and specialist gastroenterologist care in rural and urban inflammatory bowel disease (IBD) patients in Canada.

METHODS

We used validated algorithms that were applied to population-based health administrative data to identify all people living with the following three Canadian provinces: Alberta, Manitoba, and Ontario (ON). We compared rural residents with urban residents for time to diagnosis, hospitalizations, outpatient visits, emergency department (ED) use, surgical rate, and gastroenterologist care. Multivariable regression compared the outcomes in rural/urban patients, controlling for confounders. Provincial results were meta-analyzed using random-effects models to produce overall estimates.

RESULTS

A total of 36,656 urban and 5,223 rural residents with incident IBD were included. Outpatient physician visit rate was similar in rural and urban patients. IBD-specific and IBD-related hospitalization rates were higher in rural patients (incidence rate ratio [IRR] 1.17, 95% CI 1.02-1.34, and IRR 1.27, 95% CI 1.04-1.56, respectively). The rate of ED visits in ON were similarly elevated for rural patients (IRR 1.53, 95% CI 1.42-1.65, and IRR 1.33, 95% CI 1.25-1.40). There were no differences in surgical rates or prediagnosis lag time between rural and urban patients. Rural patients had fewer IBD-specific gastroenterologist visits (IRR 0.79, 95% CI 0.73-0.84) and a smaller proportion of their IBD-specific care was provided by gastroenterologists (28.3% vs 55.2%, P<0.0001). This was less pronounced in children <10 years at diagnosis (59.3% vs 65.0%, P<0.0001), and the gap was widest in patients >65 years (33.0% vs 59.2%, P<0.0001).

CONCLUSION

There were lower rates of gastroenterologist physician visits, more hospitalizations, and greater rates of ED visits in rural IBD patients. These disparities in health services use result in costlier care for rural patients. Innovative methods of delivering gastroenterology care to rural IBD patients (such as telehealth, online support, and remote clinics) should be explored, especially for communities lacking easy access to gastroenterologists.

Gendered mortality differentials over the rural-urban continuum: The analysis of census linked longitudinal data from England and Wales

BACKGROUND

Previous research shows that mortality varies significantly by residential context; however, the nature of this variation is unclear. Some studies report higher mortality levels in urban compared to rural areas, whereas others suggest elevated mortality in rural areas or a complex U-shaped relationship. Further, the extent to which compositional factors explain urban-rural mortality variation, the extent to which contextual factors play a role and whether and how the patterns vary by gender also remain unclear. This study investigates urban-rural mortality variation in England and Wales and the causes of this variation.

METHOD

The study applies survival analysis to the Office for National Statistics Longitudinal Study; the population aged 20 and older in 2001 is followed for 10 years.

RESULTS AND CONCLUSIONS

The analysis demonstrates a clear urban-rural mortality gradient, with the risk of dying increasing with each level of urbanisation. The exceptions are those living in areas adjacent to London, who consistently exhibit lower mortality than anticipated. Once the models are adjusted to individuals' socio-economic characteristics, the variation across the urban-rural continuum reduces substantially, although the gradient persists suggesting contextual effects. Females are found to be influenced more by their surrounding environment and males by their socio-economic position, although both experience lower mortality in rural compared to urban areas.

Grasping the Ongaonga: When will New Zealand really integrate rural clinical education?

Compared to Australia, substantial rural-based clinical education in New Zealand started small and still has some way to go if it is to fulfil its potential in workforce retention and recruitment to under-served areas. The authors share some of their experiences in rural medical education and then speculate on how it could develop. They discuss the merits of a clinical school composed of a dispersed network of rural sites, which provide and coordinate rural health education.

Does living in remote Australia lessen the impact of hardship on psychological distress?

AIMS

Rural and remote regions tend to be characterised by poorer socioeconomic conditions than urban areas, yet findings regarding differences in mental health between rural and urban areas have been inconsistent. This suggests that other features of these areas may reduce the impact of hardship on mental health. Little research has explored the relationship of financial hardship or deprivation with mental health across geographical areas.

METHODS

Data were analysed from a large longitudinal Australian study of the mental health of individuals living in regional and remote communities. Financial hardship was measured using items from previous Australian national population research, along with measures of psychological distress (Kessler-10), social networks/support and community characteristics/locality, including rurality/remoteness (inner regional; outer regional; remote/very remote). Multilevel logistic regression modelling was used to examine the relationship between hardship, locality and distress. Supplementary analysis was undertaken using Australian Household, Income and Labour Dynamics in Australia (HILDA) Survey data.

RESULTS

2161 respondents from the Australian Rural Mental Health Study (1879 households) completed a baseline survey with 26% from remote or very remote regions. A significant association was detected between the number of hardship items and psychological distress in regional areas. Living in a remote location was associated with a lower number of hardships, lower risk of any hardship and lower risk of reporting three of the seven individual hardship items. Increasing hardship was associated with no change in distress for those living in remote areas. Respondents from remote areas were more likely to report seeking help from welfare organisations than regional residents. Findings were confirmed with sensitivity tests, including replication with HILDA data, the use of alternative measures of socioeconomic circumstances and the application of different analytic methods.

CONCLUSIONS

Using a conventional and nationally used measure of financial hardship, people residing in the most remote regions reported fewer hardships than other rural residents. In contrast to other rural residents, and national population data, there was no association between such hardship and mental health among residents in remote areas. The findings suggest the need to reconsider the experience of financial hardship across localities and possible protective factors within remote regions that may mitigate the psychological impact of such hardship.

The development of an index of rural deprivation: A case study of Norfolk, England

Geographical deprivation indices such as the English Index of Multiple Deprivation (IMD) have been widely used in healthcare research and planning since the mid-1980s. However, such indices normally provide a measure of disadvantage for the whole population and can be inflexible to adaptation for specific geographies or purposes. This can be an issue, as the measurement of deprivation is subjective and situationally relative, and the type of deprivation experienced within rural areas may differ from that experienced by urban residents. The objective of this study was to develop a Rural Deprivation Index (RDI) using the English county of Norfolk as a case study, but with a view to adopting a flexible approach that could be used elsewhere. It is argued that the model developed in this research gives clarity to the process of populating an index and weighting it for a specific purpose such as rural deprivation. This is achieved by 'bundling' highly correlated indicators that are applicable to both urban and rural deprivation into one domain, and creating a separate domain for indicators relevant to the setting of interest, in this case rural areas. A further domain is proposed to account for population differences in rural areas. Finally, a method was developed to measure variability in deprivation within small areas. The RDI results in more rural areas in Norfolk falling in the most deprived quintile, particularly those classified as 'Rural town and fringe in sparse settings'; these areas also have high levels of heterogeneity of deprivation when using the variability measure created. This model proposed has the potential to provide a starting point for those who wish to create a summary deprivation measure taking into account rurality, or other local geographic factors, and as part of a range of approaches that can be used to allocate, or apply for, resources.

Geographic Disparities in Previously Diagnosed Health Conditions in Colorectal Cancer Patients Are Largely Explained by Age and Area Level Disadvantage

Background: Geographical disparity in colorectal cancer (CRC) survival rates may be partly due to aging populations and disadvantage in more remote locations; factors that also impact the incidence and outcomes of other chronic health conditions. The current study investigates whether geographic disparity exists amongst previously diagnosed health conditions in CRC patients above and beyond age and area-level disadvantage and whether this disparity is linked to geographic disparity in CRC survival.

Methods: Data regarding previously diagnosed health conditions were collected via computer-assisted telephone interviews with a cross-sectional sample of n = 1,966 Australian CRC patients between 2003 and 2004. Ten-year survival outcomes were acquired in December 2014 from cancer registry data. Multivariate logistic regressions were applied to test associations between previously diagnosed health conditions and survival rates in rural, regional, and metropolitan areas.

Results: Results suggest that only few geographical disparities exist in previously diagnosed health conditions for CRC patients and these were largely explained by socio-economic status and age. Living in an inner regional area was associated with cardio-vascular conditions, one or more respiratory diseases, and multiple respiratory diagnoses. Higher occurrences of these conditions did not explain lower CRC-specific 10 years survival rates in inner regional Australia.

Conclusion: It is unlikely that health disparities in terms of previously diagnosed conditions account for poorer CRC survival in regional and remote areas. Interventions to improve the health of regional CRC patients may need to target issues unique to socio-economic disadvantage and older age.

Rural dwellers are less likely to survive cancer - An international review and meta-analysis

BACKGROUND

Existing research from several countries has suggested that rural-dwellers may have poorer cancer survival than urban-dwellers. However, to date, the global literature has not been systematically reviewed to determine whether a rural cancer survival disadvantage is a global phenomenon.

METHODS

Medline, CINAHL, and EMBASE were searched for studies comparing rural and urban cancer survival. At least two authors independently screened and selected studies. We included epidemiological studies comparing cancer survival between urban and rural residents (however defined) that also took socioeconomic status into account. A meta-analysis was conducted using 11 studies with binary rural:urban classifications to determine the magnitude and direction of the association between rurality and differences in cancer survival. The mechanisms for urban-rural cancer survival differences reported were narratively synthesised in all 39 studies.

FINDINGS

39 studies were included in this review. All were retrospective observational studies conducted in developed countries. Rural-dwellers were significantly more likely to die when they developed cancer compared to urban-dwellers (HR 1.05 (95% CI 1.02 - 1.07). Potential mechanisms were aggregated into an ecological model under the following themes: Patient Level Characteristics; Institutions; Community, Culture and Environment; Policy and Service Organization.

INTERPRETATION

Rural residents were 5% less likely to survive cancer. This effect was consistently observed across studies conducted in various geographical regions and using multiple definitions of rurality. High quality mixed-methods research is required to comprehensively evaluate the underlying factors. We have proposed an ecological model to provide a coherent framework for future explanatory research.

FUNDING

None.

Rural Women's Perceptions About Cancer Disparities and Contributing Factors: a Call to Communication

Rural cancer disparities are increasingly documented in the USA. Research has identified and begun to address rural residents' cancer knowledge and behaviors, especially among women. Little, however, is known about rural female residents' awareness of cancer inequities and perceived contributing factors affecting them and their families. The purpose of this study was to address these gaps in the literature via a secondary analysis of qualitative needs assessment in Illinois' rural southernmost seven counties, a geographic region with relatively high rates of cancer incidence, morbidity, and mortality. A convenience sample of 202 rural adult female residents was recruited and participated in 26 focus groups, with 3-13 women per group. Inductive content analysis, guided by the principle of constant comparison, was used to analyze the qualitative data. Most respondents indicated their awareness of disproportionate cancer burden in their communities. Individual-level behaviors and environmental toxins were identified as contributing factors. Interestingly, however, environmental toxins were more often discussed as factors contributing to geographic differences, whereas individual-level behaviors were noted as important for overall cancer prevention and control. This study provides important insight into female rural residents' perspectives and offers novel venues for educational programs and research in the context of communication to eliminate disparities.

Building Provincial Mental Health Capacity in Primary Care: An Evaluation of a Project ECHO Mental Health Program

OBJECTIVE

Project Extension for Community Healthcare Outcomes (Project ECHO©) addresses urban-rural disparities in access to specialist care by building primary care provider (PCP) capacity through tele-education. Evidence supporting the use of this model for mental health care is limited. Therefore, this study evaluated a mental health and addictions-focused ECHO program. Primary outcome measures were PCP knowledge and perceived self-efficacy. Secondary objectives included: satisfaction, engagement, and sense of professional isolation. PCP knowledge and self-efficacy were hypothesized to improve with participation.

METHODS

Using Moore's evaluation framework, we evaluated the ECHO program on participant engagement, satisfaction, learning, and competence. A pre-post design and weekly questionnaires measured primary and secondary outcomes, respectively.

RESULTS

Knowledge test performance and self-efficacy ratings improved post-ECHO (knowledge change was significant, p < 0.001, d = 1.13; self-efficacy approached significance; p = 0.056, d = 0.57). Attrition rate was low (7.7%) and satisfaction ratings were high across all domains, with spokes reporting reduced feelings of isolation.

DISCUSSION

This is the first study to report objective mental health outcomes related to Project ECHO. The results indicate high-participant retention is achievable, and provide preliminary evidence for increased knowledge and self-efficacy. These findings suggest this intervention may improve mental health management in primary care.

Rural-urban inequities in deaths and cancer mortality amid rapid economic and environmental changes in China

OBJECTIVES

This paper examines rural-urban inequities in mortality and cancer mortality amid rapid economic growth and environmental degradation in China.

METHODS

SPSS and Joinpoint Regression were used to analyze the 2002-2015 datasets from all death registries in China and associated economic and environmental data.

RESULTS

Death and cancer mortality rates among rural residents were higher and increased faster than urban residents. In particular, rural men 30-34 years old were 44% more likely to die from cancer and over 67% more likely to die from all causes, compared to their urban counterparts. Among rural women 15-19 years old, the death rate was 47% higher and the cancer mortality rate was 44% higher than among urban women. Death and cancer mortality rates tended to be positively associated with economic growth and air pollution variables.

CONCLUSIONS

Rural-urban health inequities have widened in China, with rural youth at the greatest disadvantage. The anticipated health benefits from income growth may have been offset by the impact of air pollution, which calls for further investigation into the causes of rural-urban health inequities.

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

Different perspectives on the key challenges facing rural health: The challenges of power and knowledge

OBJECTIVE

To examine the effects of dominant knowledge in rural health, including how they shape issues central to rural health. In particular, this article examines the roles of: (i) deficit knowledge of rural health workforce; (ii) dominant portrayals of generalism; and (iii) perceptions of inferiority about rural communities in maintaining health disparities between rural- and metropolitan-based Australians.

DESIGN

A Foucauldian framework is applied to literature, evidence, case studies and key messages in rural health. Three scenarios are used to provide practical examples of specific knowledge that is prioritised or marginalised.

RESULTS

The analysis of three areas in rural health identifies how deficit knowledge is privileged despite it undermining the purpose of rural health. First, deficit knowledge highlights the workforce shortage rather than the type of work in rural practice or the oversupply of workforce in metropolitan areas. Second, the construction of generalist practice as less skilled and more monotonous undermines other knowledge that it is diverse and challenging. Third, dominant negative stereotypes of rural communities discourage rural careers and highlight undesirable aspects of rural practice.

CONCLUSION

The privileging of deficit knowledge pertaining to rural health workforce, broader dominant discourses of generalism and the nature of rural Australian communities reproduces many of the key challenges in rural health today, including persisting health disparities between rural- and metropolitan-based Australians. To disrupt the operations of power that highlight deficit knowledge and undermine other knowledge, we need to change the way in which rural health is currently constructed and understood.