Characteristics and Recruitment Paths of Certified Nursing Assistants in Rural and Urban Nursing Homes

ABSTRACT:  Context: Most nursing home care is provided by certified nursing assistants (CNAs), but little is known about rural CNAs. Purpose: To develop a representative geographic profile of the CNA workforce, focusing on paths leading to present job. Methods: Cross-sectional analysis of data from the 2004 National Nursing Assistant Survey (NNAS), a nationally representative survey of 3,017 CNAs; analysis was restricted to 2,897 currently working CNAs. Location was categorized as metropolitan, micropolitan, or neither (other rural county). Demographics included age, sex, race, education, income, and years at present job. Analyses were weighted to reflect the complex sampling design. Findings: CNAs in micropolitan and other rural nursing homes were more likely to be white and US citizens than were urban CNAs. Rural or micropolitan CNAs were more likely to note "job close to home" as a reason for becoming a CNA than were urban CNAs (70.8%, 66.3%, and 43.6%, respectively; P < .001). Over half of CNAs (52.2%) entered the field from a different job category. CNAs in micropolitan and small rural counties were more likely than urban CNAs to report being trained at a nursing facility (61.4%, 65.4%, 52.5%; P < .001) rather than community college or other site. Informal means (family and friends) were the most common recruitment path. Conclusions: Career-changers (individuals entering the CNA role from another job) represent a major recruitment target. The prevalence of informal networks in CNA recruitment history suggests that nursing homes seeking to become "employers of choice" will be advantaged when recruiting.     

Time allocation of the mother and child nutrition

The effects of labor force participation of mothers on dietary and time inputs into child care, as well as the resultant impact on the nutritional status of children from 34 rural barios in Laguna, Philippines, are examined. Rural mothers who engage in market activities especially in jobs incompatible with child care, are shown to reduce the time they devote to leisure and child care. Child care provided by older-sibling mother substitutes replaces a part of the mother's reduced child care time. Mothers who engage in market activities are able to provide their children with more calories and protein in relation to their needs. Analysis showed, however, that the intrahousehold time substitutions have net negative effects on the average nutritional status of children ages 1-71 months in each rural household. The results of this study are compatible with other studies which indicate potential conflicts between the mother's participation in market work and child nutrition.     

Premature mortality in the United States: the roles of geographic area, socioeconomic status, household type, and availability of medical care.

OBJECTIVES: This study examined premature mortality by county in the United States and assessed its association with metro/urban/rural geographic location, socioeconomic status, household type, and availability of medical care. METHODS: Age-adjusted years of potential life lost before 75 years of age were calculated and mapped by county. Predictors of premature mortality were determined by multiple regression analysis. RESULTS: Premature mortality was greatest in rural counties in the Southeast and Southwest. In a model predicting 55% of variation across counties, community structure factors explained more than availability of medical care. The proportions of female-headed households and Black populations were the strongest predictors, followed by variables measuring low education, American Indian population, and chronic unemployment. Greater availability of generalist physicians predicted fewer years of life lost in metropolitan counties but more in rural counties. CONCLUSIONS: Community structure factors statistically explain much of the variation in premature mortality. The degree to which premature mortality is predicted by percentage of female-headed households is important for policy-making and delivery of medical care. The relationships described argue strongly for broadening the biomedical model.     

Consumer Perspectives on Medicaid Managed Care: A Comparison Between Rural and Urban Enrollees in One Selected Health Plan

This report presents the findings from a telephone survey of 313 respondents who have family members enrolled in Medicaid managed care in a multicounty region that encompasses both rural and urban counties in Wisconsin. Some demographic differences were noted between the rural and urban families that might affect their impressions of the health care system, their needs for services and their abilities to use those services appropriately. Families in the urban counties had poorer access to health care, as they were more likely to report at least one child not being assigned to a primary care provider. Inadequate preventive health behaviors were found among both rural and urban families, as evidenced by children being overdue for immunizations or health checkups. Yet respondents reported being happy with the care they received. Rural families in particular seemed to fare well in this managed care system.     

Rurality and Other Determinants of Early Colorectal Cancer Diagnosis in Nebraska: A 6-Year Cancer Registry Study, 1998-2003

ABSTRACT:  Background: There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.     

Rural-Urban Differences in Preventable Hospitalizations Among Community-Dwelling Veterans With Dementia

Context: Alzheimer's patients living in rural communities may face significant barriers to effective outpatient medical care. Purpose: We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia. Methods: Medicare and Veteran Affairs inpatient claims for 1,186 US veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey. ACSH were identified in inpatient claims over a 1-year period following collection of independent variables. Urban Influence Codes were used to classify care recipients into 4 categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and noncore rural counties. We used the Andersen Behavioral Model of Health Services to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH. Findings: Thirteen percent of care recipients had at least 1 ACSH. The likelihood of an ACSH was greater for patients in noncore rural counties versus large metropolitan areas (22.6% vs 12.8%, unadjusted odds ratio [OR]= 1.99; P < .01). The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 1.97; P < .05). Conclusions: We found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care recipient, or community factors. Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population. Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care.     

Multidisciplinary management of complex care

Rural and remote areas of Australia are facing serious health workforce shortages. Multidisciplinary teams are one way of making the most of the rural workforce. In this paper, the advantages of multidisciplinary care in terms of patient outcomes, clinician satisfaction and system efficiency are considered with reference to an innovative rural multidisciplinary model that highlights how these positive outcomes can be achieved. Ways of developing the capacity of the future workforce for work in multidisciplinary teams are discussed.     

The rural-urban distribution of health professionals in Georgia.

In this paper, the rural/urban geographic distribution of licensed health professionals living in the state of Georgia is examined. Using 1983 data from the State Examining Boards, 13 health professions were studied to determine rural and urban differences. Three indicators of ruralness were used to classify county of residence: metropolitan/nonmetropolitan, metropolitan proximity, and size of county population. Results from data analyses indicate a severe geographic maldistribution of health professionals. With all three indicators, 11 of the 13 professions had urban rates of professionals-to-population substantially higher than the corresponding rural rates. A linear configuration seems to illustrate the relationship between the availability of health professionals and the ruralness of the county--as the county becomes more rural, the number of health professionals per population decreases. The percentage increase in physicians since 1968 and nurses since 1979 in nonmetropolitan counties was slightly higher than in metropolitan counties, indicating that this gap is closing somewhat. The most severe rural/urban differences in the number of professionals which per population were found in the more specialized health professions per tended to be the smallest in terms of numbers of members (e.g., occupational therapists, psychologists, speech pathologists/audiologists, podiatrists, opticians and physical therapists). These differences ranged up to a 20 plus-fold difference. Physicians, chiropractors, dentists, physician assistants and registered nurses also had relatively large rural/urban differences but less than the more specialized professions.     

Is rural mental health workforce a policy imperative?

An available and effective rural mental health workforce is critical to the provision of contemporary mental health care. During the last 5 years new mental health plans and strategies have been released every state and territory of Australia. This policy analysis examines the extent to which workforce, and particularly rural workforce issues are considered in these policies. The analysis revealed that rural workforce issues receive scant attention in state and territory mental health plans. Rural Australians comprise 28% of the total population, yet rural workforce issues are canvased, on average only 6% of the time general workforce issues are addressed. National mental health workforce plans do focus on the rural workforce, but these are not referenced in the state or territory strategies or workforce plans. Given the rural mental health workforce shortages, and consumer challenges in accessing rural mental health services, more planning and consideration to supporting and developing a rural workforce appears warranted.     

A Comparison of Metropolitan and Rural Medical Schools in China: Which Schools Provide Rural Physicians?

ABSTRACT: To compare the role of metropolitan and rural medical schools in the provision of rural physicians, a survey was conducted in 12 metropolitan and 10 rural medical schools. Rural medical schools enrolled fewer students (P = 0.019), and produced fewer graduates (P = 0.023) than metropolitan medical schools. Students in rural medical schools were mainly from surrounding regional cities and counties, whereas those in metropolitan schools were from cities nationwide (P < 0.001). All rural medical schools produced rural physicians; one rural school reported that of its 256 graduates, 88 (34.4%) entered rural practice. Ten of the 12 metropolitan medical schools did not produce any rural physicians, whereas the remaining two metropolitan schools registered a total of 73 graduates who selected a rural practice location. These results indicate that rural medical schools may play a key role in overcoming the shortage of physicians in rural communities in China.     

Do health and medical workforce shortages explain the lower rate of rural consumers' complaints to Victoria's Health Services Commissioner?

OBJECTIVE: To identify which explanations account for lower rural rates of complaint about health services--(i) fear of consequences where there is little choice of alternative provider; (ii) a higher complaint threshold for rural consumers; (iii) lack of access to complaint mechanisms; or (iv) reduced access to services about which to complain. DESIGN: Ecological study incorporating consumer complaint, population and workforce distribution data sources. SETTING: All health care providers practising in Victoria. PARTICIPANTS: De-identified records of all closed consumer complaints made to the Health Services Commissioner, Victoria, between March 1988 and April 2001 by Victorian residents (13 856 records). MAIN OUTCOME MEASURES: Differences in the percentage of under-representation in complaint rates in total and for each of four categories of health services providers for different size communities. RESULTS: No consistent relationship was observed between community size and either degree of under-representation of complaints against any category of provider, or the proportion of serious or substantial complaints. Rural under-representation was highest (41%) for dentists, the provider category with the lowest proportion working in rural areas (17%), and lowest (18%) for hospitals, with the highest representation in rural areas (28% of beds). More rural complaints were about access issues (10.7% rural and 8.4% metropolitan). CONCLUSIONS: Reduced opportunity to use health services due to rural health and medical workforce shortages was the best-supported explanation for the lower rural complaint rate. Workforce shortages impact on the quality of rural health services and on residents' opportunities to improve their health status.     

Lung cancer: An exploration of patient and general practitioner perspectives on the realities of care in rural Western Australia

Objective: This study investigates if the pattern of diagnostic testing for suspected lung cancer, stage at diagnosis, patterns of specialist referral and treatment options offered to people in rural Western Australia are similar to those in the metropolitan area. It then explores the barriers to quality care in rural areas as perceived by GPs and patients. Methods: There was a review of GP records to obtain clinical and referral information and an in‐depth interview with patients and GPs concerning their perspectives of the quality of care. Results/Discussion: We selected age and sex‐matched samples of 22 rural and 21 metropolitan patients. Rural patients had more symptoms and took longer to consult their GPs, leading to later diagnosis and fewer treatment options. They experienced longer waits for specialist consultation and underwent less diagnostic testing. The GPs always referred lung cancer patients to a specialist, usually a respiratory physician. Teaching hospitals were preferred because of their comprehensive facilities and multidisciplinary teams. Rural GPs reported distance, time and availability of appointments as barriers; they also raised concerns about late confirmation of diagnosis. Rural and metropolitan patients were equally satisfied with their quality of care, but rural patients desired more information and better communication between hospital and GPs. Facilities for rural patients at some metropolitan hospitals were criticised. In conclusion, rural patients received a different care pattern from metropolitan patients and they and their GPs raised concerns about the equity and quality of lung cancer care.     

Staff Training Interests,Barriers, and Preferences in Rural and Urban Child Care Programs in Minnesota

Objectives

To describe any rural–urban differences in child care providers’ (1) past training on the facilitation of child healthy eating and physical activity and (2) views relevant to the design of trainings.

Where do students in the health professions want to work?

Background  

Rural and remote areas of Australia are facing serious health workforce shortages. While a number of schemes have been developed to improve recruitment to and retention of the rural health workforce, they will be effective only if appropriately targeted. This study examines the factors that most encourage students attending rural clinical placements to work in rural Australia, and the regions they prefer.     

Prevalence of Children with Special Health Care Needs in Metropolitan and Micropolitan Statistical Areas in the United States

Objectives We estimate the prevalence of children with special health care needs (CSHCN) in 70 metropolitan and four micropolitan statistical areas across the United States. Methods The data are from the 2001 National Survey of CSHCN, which was sponsored by the Maternal and Child Health Bureau and conducted by the National Center for Health Statistics. Prevalence estimates were generated for 74 metropolitan and micropolitan statistical areas (M/MSAs) and 45 individual counties that were represented by at least 1,000 children in the sample. To generate the estimates, the child-level sample weights (representative at the national and state level) were recalibrated within each M/MSA and county to match Census 2000 counts of the child population by age, sex, and Hispanic ethnicity. Results M/MSA-level and county-level prevalence of CSHCN are compared with national- and state-level prevalence, and within M/MSAs and counties, prevalence is reported by age, sex and race/ethnicity. Most, but not all, M/MSA- or county-level prevalence estimates did not differ significantly from state-level estimates. Some M/MSAs and counties that did not differ from their states in overall prevalence of CSHCN did show some differences in prevalence for certain demographic subgroups. Conclusions Metropolitan health departments and Maternal and Child Health agencies that serve urban areas may find these new small area estimates useful for program planning purposes. This study demonstrates the importance of assessing whether state estimates may approximate local area estimates of the prevalence of CSHCN.     

A comparison of the rural-urban mortality differential for deaths from all causes, cardiovascular disease and cancer.

Using a nine category continuum of residence ranging from major metropolitan counties of one million or more to isolated rural counties with las than 2,500 residents, the data presented indicate that although ruralurban differentials in mortality narrowed over the decade of the 1970s, by 1980 non-metropolitan counties continuedto have crude death rates that were significantly higher than metropolitan counties for deaths from all causes, cardiovascular disease, and cancer. A detailed examination of directly standardized rates reveals that virtually all of the rural-urban mortality differential is due not to residence per se, but to differences in demographic structure, particularly age composition. Rural areas have an age distribution more heavily skewed toward the older ages where the probability of death is higher. The implications of the findings for broad-based rural health care policy are discussed with an emphasis on the need to consider the special health and service needs ofan aging population.