The importance of location for tobacco cessation: rural-urban disparities in quit success in underserved West Virginia Counties.

CONTEXT: Adults who live in rural areas of the United States have among the highest smoking rates in the country. Rural populations, including Appalachian adults, have been historically underserved by tobacco control programs and policies and little is known about their effectiveness. PURPOSE: To examine the end-of-class quit success of participants in A Tobacco Cessation Project for Disadvantaged West Virginia Communities by place of residence (rural West Virginia and the urban area of Greater Charleston). METHODS: This collaborative program was implemented in 5 underserved rural counties in West Virginia and consisted of 4 intervention approaches: (1) a medical examination; (2) an 8-session educational and behavioral modification program; (3) an 8-week supply of pharmacotherapy; and (4) follow-up support group meetings. FINDINGS: Of the 725 program participants, 385 (53.1%) had successfully quit using tobacco at the last group cessation class they attended. Participants who lived in rural West Virginia counties had a lower end-of-class quit success rate than those who lived in the urban area of Greater Charleston (unadjusted odds ratio [OR]= 0.69, 95% confidence interval [CI]= 0.48, 0.99), even after taking into account other characteristics known to influence quit success (adjusted OR = 0.58, 95% CI = 0.35, 0.94). CONCLUSIONS: Tobacco control programs in rural West Virginia would do well to build upon the positive aspects of rural life while addressing the infrastructure and economic needs of the region. End-of-class quit success may usefully be viewed as a stage on the continuum of change toward long-term quit success.     

The Importance of Location for Tobacco Cessation: Rural–Urban Disparities in Quit Success in Underserved West Virginia Counties

ABSTRACT:  Context: Adults who live in rural areas of the United States have among the highest smoking rates in the country. Rural populations, including Appalachian adults, have been historically underserved by tobacco control programs and policies and little is known about their effectiveness. Purpose: To examine the end-of-class quit success of participants in A Tobacco Cessation Project for Disadvantaged West Virginia Communities by place of residence (rural West Virginia and the urban area of Greater Charleston). Methods: This collaborative program was implemented in 5 underserved rural counties in West Virginia and consisted of 4 intervention approaches: (1) a medical examination; (2) an 8-session educational and behavioral modification program; (3) an 8-week supply of pharmacotherapy; and (4) follow-up support group meetings. Findings: Of the 725 program participants, 385 (53.1%) had successfully quit using tobacco at the last group cessation class they attended. Participants who lived in rural West Virginia counties had a lower end-of-class quit success rate than those who lived in the urban area of Greater Charleston (unadjusted odds ratio [OR]= 0.69, 95% confidence interval [CI]= 0.48, 0.99), even after taking into account other characteristics known to influence quit success (adjusted OR = 0.58, 95% CI = 0.35, 0.94). Conclusions: Tobacco control programs in rural West Virginia would do well to build upon the positive aspects of rural life while addressing the infrastructure and economic needs of the region. End-of-class quit success may usefully be viewed as a stage on the continuum of change toward long-term quit success.     

Assessment of school-based health centers in a rural state: the West Virginia experience.

PURPOSE: To assess the capability of school-based health centers (SBHCs) to provide access to health care for rural youth. METHODS: Review of annual patient records from SBHCs in West Virginia. Ten of 24 SBHCs in West Virginia in operation from July 1994 to June 1997 were selected for the study. Enrollment and utilization rates were generated for each site. A comparison was made between rates of enrollment, utilization, and annual visits among youth with private insurance, those covered by Medicaid, and youth without insurance. Rural and urban SBHCs within West Virginia were compared based on enrollment, utilization, and visit rates. The diagnostic categories were analyzed. Finally, enrollment rates, utilization rates, and insurance status for the West Virginia SBHCs were compared with national norms. RESULTS: Enrollment rates rose steadily during the study period from 27% in Year 1 to 64% by the end of Year 3. The utilization rate was 67% in Year 3. The youth with either Medicaid or no insurance comprised 52% of enrollees, but they accounted for 63% of all visits. West Virginia SBHCs have a higher rate of Medicaid users than the national average for SBHCs, and the annual visit rate for West Virginia youth is higher than the national average for nonmetropolitan adolescents. The enrollment rate of 64% is slightly higher than the national average for SBHCs. Within West Virginia, the enrollment rate in rural schools was significantly higher, 86% compared to 46% (p < .001), and the utilization rate was 70% in rural centers compared to 63% in the urban centers (p < .001). CONCLUSION: When SBHCs are available in rural areas, students use them. In West Virginia, SBHCs have contributed to providing access to health care for rural youth.     

Female specialists were more likely to respond to a postal questionnaire about drug treatments for Alzheimer disease

OBJECTIVE: To assess demographic predictors of response for specialists who were mailed a postal questionnaire on drug treatments for Alzheimer disease. STUDY DESIGN AND SETTING: The questionnaire was sent to 317 specialists in Quebec, Canada. Demographic variables included specialty, urban/rural practice, language, sex, and 'number of years since receiving a medical license.' The specialists were stratified according to responder status (i.e., respondent/nonrespondent), and respondents were further stratified as early or late responders. Variables differing between these strata were entered into logistic regression models to see if they predicted response. RESULTS: Only 'female sex' was a predictor of response in the respondent/nonrespondent analysis (OR 2.03; 95% CI 1.17, 3.53). No demographic variables predicted early or late response. CONCLUSION: Researchers planning postal questionnaires should target male specialists with modified or additional mailings to increase response and reduce the potential for nonresponse bias. Caution should be exercised when comparing early vs. late responders as a means of assessing nonresponse bias.     

An assessment of the Doctorate of Medicine (Internal Medicine), University of the West Indies

The outcome is described of 48 entrants to a postgraduate degree course (DM) in Internal Medicine established at the University of the West Indies in 1974. Contact by postal questionnaire was established in 96% of 26 graduates and 82% of 22 non-graduates. 22 of 25 DM graduate responders have remained in the Caribbean, working in six Caribbean territories. All graduate responders developed a subspecialty interest. The graduates' primary employers are the University (9) and the Government (12). However, failure to graduate did not necessarily preclude qualification as consultant physician (7 of 18 responders). Major difficulties with the DM programme included: (1) in practice, lack of recognition by contributing territories of individual DM (Internal Medicine) graduates; (2) incomplete regional coverage; (3) lack of adequate funding for the programme; (4) an inadequate research training input; and (5) difficulties with seniority for staff who trained in Jamaica to go to work in another territory. All these problems have solutions. Overall, the international recognition of the new degree programme has been satisfactory and the graduates' own assessment of the training was complimentary. At last a system has been devised that enables postgraduates to train as internal medicine specialists in the Caribbean to practise effectively within the Caribbean health system.     

Telerehabilitation at the University of Alberta

We established a telerehabilitation system to link staff at the University of Alberta with clinicians and students located in Two Hills, a rural community approximately 180 km east of Edmonton. From February 1996 to March 1999, the faculty of Rehabilitation Medicine conducted a total of 254 telehealth sessions, most of which involved participants in the rehabilitation discipline. Of these connections, only 11 were unsuccessful owing to technical or telecommunication problems (i.e. 96% were successful). The average duration of a session was 1 h 15 min. There were benefits to the Faculty in the areas of clinical supervision of students, clinical consultation, undergraduate and graduate education as well as professional development. The future benefits of such an initiative will depend on how well we address challenges pertaining to training, human resource and infrastructure.     

Cancer treatment in rural areas

The inability to deliver cancer prevention and treatment to the rural population poses a significant barrier in the national effort to reduce cancer mortality. Since 25 percent of the U.S. population lives in rural areas and few rural areas are readily accessible to cancer centers or Community Clinical Oncology Programs (CCOPs), the prospects for accomplishing the National Cancer Institute (NCI) Goals for the Year 2000 are limited unless substantive changes occur in rural cancer care delivery. This article reviews the problem of cancer risk and care in rural areas and describes one effort to deliver state-of-the-art cancer treatment to rural patients in Virginia. It describes the needs and barriers to access in rural Virginia, the structural elements of the Rural Cancer Outreach Program, and the health policy issues that result when subspecialty care is exported to disadvantaged areas.     

Fatal traumatic brain injury, West Virginia, 1989-1998

OBJECTIVE: The objective of this study was to describe fatal cases of traumatic brain injury (TBI) among West Virginia residents. METHODS: The authors analyzed data from the National Center for Health Statistics Multiple Cause of Death tapes for the period 1989-1998. They compared West Virginia's annualized average TBI death rate with the rates of other states and with the rate among U.S. residents for the same period. U.S. Bureau of Census population estimates were used as denominators. RESULTS: A total of 4,416 TBI deaths occurred in West Virginia in 1989-1998, for an annual average death rate of 23.6 per 100,000 population. From 1989 to 1998, TBI death rates declined 5% (p=0.4042). Seventy-five percent (n=3,315) of fatalities occurred among men. Adults > or =65 years of age accounted for the highest percentage of fatal injuries (n=1,135). The leading external causes of fatal TBI were: firearm-related (39% of reported fatalities), motor vehicles-related (34%), and fall-related (10%). Firearm-related TBI became the leading cause of TBI fatalities in 1991, surpassing motor vehicle-related TBI. Seventy-five percent of firearm-related TBI deaths were suicides (n=1,302). West Virginia's TBI death rate (23.6 per 100,000) was higher than the national rate (20.6 per 100,000). In 23 states, the average TBI death rates over the 10-year period were higher than West Virginia's. Whereas modest declines in TBI death rates occurred for motor vehicle-related and firearm-related causes in West Virginia, a concomitant 38% increase occurred in the fall-related TBI death rate during the decade. CONCLUSION: Data presented in this report can be used to develop targeted prevention programs in West Virginia.     

Predictors of childhood immunization completion in a rural population.

Despite the availability of effective vaccines, immunization rates among two-year old children continue to be low in many areas of the United States including rural West Virginia. The goal of this study was to identify barriers to childhood immunization in rural West Virginia and determine factors that were important in the completion of the childhood immunization schedule. A telephone survey was used to collect data from a randomly selected sample of 316 mothers, of two-year olds, from 18 rural counties of West Virginia. Results indicated that two-thirds or 65% of the children in the study sample had completed their recommended immunizations by two years of age. Immunization barriers identified in this study include: living in health professional shortage areas, lack of health insurance, negative beliefs and attitudes regarding childhood immunizations, problems accessing the immunization clinic, and a perception of inadequate support from the immunization clinic. Results of the structural equation modeling, using LISREL-8, indicated that 20% of the variation in immunization completion (R2 = 0.197) was explained by attitude towards immunization and perceived support received from the immunization clinic. Furthermore, 42% of the variation in attitude towards immunization (R2 = 0.419) was explained by immunization-related beliefs, and 28% of the variation in immunization-related beliefs (the R2 = 0.277) was explained by general problems faced during immunization and perceived clinic support. The study concluded that positive immunization-related beliefs and attitudes, support from the immunization clinic, and ease of the immunization seeking process are important factors in the timely completion of the childhood immunization schedule.     

Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education

Twenty percent of the US population lives in rural communities, but only about 9% of the nation's physicians practice in those communities. There is little doubt that the more highly specialized physicians are, the less likely they are to practice or settle in rural areas. There is clearly a population threshold below which it is not feasible for specialist (in contrast to generalist) physicians to pursue the specialty in which they have trained. Much of rural America falls below that threshold. This leaves large geographic areas of America to the primary care physician. The proportional supply of family physicians to specialists increases as urbanization decreases. Family physicians are the largest single source of physicians in rural areas. Family medicine residency programs based in rural locations provide a critical mechanism for addressing rural primary care needs. Graduates from rural residency programs are three times more likely to practice in rural areas than urban residency program graduates. There are two primary goals of training residents in rural areas: producing more physicians who will practice in rural areas and producing physicians who are better prepared for the personal and professional demands of rural practice. Rural Training Tracks, where the first year of residency is completed in an urban setting and the second and third years at a rural site (1-2 model), initially proposed by Family Medicine Spokane in 1985, have been highly successful in placing and maintaining more than 70% of their graduates in rural communities. Similar and modifications of the "Spokane RTT model" have been established around the country. Now, more than 24 years of educational experience has been accumulated and can be applied to further development of these successful family medicine residency programs.     

A telephone survey of patient satisfaction with realtime telemedicine in a rural community in Colombia

We conducted a telephone survey of all patients referred to a realtime telemedicine consultation at the Centre for Telehealth in Bogotá. Over a six-month period, 281 teleconsultations were conducted, and we were able to retrieve telephone numbers for 156 patients. Of these, 121 patients (78%) agreed to answer the questionnaire. Eighty percent of the respondents were satisfied or very satisfied with the teleconsultation and 63% would use telemedicine again. Sixty-five percent thought that telemedicine improved their medical care. More than 50% believed that telemedicine had a positive effect in terms of medical care improvement, time- and cost-savings. Twenty-seven percent felt that teleconsultation was not as good as a traditional face-to-face consultation. Lack of familiarity with ICT did not appear to act as a major barrier to telemedicine, and cognitive factors may be more important in acceptability to patients and their satisfaction. The results of the present study may also be relevant to the poorest countries of the world, where two-thirds of the population live in rural areas.     

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

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

A Proposal for Certification of School Nurses The West Virginia Model

The need for school nurse certification has been a longstanding concern of school health providers and citizens interested in school health. The West Virginia School Health Association formed a task force to study this need in West Virginia and to formulate a proposal for submission to the West Virginia Department of Education. The proposal addresses the need for school nurse certification, supplies supportive information regarding scope of problem, relates this problem to West Virginia's educational goals and provides information for potential improvement for education. A committee of educators and nurses are in the process of formulating educational and competency requirements for certification of school nurses in West Virginia.     

A “Medical Mission” at Home: The Needs of Rural America in Terms of Otolaryngology Care

Objectives: Describe the population, Medicaid, uninsured, and otolaryngology practice demographics for 7 representative rural Southeastern states, and propose academic‐affiliated outreach clinics as a service to help meet the specialty care needs of an underserved rural population, based on the “medical mission” model employed in international outreach clinics. Methods: A needs assessment was conducted via review of medical licensing and practice location data from state medical licensing authorities, together with population, Medicaid, and uninsured data from state health/human services departments and the US Census Bureau. Results: In all states examined, there are significantly more practicing otolaryngologists per capita in urban areas compared to rural areas (P < .05), with the exception of West Virginia, where the difference was not statistically significant (P= .33). In the majority of the states examined, there were higher rates (expressed as a percentage of total county population) of both Medicaid recipients and uninsured patients in rural counties compared to urban counties. Notable exceptions include Louisiana and West Virginia, where there are higher percentages of Medicaid patients in urban areas, and Kentucky and Tennessee, where there are higher percentages of uninsured patients in the urban areas (P < .05 for each comparison). Conclusions: Borrowing design elements from the international outreach clinics, which involve many US otolaryngologists, a similar medical mission model could be of benefit domestically. There are rural areas of the Southeast where visiting outreach clinics could improve access to otolaryngology care and facilitate effective use of existing “safety net” health care resources.     

Know Your Search Engine

Abstract

Over the past decade, the Internet has become a vital part of our society, playing a significant role in bridging the traditionally extensive gap between knowledge seekers and knowledge providers and creating an opportunity for consumers in rural communities to access health information previously either unavailable or available through very limited sources. This exploratory study was conducted to examine utilization of the Internet for health information retrieval by rural West Virginia consumers. Surprisingly, the researchers discovered that more West Virginia rural respondents had access to the Internet than the national average for rural consumers and that health care professionals in rural West Virginia rarely suggest the Internet to their patients as a secondary source of health information.     

Effectiveness of Tele-guided Interceptive Prosthodontic treatment in rural India: A comparative pilot study

Loss of teeth and resultant resorption of the residual ridges is a major oral health problem in India. The resorption leads to irreversible loss of bone volume of the jaws and seriously undermines retention and stability of future dentures. Loss of masticatory efficiency causes nutritional deficiencies and affects quality of life. However, construction of over-dentures (dentures anchored to modified teeth or roots), a sophisticated procedure requiring skills of several dental specialists, can arrest the resorption and provide retentive dentures. Dental specialists in India are, however, concentrated in urban areas leaving the rural populace under-serviced. The aim of our study was to find out whether newly graduated dentists, under remote guidance from specialists, can fabricate over-dentures that are functional and improve the oral health related quality of life.Two groups of subjects were treated with over-dentures. Group 1 consisted of subjects attending a rural dental health clinic (site1) and group 2 at a university teaching hospital (site 2). Two dental graduates at each site carried out treatments. Operators at site 1 were guided remotely over a telemedicine link, cell phones, and emails while those at site 2 were guided directly. Functional assessment of dentures was carried out at the end of the treatment period to determine the technical quality of dentures. Subjective evaluation was carried out by subjects completing the Oral Health Impact Profile (OHIP-EDENT) questionnaire for edentulous subjects before and after treatment.No statistically significant difference was seen between the functional assessment scores of dentures from the two sites (p=0.08) at 95% confidence interval. Both groups also experienced significant improvement in all domains of OHIP - EDENT.Remotely supervised newly graduated general dentists can provide over-dentures of sufficient quality to rural population. This strategy has the potential to improve access to care and elevate the level of dentistry available to rural population when referral to specialists in not feasible. The results of the study provide pointers for dental public health policy makers and administrators in developing nations on how to leverage Information and Communication Technology infrastructure to enhance access to care in rural areas.Key Words (MeSH): General Practice, Dental/methods, Health Services Accessibility, Humans India, Remote consultation, Telemedicine, Denture, Overlay, General Practice, Dental/education*, Quality of life, Prosthodontics     

Itinerant Surgical and Medical Specialist Care in Kansas: Report of a Survey of Rural Hospital Administrators

In most rural areas, specialist nonprimary care, when available, is provided by "itinerant" physicians and surgeons who periodically visit from a distant home base. Little is known about current usage and acceptability of itinerant specialists in rural communities. Administrators of hospitals in rural and frontier Kansas counties were asked to report the frequency of itinerant care in their facilities, the home base of each specialist and a listing of procedures performed during specialist visits. Administrators were also asked to respond on a Likert scale to six questions inviting their assessment of itinerant care. Responses were received from 53 of 56 hospitals. All offered at least one monthly session of itinerant medical or surgical care. The most common specialties represented were cardiology (in 87 percent of hospitals), urology (68 percent), orthopedics (68 percent) and radiology (60 percent). General surgeons consulted in over 80 percent of responding hospitals. Psychiatrists, dermatologists and neurologists were rarely available in the hospitals surveyed. Administrators generally rated itinerant care highly, though some expressed concern about revenue lost when specialists performed procedures in their home-base office or hospital. No associations were found between amount of care offered and potential explanatory variables such as hospital size, distance from subregional centers, or percentage of patients hospitalized locally. Further study is needed to better understand differences in itinerant specialist utilization and acceptance among rural Kansas hospitals. Because Kansas demographics are similar to those of many other American rural areas, such study may offer insights applicable to other regions.     

The West Virginia Health Education Assessment Project

Well-designed school health education should provide students with the knowledge and skills to prevent the health risk behaviors most responsible for the major causes of morbidity and mortality. This paper reports the methodology and findings of a West Virginia statewide health education assessment initiative and describes how the findings are used to design professional development training for school health educators. Selected response items from the State Collaborative on Assessment and Student Standards, Health Education Assessment Project were used to develop a 40-item assessment instrument for 6 health education content areas. In West Virginia, 51 counties and 242 schools were recruited (county response rate = 93%; school response rate = 53%); 17,549 students were tested in grades 6, 8, and high school health education classes. Mean total scores by grade were 30.61 (grade 6), 26.55 (grade 8), and 26.53 (high school), indicating a slight decline in scores as grade level increased. Females in each grade level scored higher on total Health Education Assessment Project (HEAP) scores and subtest scores than males. The results suggest notable differences across grade levels. High school students failed to meet the standard on any health education content areas, indicating the need for enhanced knowledge and skill development. During professional development training, HEAP scores were examined in the context of results from the West Virginia Youth Risk Behavior Survey to underscore the importance of providing quality skills-based health education in West Virginia schools.     

Technology, Job Satisfaction, and Retention: Rural Mental Health Practitioners

CONTEXT: Job satisfaction as it relates to retention of mental health professionals is a major problem in rural areas. Several authors have suggested that technology can positively influence job satisfaction and thus improve retention. OBJECTIVES: This study examined technology use and technology expertise in relationship to job satisfaction. It is based on a theoretical framework that asserts as technology use increases, communication among providers and access to educational and consultative resources increase as well, resulting in a boost in professional support and a reduction in isolation. METHODS: Surveys were sent to 320 providers in rural southeast Ohio; 163 returned usable surveys. FINDINGS: There was a statistically significant relationship between the combination of technology use and expertise and job satisfaction. Use alone, however, was not significant. Despite the fact that over 90% of respondents had access to both a computer and the Internet, just 45% used technology to communicate with peers and nearly 96% indicated that they never or rarely used the Internet for educational programs. CONCLUSIONS: The results challenge the assertion that technology plays a major role in job satisfaction and rural retention since access and perceived expertise did not guarantee technology usage. Decisions to stay or leave a rural practice involve a complex array of factors. Technology, with its ability to link providers to resources outside the geographic bounds of an individual's practice, may play a role, but since its adoption can be costly in both time and money, future studies need to determine its place in the retention model.