The concept of well-being in a rural setting: understanding health and illness

Understanding farmers' barriers to health and mental health-related help-seeking: The development, factor structure, and reliability of the Farmer Help-Seeking Scale

PURPOSE

The aim of this research was to develop a contextually and culturally appropriate scale to assess farmers' barriers to health-related help-seeking.

METHODS

An initial pool of items was developed from the academic literature and input from an expert panel of farmers, rural academics, and rural clinicians. A draft 32-item questionnaire was then developed and sent to farmers registered with FARMbase, which is an Australian national farmer database.

FINDINGS

Two hundred and seventy-four farmers completed the draft questionnaire (93.7% male, 73.7% aged 56-75 years). An exploratory factor analysis identified 6 factors; "Health Issues are a Low Priority," "Concerns about Stigma," "Structural Health System Barriers," "Minimization and Normalization," "Communication Barriers," and "Continuity of Care.". Test-retest reliability was examined with a further 10 farmers (90% male, Mean age = 57, SD = 5.91), who completed the questionnaire twice (at 2- to 3-week intervals). Results indicated moderate-good test-retest reliability.

CONCLUSIONS

The resulting 24-item Farmer Help-Seeking Scale provides a measure of help-seeking that is specifically designed to capture the unique context, culture, and attitudes that can interfere with farmers' help-seeking, and inform the development of strategies to increase health-service utilization in this at-risk group.

The Alonissos Study: Cross-Sectional Study of the Healthcare Access and User Satisfaction in the Community of a Non-Profit-Line Greek Island

Healthcare access and a high quality of the provided services to healthcare users are fundamental human rights according to the Alma Ata Declaration of 1978. Although 45 years have passed since then, health inequalities still exist, not only among countries but also within populations of the same country. For example, several small Greek islands have only a small Primary Healthcare Center in order to provide healthcare services to the insular population. In the current study, we investigated the level of self-reported overall, dental and mental health status and the level of satisfaction regarding the access to and the quality of the healthcare services provided by the Primary Healthcare center of Alonissos, along with registering the requirements for transportation to the mainland in order to receive such services. In this questionnaire-based cross-sectional study, 235 inhabitants of the remote Greek island of Alonissos that accounts for nearly 9% of the population participated (115 males and 120 females). The self-reported overall health status was reported to be moderate to very poor at a percentage of 31.49%, and the results were similar for dental and self-reported mental health status. Although nearly 60% of the participants reported very good/good quality of the healthcare provision, only 37.45% reported that the access to healthcare was very good/good, while around 94% had at least one visit to the mainland in order to receive proper healthcare services. Strategies for improving access to healthcare services need to be placed in remote Greek islands like Alonissos.

An integrated review of the barriers and facilitators for accessing and engaging with mental health in a rural setting

The review investigated the barriers and facilitators associated with assessing and engaging with mental health in a rural setting. The aim is to describe and synthesize the literature that examines the experiences of adults who access or attempt to access mental health services in rural settings. A systematic search from 2010 to 2020 was conducted using CINAHL, PsycINFO, Web of Science Core Collection, PubMed, Psychology and Behavioural Sciences Collection, Google Scholar, and Scopus. PRISMA protocols located 32 relevant papers from the overall 573 first selected. Braun and Clarke (Qualitative Research in Psychology, 3:77-101, 2006) thematic analysis methodology was applied to the data resulting in two themes: first theme identified help-seeking with subthemes of stigma and locality of health services. The second theme was connectedness, inclusive of subthemes of support systems and personal identity. The review identified gender-related perspectives concerning accessing mental health support, exposing the need for more research to examine the diverse social connections and support networks in rural communities. The findings suggest the need to further explore the impediments that reduce the likelihood of accessing mental health services in rural communities.

Prehospital barriers for rural New Zealand parents in paediatric appendicitis: a qualitative analysis

BACKGROUND

Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist.

METHODS

We conducted individual, semi-structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019-January 2020. Utilising grounded theory methodology, we created an exploratory framework.

RESULTS

Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to 'watch and wait' due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community-based health advice to mitigate these barriers, leading to earlier hospital presentation.

CONCLUSION

Prehospital delay in rural families occurred most frequently due to an extended decision-making phase where families evaluated the costs and benefits of accessing hospital-level care. The utilisation of informal community expertise and whānau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Māori families.

Conceptualising Therapeutic Environments through Culture, Indigenous Knowledge and Landscape for Health and Well-Being

Academic research has long established that interaction with the natural environment is associated with better overall health outcomes. Notably, the area of therapeutic environments has been borne out of the recognition of this critical relationship, but much of this research comes from a specific Western perspective. In Aotearoa-New Zealand, Māori (the Indigenous people of the land) have long demonstrated significantly worse health outcomes than non-Māori. Little research has examined the causes compared to Western populations and the role of the natural environment in health outcomes for Māori. The present study aimed to explore the relationship between Māori culture, landscape and the connection to health and well-being. Eighteen Māori pāhake (older adults) and kaumātua (elders) took part in semi-structured interviews carried out as focus groups, from June to November 2020. Transcribed interviews were analysed using interpretative phenomenological analysis and kaupapa Māori techniques. We found five overarching and interrelated key themes related to Indigenous knowledge (Mātauranga Māori) that sit within the realm of therapeutic environments, culture and landscape. A conceptual framework for Therapeutic Cultural Environments (TCE) is proposed in terms of the contribution to our understanding of health and well-being and its implications for conceptualising therapeutic environments and a culturally appropriate model of care for Māori communities.

Sociodemographic Predictors of Attitudes to Support Seeking From a Medical Doctor or Other Health Provider Among Rural Australians

BACKGROUND

Rural Australians experience higher prevalence of several chronic diseases than metropolitan Australians and are less likely to access supportive health services. This study explored associations of sociodemographic factors and barriers to support seeking for health in a sample of rural South Australians.

METHODS

Participants (n = 610) from three rural regions participated in a computer-assisted telephone interview (CATI), based on the Barriers to Help Seeking Scale. Each participant reported on barriers in one of three health contexts: 'general' physical health, skin cancer, and mental health. Sociodemographic factors included gender, age, highest education, region of residence, and presence of chronic conditions. Chi-squared Automatic Interaction Detection (CHAID) determined independent associations of sociodemographic factors and barrier categories (high, medium and low importance).

RESULTS

Privacy was a high-importance barrier in the mental health context, particularly among participants of age < 63 years. The tendency to minimise and normalise health issues was also a high-importance barrier in the mental health context. In the physical health context, those with a chronic condition were more likely to perceive normalisation as a barrier than those without a chronic condition. Need for control and self-reliance was a high-importance barrier in the mental health context and a low-importance barrier in the skin cancer context, particularly among participants < 63 years. Structural factors and distrust of providers were high-importance barriers among those who did not complete secondary education, regardless of context.

CONCLUSION

This study highlights the importance of a nuanced approach to promoting help-seeking in rural Australians, with message content and delivery tailored to specific health conditions and demographic circumstances.

Cancer-related help-seeking in cancer survivors living in regional and remote Australia

OBJECTIVES

To measure rates of detection via screening, perceived self-imposed delays in seeking medical attention, and support seeking in a sample of regional and remote people with a cancer diagnosis and to test whether an association exists between these behaviours and minimising problems and resignation, a need for self-control and reliance and fatalism. Correlations and binary logistic regressions were conducted to test the associations between demographic characteristics, attitudes and behaviours.

RESULTS

Females were more likely to have had their cancer detected via screening (OR = 10.02, CI = 3.49-28.78). Younger participants (r = -0.103, p = 0.009) were slightly more likely to seek at least one form of support and online support was sought more often by younger patients (r = -0.269, p < 0.001), females (r = 0.152, p < 0.001), those from higher socio-economic (SES) areas (r = 0.100, p = 0.012), and those with higher education levels (r = 0.247, p < 0.001). Younger (r = -0.161, p < 0.001), and female (r = 0.82, p = 0.013), participants were also slightly more likely to seek support specifically through cancer support groups. No significant relationships between minimising problems and resignation, needs for control and self-reliance or fatalism and detection via screening, support seeking, or perceived self-imposed delays to seeking medical attention were apparent, with the exception that those with higher fatalism (predetermined health) were slightly less likely to report seeking support or information online (OR = 0.79, CI = 0.65-0.95) and slightly more likely to report using Cancer Council's support services (OR = 1.24, CI = 1.02-1.52).

CONCLUSIONS

Strategies to improve the accessibility and appropriateness of support available for regional and remote cancer patients should consider interventions that remove barriers to access associated with age, gender, and education as opposed to those which address the attitudinal traits measured here.

Men's Help-Seeking Attitudes in Rural Communities Affected by a Natural Disaster

The article describes a mixed methods study of help-seeking in men living in the Chilean Central Valley, following exposure to a major earthquake event in 2010. The results identify that, within the sample, positive attitudes toward help-seeking correlated with younger age, higher education levels, above-average incomes, and stable personal relationships. It appears that education plays a significant role in shaping such positive attitudes, particularly by influencing views of gender roles and help-seeking. Conversely, older men's reticence toward seeking help appeared linked to negative perceptions of available services and the influence of traditional notions of masculinity. The study concludes that adapting interventions and service offers to men's needs in rural contexts must include an ecosystemic analysis of their reality and incorporate an understanding of masculinity socialization processes.

The hidden costs: Identification of indirect costs associated with acute gastrointestinal illness in an Inuit community

BACKGROUND

Acute gastrointestinal illness (AGI) incidence and per-capita healthcare expenditures are higher in some Inuit communities as compared to elsewhere in Canada. Consequently, there is a demand for strategies that will reduce the individual-level costs of AGI; this will require a comprehensive understanding of the economic costs of AGI. However, given Inuit communities' unique cultural, economic, and geographic contexts, there is a knowledge gap regarding the context-specific indirect costs of AGI borne by Inuit community members. This study aimed to identify the major indirect costs of AGI, and explore factors associated with these indirect costs, in the Inuit community of Rigolet, Canada, in order to develop a case-based context-specific study framework that can be used to evaluate these costs.

METHODS

A mixed methods study design and community-based methods were used. Qualitative in-depth, group, and case interviews were analyzed using thematic analysis to identify and describe indirect costs of AGI specific to Rigolet. Data from two quantitative cross-sectional retrospective surveys were analyzed using univariable regression models to examine potential associations between predictor variables and the indirect costs.

RESULTS/SIGNIFICANCE

The most notable indirect costs of AGI that should be incorporated into cost-of-illness evaluations were the tangible costs related to missing paid employment and subsistence activities, as well as the intangible costs associated with missing community and cultural events. Seasonal cost variations should also be considered. This study was intended to inform cost-of-illness studies conducted in Rigolet and other similar research settings. These results contribute to a better understanding of the economic impacts of AGI on Rigolet residents, which could be used to help identify priority areas and resource allocation for public health policies and programs.

Providing Palliative Care in Rural Nepal: Perceptions of Mid-Level Health Workers

Introduction:

Nepal is beginning to develop palliative care services across the country. Most people live in rural areas, where the Mid-Level Health Workers (MHWs) are the major service providers. Their views on providing palliative care are most important in determining how the service is organized and developed.

Aim:

This study aims to ascertain the perceptions of MHWs about palliative care in their local community, to inform service development.

Methods:

A qualitative descriptive design, using focus group discussions, was used to collect data from a rural district of Makwanpur, 1 of the 75 districts of Nepal. Twenty-eight MHWs participated in four focus group discussions. The data were analyzed using content analysis.

Result:

Four themes emerged from the discussion: (i) suffering of patients and families inflicted by life-threatening illness, (ii) helplessness and frustration felt when caring for such patients, (iii) sociocultural issues at the end of life, and (iv) improving care for patients with palliative care needs.

Conclusion:

MHWs practicing in rural areas reported the suffering of patients inflicted with life-limiting illness and their family due to poverty, poor access, lack of resources, social discrimination, and lack of knowledge and skills of the health workers. While there are clear frustrations with the limited resources, there is a willingness to learn among the health workers and provide care in the community.

Commentary: Rehabilitation for Rural and Remote Residents Following a Traumatic Hand Injury

A traumatic hand injury can involve damage to a number of structures including skin, nerves, tendons, muscle bone, and soft tissue. Impairments such as pain or stiffness and loss of range of motion can last for many years and result in a moderate to extreme impact on a person’s day-to-day life. Work, leisure, financial security, and emotional well-being often most affected. This commentary provides an analysis of those factors that inhibit (barriers) and support (enablers) the provision of hand therapy rehabilitation in rural and remote areas. Providing a collaborative and flexible rehabilitation programme to rural and remote residents following a traumatic hand injury can be seen as a challenge due to issues such as a limited access to health care services. Established protocols that work in regional or metropolitan locations are unlikely to be effective and innovative and pragmatic strategies are required. The provision of a collaborative and flexible rehabilitation programme regardless of residential location is an important part of the therapist’s intervention plan.

Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

BACKGROUND

Several studies have reported a survival disadvantage for rural dwellers who develop colorectal cancer, but the underlying mechanisms remain obscure. Delayed presentation to GPs may be a contributory factor, but evidence is lacking.

AIM

To examine the association between rurality and travel time on diagnosis and survival of colorectal cancer in a cohort from northeast Scotland.

DESIGN AND SETTING

The authors used a database linking GP records to routine data for patients diagnosed between 1997 and 1998, and followed up to 2011.

METHOD

Primary outcomes were alarm symptoms, emergency admissions, stage, and survival. Travel time in minutes from patients to GP was estimated. Logistic and Cox regression were used to model outcomes. Interaction terms were used to determine if travelling time impacted differently on urban versus rural patients.

RESULTS

Rural patients and patients travelling farther to the GP had better 3-year survival. When the travel outcome associations were explored using interaction terms, the associations differed between rural and urban areas. Longer travel in urban areas significantly reduced the odds of emergency admissions (odds ratio [OR] 0.62, P<0.05), and increased survival (hazard ratio 0.75, P<0.05). Longer travel also increased the odds of presenting with alarm symptoms in urban areas; this was nearly significant (OR 1.34, P = 0.06). Presence of alarm symptoms reduced the likelihood of emergency admissions (OR 0.36, P<0.01).

CONCLUSION

Living in a rural area, and travelling farther to a GP in urban areas, may reduce the likelihood of emergency admissions and poor survival. This may be related to how patients present with alarm symptoms.

The functional impact of a traumatic hand injury: a comparison of rural/remote and metropolitan/regional populations

Background/Aims:

The aim of this research was to explore the commonalities and differences in the issues associated with the functional recovery and rehabilitation of a traumatic hand injury experienced by people in rural/remote and metropolitan/regional areas of North Queensland, Australia.

Methods:

Responses to a previously mailed survey exploring the functional impact on a rural/remote population and a metropolitan/regional population were used for analysis and comparison.

Findings:

Both populations reported a loss of movement, pain and stiffness, and a significantly greater percentage of metropolitan/regional respondents reported a loss of strength. Leisure and work tasks were affected for both groups as a result of their impairment. Rural and remote respondents would have liked more appointments but found that it was expensive to get to them. There was a significant reduction for both populations of respondents reporting their occupation as labourers after having a hand injury. There was also a significant increase in those who reported undertaking home duties, were pensioners or unemployed.

Conclusion:

A traumatic hand injury can have a moderate to extreme impact on work and leisure, regardless of residential location. Contextual factors related to living in rural and remote areas can be both a barrier and a facilitator to participation in functional activities. A review of service provision in rural/remote areas to address concerns regarding the expense of attending appointments and the minimal number of appointments required for rural and remote residents following a traumatic hand injury is recommended. Distance technology such as telehealth can increase flexibility of treatment and reduce the requirement to travel. The ongoing development and implementation of this technology is important to facilitate equitable health care between rural/remote and metropolitan/regional populations.

Development of ACROSSnet: an online support system for rural and remote community suicide prevention workers in Queensland, Australia

Communication and information technologies can reduce the barriers of distance and space that disadvantage communities in Australia's underserved rural areas, where the health status of residents is often worse than that of their urban counterparts. ACROSSnet (Australians Creating Rural Online Support Systems) is a 3 year collaborative action research project that aims to design and develop an online support system that will assist rural communities in accessing information, education and support regarding suicide and its prevention, whilst considering the challenges of Internet speed, cost and availability that can impede the delivery of online services. The site provides three distinct levels of access: one level for community members, and two further levels for appropriately credentialled mental health workers. In creating this environment, the ACROSSnet team hopes that online communities of practice will develop, engaging participants of different ages, income and education levels, location, and socioeconomic backgrounds.

A systematic review and meta-analysis of primary prevention programmes to improve cardio-metabolic risk in non-urban communities

INTRODUCTION

Although cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) prevention programmes have been effective in urban residents, their effectiveness in non-urban settings, where cardio-metabolic risk is typically elevated, is unknown. We systematically reviewed the effectiveness of primary prevention programmes aimed at reducing risk factors for CVD/T2DM, including blood pressure, body mass index (BMI), blood lipid and glucose, diet, lifestyle, and knowledge in adults residing in non-urban areas.

METHODS

Twenty-five manuscripts, globally, from 1990 were selected for review (seven included in the meta-analyses) and classified according to: 1) study design (randomised controlled trial [RCT] or pre-/post-intervention); 2) intervention duration (short [<12months] or long term [≥12months]), and; 3) programme type (community-based programmes or non-community-based programmes).

RESULTS

Multiple strategies within interventions focusing on health behaviour change effectively reduced cardio-metabolic risk in non-urban individuals. Pre-/post-test design studies showed more favourable improvements generally, while RCTs showed greater improvements in physical activity and disease and risk knowledge. Short-term programmes were more effective than long-term programmes and in pre-/post-test designs reduced systolic blood pressure by 4.02mmHg (95% CI -6.25 to -1.79) versus 3.63mmHg (95% CI -7.34 to 0.08) in long-term programmes. Community-based programmes achieved good results for most risk factors except BMI and (glycated haemoglobin) HbA1c.

CONCLUSION

The setting for applying cardio-metabolic prevention programmes is important given its likelihood to influence programme efficacy. Further investigation is needed to elucidate the individual determinants of cardio-metabolic risk in non-urban populations and in contrast to urban populations.

The Mental Health Outcomes of Drought: A Systematic Review and Causal Process Diagram

Little is understood about the long term, indirect health consequences of drought (a period of abnormally dry weather). In particular, the implications of drought for mental health via pathways such as loss of livelihood, diminished social support, and rupture of place bonds have not been extensively studied, leaving a knowledge gap for practitioners and researchers alike. A systematic review of literature was performed to examine the mental health effects of drought. The systematic review results were synthesized to create a causal process diagram that illustrates the pathways linking drought effects to mental health outcomes. Eighty-two articles using a variety of methods in different contexts were gathered from the systematic review. The pathways in the causal process diagram with greatest support in the literature are those focusing on the economic and migratory effects of drought. The diagram highlights the complexity of the relationships between drought and mental health, including the multiple ways that factors can interact and lead to various outcomes. The systematic review and resulting causal process diagram can be used in both practice and theory, including prevention planning, public health programming, vulnerability and risk assessment, and research question guidance. The use of a causal process diagram provides a much needed avenue for integrating the findings of diverse research to further the understanding of the mental health implications of drought.

Rural definition of health: a systematic literature review

BACKGROUND

The advent of patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Improved understanding of how patients think about and define their health is needed to more effectively "activate" patients, and to nurture and support patients' efforts to improve their health. Researchers have intimated for over 25 years that rural populations approach health in a distinct fashion that may differ from their non-rural counterparts.

METHODS

We conducted a systematic review of the literature to assess the extent and strength of evidence for rural definition of health. Studies were eligible for inclusion if they were published in English, reported on original research and presented findings or commentary relevant to rural definition of health, were published over the last 40 years, and were based on observations of rural U.S., Canadian, or Australian populations. Two reviewers were assigned to each selected article and blinded to the other reviewer's comments. For discordant reviews, a third blinded review was performed.

RESULTS

Of the 125 published articles identified from the literature, 34 included commentary or findings relevant to a rural definition of health. Of these studies, 6 included an urban comparison group. Few studies compared rural and urban definitions of health directly. Findings relevant to rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence. This review largely confirmed many general characteristics on rural views of health, but also documented the extensive methodological limitations, both in terms of quantity and quality, of studies that empirically compare rural vs. urban samples. Most notably, the evidence base in this area is weakened by the frequent absence of parallel comparison groups and standardized assessment tools.

CONCLUSIONS

To engage and activate rural patients in their own healthcare, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed hold distinct views on how to define health, but more rigorous studies are needed to confirm these findings.

Lived experience of acute gastrointestinal illness in Rigolet, Nunatsiavut: "just suffer through it"

Enteric illness associated with foodborne and waterborne disease is thought to be common in some Canadian Indigenous communities. This study aimed to understand the lived experience of acute gastrointestinal illness (AGI), including symptoms and severity, perceived causes, and healthcare seeking behaviors of AGI in the small Inuit community of Rigolet, Canada. A concurrent mixed quantitative and qualitative methods design was used. Two cross-sectional retrospective surveys provided quantitative data to examine self-reported AGI symptoms and the distribution of potential risk factors in the community. Qualitative data from in-depth interviews with one-third of AGI cases were analyzed using a constant-comparative method to describe symptoms and severity, identify perceived risk factors, and explore health seeking behavior of AGI in Rigolet. Of the survey respondents reporting AGI, most reported symptoms of diarrhea without vomiting, followed by diarrhea with vomiting, and vomiting without diarrhea. The most common secondary symptoms included stomach cramps and abdominal pain, nausea, and extreme tiredness. Community members identified potential risk factors for AGI that reflect the epidemiology triad (host, agent, and environmental factors), including hygiene, retail food, tap water, boil water advisories, and personal stress. Risk aversion and healthcare seeking behaviors reflected the core constructs of the Health Belief Model (perceived susceptibility, severity, and benefits and barriers to action). Understanding community experience, perspectives, and beliefs related to AGI is useful for public health practitioners and health care providers. This information is important especially considering the relatively high estimated burden of AGI and the relatively low healthcare seeking behaviors in some Indigenous communities compared to national estimates. Moreover, the mixed-methods approach used to understand the burden of AGI could be extended to other health research in Indigenous contexts.

The experience of medical and rehabilitation intervention for traumatic hand injuries in rural and remote North Queensland: a qualitative study

INTRODUCTION

This research explored the experience of receiving medical and rehabilitation intervention for rural and remote residents in North Queensland, Australia who had experienced a traumatic hand injury. This study contributes to larger project that seeks to propose a model of service delivery to rural and remote residents who have sustained a traumatic injury.

METHODS

Utilising an interpretive phenomenological research design, data was gathered through in-depth, semi-structured interviews. Fifteen participants were recruited into this study and questions were designed to explore the experience of receiving medical and rehabilitation intervention following a traumatic hand injury for residents in rural and remote areas of North Queensland.

RESULTS

The major themes that emerged were experience of medical intervention, experience of rehabilitation, travel, and technology. Participants felt that medical practitioners had a lack of local knowledge and were concerned that delays in medical intervention resulted in ongoing impairment. They reported following the exercise program they were given, often modifying it to fit with their daily routine. Metropolitan therapists appeared to have limited understanding of issues relevant to rural and remote lifestyles. There was, quite often, no occupational therapist or physiotherapist at their local facility due to staff turnover, and, when available, they had limited experience in hand injuries. The distance and cost of travel to appointments were of significant concern. The use of telehealth or telerehabilitation received a mixed response.

CONCLUSION

Findings highlight the concerns regarding the provision of healthcare to rural and remote residents following a traumatic hand injury. These results provide the basis for recommendations surrounding the development of programs and service delivery models to address diverse needs in rural and remote areas.

Exploring women's experiences of health and well-being in remote northwest Queensland, Australia

Rural and remote environments are challenging places in which to achieve health and well-being. In this woman-centered, grounded theory study, I explored the meaning of health and well-being as well as how it is achieved from the perspective of women living in remote inland parts of Australia. The study was based on semistructured interviews with 23 women living in geographically remote areas. The findings are presented as a model of the capacity to flourish. Flourishing describes an optimal achievable state of well-being, delineated by four interrelated dimensions of experience: control, connecting, belonging, and identity. I identify individual, contextual, and structural factors that enable and constrain the capacity to flourish. The findings suggest that approaches to understanding and promoting women's health in remote areas should be more holistic and contextual.

Implementation of the principles of primary health care in a rural area of South Africa

Background

The philosophy of primary healthcare forms the basis of South Africa's health policy and provides guidance for healthcare service delivery in South Africa. Healthcare service provision in South Africa has shown improvement in the past five years. However, it is uncertain as to whether the changes have reached rural areas and if primary healthcare is implemented successfully in these areas.

Objectives

The aim of this article is to explore the extent to which the principles of primary healthcare are implemented in a remote, rural setting in South Africa.

Method

A descriptive, qualitative design was implemented. Data were collected through interviews and case studies with 36 purposively-sampled participants, then analysed through Interpretative Phenomenological Analysis.

Results

Findings indicated challenges with regard to client-centred care, provision of health promotion and rehabilitation, the way care was organised, the role of the doctor, health-worker attitudes, referral services and the management of complex conditions.

Conclusion

The principles of primary healthcare were not implemented successfully. The community was not involved in healthcare management, nor were users involved in their personal health management. The initiation of a community-health forum is recommended. Service providers, users and the community should identify and address the determinants of ill health in the community. Other recommendations include the training of service managers in the logistical management of ensuring a constant supply of drugs, using a Kombi-type vehicle to provide user transport for routine visits to secondary- and tertiary healthcare services and increasing the doctors’ hours.

Helping policy-makers address rural health access problems

This paper provides a comprehensive review of the key dimensions of access and their significance for the provision of primary health care and a framework that assists policy-makers to evaluate how well policy targets the dimensions of access. Access to health care can be conceptualised as the potential ease with which consumers can obtain health care at times of need. Disaggregation of the concept of access into the dimensions of availability, geography, affordability, accommodation, timeliness, acceptability and awareness allows policy-makers to identify key questions which must be addressed to ensure reasonable primary health care access for rural and remote Australians. Evaluating how well national primary health care policies target these dimensions of access helps identify policy gaps and potential inequities in ensuring access to primary health care. Effective policies must incorporate the multiple dimensions of access if they are to comprehensively and effectively address unacceptable inequities in health status and access to basic health services experienced by rural and remote Australians.

Psychometric analysis of the Swedish translation of the WHO well-being index

PURPOSE

The purpose of this study is to validate the Swedish translation of the WHO (Ten) and WHO (Five) Well-Being Questionnaires among three samples of Swedes.

METHODS

Baseline data collected in 2008 from the Health Assets Project are the data source consisting of three cohorts of Swedes aged 19-64 years: (1) a randomized general population cohort (n = 4,027); (2) employees sick-listed reported by the employer (n = 3,310); and (3) self-certified sick-listed individuals (n = 498). The psychometric properties of the scales are assessed using factor analysis, Cronbach's alpha, and examination of the relationship between scale scores and participants' self-reported adverse health conditions.

RESULTS

Factor analysis revealed a unidimensional factor structure for both scales, and Cronbach's alphas are very good to excellent. The scales correlate in the expected direction with almost all of the adverse health conditions considered.

CONCLUSIONS

The Swedish translation of the WHO (Ten) and WHO (Five) Well-Being Questionnaires is psychometrically sound, but the first item of both scales has weaker psychometric qualities in comparison with other scale items.

Diagnosing cancer in the bush: a mixed-methods study of symptom appraisal and help-seeking behaviour in people with cancer from rural Western Australia

BACKGROUND

Previous studies have focused on the treatment received by rural cancer patients and have not examined their diagnostic pathways as reasons for poorer outcomes in rural Australia.

OBJECTIVES

To compare and explore symptom appraisal and help-seeking behaviour in patients with breast, lung, prostate or colorectal cancer from rural Western Australia (WA).

METHODS

A mixed-methods study of people recently diagnosed with breast, lung, prostate or colorectal cancer from rural WA. The time from first symptom to diagnosis (i.e. total diagnostic interval, TDI) was calculated from interviews and medical records.

RESULTS

Sixty-six participants were recruited (24 breast, 20 colorectal, 14 prostate and 8 lung cancer patients). There was a highly significant difference in time from symptom onset to seeking help between cancers (P = 0.006). Geometric mean symptom appraisal for colorectal cancer was significantly longer than that for breast and lung cancers [geometric mean differences: 2.58 (95% confidence interval, CI: 0.64-4.53), P = 0.01; 3.97 (1.63-6.30), P = 0.001, respectively]. There was a significant overall difference in arithmetic mean TDI (P = 0.046); breast cancer TDI was significantly shorter than colorectal or prostate cancer TDI [mean difference : 266.3 days (95% CI: 45.9-486.8), P = 0.019; 277.0 days, (32.1-521.9), P = 0.027, respectively]. These differences were explained by the nature and personal interpretation of symptoms, perceived as well as real problems of access to health care, optimism, stoicism, machismo, fear, embarrassment and competing demands.

CONCLUSIONS

Longer symptom appraisal was observed for colorectal cancer. Participants defined core characteristics of rural Australians as optimism, stoicism and machismo. These features, as well as access to health care, contribute to later presentation of cancer.

Last resort or roll of the die? Exploring the role of metaphors in cancer clinical trials education among medically underserved populations

Improving communication about cancer clinical trials may help increase patients' understanding of medical research and their interest in participating. It is unfortunate that there is little empirical research to provide guidance on how to adapt clinical trial messages to maximize cultural sensitivity. This study examines (a) how medically underserved women conceptualize clinical trials by examining the language they use to describe them and (b) how this audience interprets metaphorical language used to explain randomization in the context of Phase III cancer clinical trials. The author conducted in-depth interviews and focus groups with 41 rural, low-income older women who either had been diagnosed with cancer or were caregivers for a person with cancer. The most commonly used lay metaphors for clinical trials had strong negative connotations and included treatment by trial and error, patients are guinea pigs, and treatment of last resort. Participants also expressed strong, unfavorable responses to conventional metaphors that equate randomization with the roll of a die or use other gambling language. Low-literacy definition approaches were unexpectedly problematic, suggesting the potential effectiveness of culturally grounded metaphors for communicating about clinical trials. Ethical implications of these findings for cancer communication are discussed.

Psychosocial service use: a qualitative exploration from the perspective of rural Australian cancer patients

PURPOSE

This study aims to identify key issues associated with the provision of psychosocial care from the perspective of rural Australian cancer patients and determine culturally appropriate methods that may reduce barriers to service use.

METHOD

Seventeen purposively sampled adult South Australians who lived outside metropolitan Adelaide, had a diagnosis of cancer and various demographic and medical histories participated in semi-structured, face-to-face interviews. Participants also completed a demographic questionnaire. Qualitative data were analysed using thematic analysis.

RESULTS

Five key themes were identified: (1) psychosocial support is highly valued by those who have accessed it, (2) having access to both lay and professional psychosocial support is vitally important, (3) accessing psychosocial services is made difficult by several barriers (lack of information about services, initial beliefs they are unnecessary, feeling overwhelmed and concerns about stigma and dual relationships), (4) medical staff located in metropolitan treatment centres are not sufficiently aware of the unique needs of rural patients and (5) patients require better access to psychosocial services post-treatment. Methods through which rural patients believe access to psychosocial services could be improved include: (1) providing more rural-specific information on psychosocial care, (2) improving communication between health care providers and referral to psychosocial services and (3) making psychosocial services a standard part of care.

CONCLUSIONS

Rural cancer patients want their unique needs to be recognised and to be treated differently to their urban counterparts. There is a need for more targeted and rurally relevant information for rural cancer patients, both to inform them of, and change their attitudes towards, psychosocial services. Other practical recommendations are also discussed.

The injured and diseased farmer: occupational health, embodiment and technologies of harm and care

Occupational health in agriculture is a significant public health issue in industrialised agricultural nations. This article reports on 26 in-depth interviews with farmers throughout New Zealand. Farmers are exposed to a range of technologies which place them at risk of injury and disease and/or prevent injury and disease. In this article these technologies are respectively conceptualised as technologies of harm and technologies of care. Despite being vulnerable to high rates of injury, fatality and occupationally related diseases the uptake of technologies of care amongst farmers in New Zealand is poor. The analysis draws on body theory to explore the meaning attached to injury and disease and to examine the socio-cultural field of agriculture. It is argued that the key features of subjective embodiment and social, cultural and symbolic capital can undermine the uptake of technologies of care, ensuring poor occupational health outcomes on New Zealand farms.

The role of social support in multiple morbidity: self-management among rural residents

Social support generally is considered a valuable asset that may compensate for health service deficiencies among rural populations. Employing a mixed methods approach, we explored how vulnerable rural residents described social support in the context of self-management for multiple chronic conditions. Participants generally felt support was available, though emotional/informational support was perceived as less available than other types of support. Participants did not rely heavily on informal support to help them manage their multiple morbidities, preferring to call on their doctor and their own resources. We discuss implications of these findings for meeting this vulnerable population's self-management needs.

Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa

OBJECTIVE

Access barriers to health care for minority populations has been a feature of medical, health and social science literature for over a decade. Considerations of cultural barriers have featured in this literature, but definitions of what constitutes a cultural barrier have varied. In this paper, data from recent interviews with Aboriginal and Torres Strait Islander people, Aboriginal Health Workers and other non-Indigenous health professionals in north-west Queensland assist to refine the meaning of this term and uncovered other issues disguised as 'cultural' difference.

DESIGN

Semistructured interviews with community and health professionals.

SETTING

Mount Isa, Queensland, Australia.

PARTICIPANTS

Aboriginal and Torres Strait Islanders, Aboriginal Health Workers and other health professionals in Mount Isa between 2007 and 2009.

RESULTS

Cultural barriers were considered differently by Aboriginal patients and health practitioners. While Aboriginal patients focused heavily on social relationships and issues of respect and trust, most practitioners seemed more focused on making Aboriginal people feel comfortable with changes to physical environments and systems, with less emphasis on creating strong interpersonal relationships.

CONCLUSIONS

For Aboriginal patients the focus on interpersonal relationships between themselves and health practitioners is paramount. Creating comforting physical environments and systems that are easier to navigate do assist in overcoming cultural barriers, but are often seen as little more than token gestures if trusting interpersonal relationships are not formed between patient and practitioner.

An evaluation of access to health care services along the rural-urban continuum in Canada

Background

Studies comparing the access to health care of rural and urban populations have been contradictory and inconclusive. These studies are complicated by the influence of other factor which have been shown to be related to access and utilization. This study assesses the equity of access to health care services across the rural-urban continuum in Canada before and after taking other determinants of access into account.

Methods

This is a cross-sectional study of the population of the 10 provinces of Canada using data from the Canadian Community Health Survey (CCHS 2.1). Five different measures of access and utilization are compared across the continuum of rural-urban. Known determinants of utilization are taken into account according to Andersen's Health Behaviour Model (HBM); location of residence at the levels of province, health region, and community is also controlled for.

Results

This study found that residents of small cities not adjacent to major centres, had the highest reported utilisation rates of influenza vaccines and family physician services, were most likely to have a regular medical doctor, and were most likely to report unmet need. Among the rural categories there was a gradient with the most rural being least likely to have had a flu shot, use specialist physicians services, or have a regular medical doctor. Residents of the most urban centres were more likely to report using specialist physician services. Many of these differences are diminished or eliminated once other factors are accounted for. After adjusting for other factors those living in the most urban areas were more likely to have seen a specialist physician. Those in rural communities had a lower odds of receiving a flu shot and having a regular medical doctor. People residing in the most urban and most rural communities were less likely to have a regular medical doctor. Those in any of the rural categories were less likely to report unmet need.

Conclusion

Inequities in access to care along the rural-urban continuum exist and can be masked when evaluation is done at a very large scale with gross indicators of rural-urban. Understanding the relationship between rural-urban and other determinants will help policy makers to target interventions appropriately: to specific demographic, provincial, community, or rural categories.

Measuring outcomes in people who have had a stroke and their carers: can the telephone be used?

PURPOSE

Telephone interviews may be a cost-effective alternative to administering stroke outcome measures for people who are living in the community following a stroke, but there is a lack of research that has compared the different modes of administering outcome measures. The aim of this study was to determine whether telephone administration of selected stroke outcome measures resulted in significantly different results to face-to-face administration of the same outcome measures.

METHOD

Nineteen participants who were taking part in a randomised controlled trial (RCT) evaluating the effectiveness of a postdischarge education and support package for stroke patients and their carers were recruited for this study. Participants had the RCT follow-up outcome measures, at 3 months post discharge, administered by both telephone and face-to-face. Participants were randomised to receive either the telephone or face-to-face administration first and a period of 2 weeks separated the two administrations. Outcome measures were the Knowledge of Stroke Questionnaire, a stroke self-efficacy questionnaire, Hospital Anxiety and Depression Scale, Stroke and Aphasia Quality of Life Scale, and the Caregiver Strain Index.

RESULTS

There were no significant differences between scores obtained on any of the outcome measures that were administered by telephone and face-to-face (P > .05).

CONCLUSION

The telephone can be used to administer the outcome measures that were evaluated in this study to stroke patients and carers. These findings may be of benefit to stroke researchers and clinicians who wish to incorporate the use of telephone measures into the follow-up care of stroke patients and their carers.

Geographic disparities in the risk of perforated appendicitis among children in Ohio: 2001-2003

Background

Rural-urban disparities in health and healthcare are often attributed to differences in geographic access to care and health seeking behavior. Less is known about the differences between rural locations in health care seeking and outcomes. This study examines how commuting patterns in different rural areas are associated with perforated appendicitis.

Results

Controlling for age, sex, insurance type, comorbid conditions, socioeconomic status, appendectomy rates, hospital type, and hospital location, we found that patient residence in a rural ZIP code with significant levels of commuting to metropolitan areas was associated with higher risk of perforation compared to residence in rural areas with commuting to smaller urban clusters. The former group was more likely to seek care in an urbanized area, and was more likely to receive care in a Children's Hospital.

Conclusion

To our knowledge, this is the first study to differentiate rural dwellers with respect to outcomes associated with appendicitis as opposed to simply comparing "rural" to "urban". Risk of perforated appendicitis associated with commuting patterns is larger than that posed by several individual indicators including some age-sex cohort effects. Future studies linking the activity spaces of rural dwellers to individual patterns of seeking care will further our understanding of perforated appendicitis and ambulatory care sensitive conditions in general.

How does being female assist help-seeking for mental health problems?

OBJECTIVE

In Australia the prevalence of mental health problems does not vary by gender, but help-seeking and service utilization do. The aim of the present study was to examine a number of attitudinal factors that may influence help-seeking for mental health problems.

METHOD

A cross-sectional community survey was conducted with a sample of 579 rural residents (57.9% female), who completed self-report measures assessing stoicism, alexithymia, perceived and personal stigma and the various facets of the personality trait of openness to experience.

RESULTS

Men scored higher on measures of stoicism and personal stigma associated with mental health problems than women, and compared to women had lower scores on the facets of openness to experience.

CONCLUSIONS

Higher rates of help-seeking for mental health problems by women may be due to lower levels of stoicism and personal stigma related to mental health problems in women compared to men.

The influence of stigma and attitudes on seeking help from a GP for mental health problems: a rural context

BACKGROUND

Lack of mental health specialists in rural and remote communities suggest that rural communities depend more on general practitioners (GPs) for mental health care. Residents of rural communities are less likely than urban residents to seek help from their GPs for mental health issues. The aim of the current study was to examine whether attitudinal factors including perceived stigma, influenced rural residents seeking help from GPs.

METHOD

Help-seeking for psychological issues was retrospectively reported by 300 community residents in rural north-west Victoria. Current distress levels, functional disability, and current or lifetime syndromal disorder were recorded. Attitudes towards seeking professional psychological help, perceptions of stigma about mental illness, and belief in helpfulness of GPs, were also measured.

RESULTS

Having a positive attitude towards seeking professional help, and believing that a GP would be helpful, were significant predictors of ever having sought help from a GP for mental health problems. Other independent predictors of help-seeking included having a mood, anxiety or substance use disorder, higher distress levels, and greater functional disability due to physical problems.

CONCLUSIONS

Seeking help from a GP for psychological problems was predicted by having a positive attitude towards seeking professional psychological help as well as believing a GP would be helpful in treating psychological problems. Illness variables were also strong predictors of help-seeking behaviour. Contrary to expectations, perceived stigma did not influence help-seeking. The findings of this study highlight the important role of GPs in the treatment of mental health problems in the rural community.