What affects rural beneficiaries use of urban and rural hospitals?

Analysis of the Medicare provider analysis record (MEDPAR) data during fiscal years 1984 through 1989 indicates that the proportion of rural Medicare beneficiaries hospitalized in urban hospitals has remained constant during the prospective payment system (PPS). Much of the use of urban hospitals by rural beneficiaries during this period was to obtain specialized care or surgery, as suggested by the analysis, and is consistent with historical patterns of referral of rural patients. Thus, the bypassing of rural hospitals by rural beneficiaries for treatment in urban hospitals has probably not increased during PPS.     

What can rural agencies do to address the additional costs of rural services? A typology of rural service innovation

There is a national commitment to ensuring that, regardless of where patients live, they should be provided with an acceptable level of service in terms of quality, effectiveness and accessibility. Because of differences in the distributions of their populations, rural and urban areas present quite different challenges for the optimal design of health services and social care. However, this has not been fully acknowledged in the development of national policies to unify service standards. The problems of providing services in sparsely populated areas are not new. However, until the case for a rural premium in English health resource allocation is accepted, rural agencies must either tolerate lower levels of services (an option made difficult by the introduction of national service standards) or develop very different approaches to service delivery. To date, there has been little systematic knowledge about the extent of innovative rural practice, a paucity of evaluation of such initiatives and few opportunities to disseminate learning from one area to another. The present paper begins to address this deficit. Drawing upon a review of the formal literature and a comprehensive evaluation of projects developed within a rural Health Action Zone, it presents a typology of innovative responses at the health/social care interface. Examples of service innovations which fall into six broad categories are provided. These not only suggest possibilities for the transfer of good practice, but also the potential for future research.     

Where is the evidence that rural exposure increases uptake of rural medical practice?

Australian Government initiatives to address medical workforce shortages in rural Australia include increasing the intake of students of rural background and increasing exposure to rural medicine during training. Rural-orientated medical training programs in the USA that selectively admit students from rural backgrounds and who intend to practise as family practitioners have demonstrated success in increasing uptake of practice in rural/underserved areas. However, in examining the specific contribution of rural exposure towards increasing uptake of rural practice, the evidence is inconclusive, largely due to the failure to adjust for these critical independent predictors of rural practice. This paper identifies this evidence gap, examines the concept of rural exposure, and highlights the need to identify which aspects of rural exposure contribute to a positive attitude towards rural practice, thereby influencing students to return to rural areas. The cost of rural exposure through student placements is not insignificant, and there is a need to identify which aspects are most effective in increasing the uptake of rural practice, thereby helping to address the medical workforce shortage experienced in rural Australia.     

Starting rural,staying rural: How can we strengthen the pathway from rural upbringing to rural practice?

Objective: To determine if selecting rural background students into the Monash Bachelor of Medicine and Bachelor of Surgery (MBBS) program affects vocational training location and intended practice location after training. Design: Retrospective cohort mail survey. Setting: Australia. Participants: Rural‐background students at Monash 1992–1994 (n = 24/40) and 1995–1999 (n = 59/120) and urban background students (n = 36/93 and 104/300, respectively). Overall study population: 62% female, average age of 28 years; 79% Australian‐born; and 60% married/partnered. Interventions: Rural or urban background, rural undergraduate exposure. Main outcome measures: Intent towards rural medical practice, vocational training location and subsequent practice location. Results: There was a positive and significant (P ≤ 0.05) association between rural background and rural practice intent when respondents began (10‐times higher than urban graduates) and completed (three times higher) their MBBS course. Rural practice intent increased fourfold in urban background graduates. There was a positive and significant association between rural background and preferred place of practice in 5–10 years in a Rural, Remote and Metropolitan Area (RRMA) 3–7 community (three times higher). There was a positive, but non‐significant association between rural background and RRMA 3–7 community as their current location and first place of practice once vocationally qualified. Conclusions: Interest in rural practice is not fully reflected in location during or after vocational training. The beneficial effects of rural undergraduate exposure might be lost if internship and vocational training programs provide insufficient rural clinical experiences and curriculum content. Continuation of the rural pathway might be needed to maintain rural practice intent.     

Correlates of quality of life in China rural–urban female migrate workers

Background  

Rural–urban female migrant workers living in factories are a special majority group in the city of Shenzhen, China. These female workers came from different provinces of mainland China. The health-related issues and quality of life (QOL) of this migrator have become serious public health and social problems, which have not been well characterized. This study aimed to explore the QOL and related factors of rural–urban female migrant workers living in factories in China.     

Addressing the health disadvantage of rural populations: How does epidemiological evidence inform rural health policies and research?

We reviewed evidence of any apparently significant 'rural-urban' health status differentials in developed countries, to determine whether such differentials are generic or nation-specific, and to explore the nature and policy implications of determinants underpinning rural-urban health variations. A comprehensive literature review of rural-urban health status differentials within Australia, New Zealand, Canada, the USA, the UK, and a variety of other western European nations was undertaken to understand the differences in life expectancy and cause-specific morbidity and mortality. While rural location plays a major role in determining the nature and level of access to and provision of health services, it does not always translate into health disadvantage. When controlling for major risk determinants, rurality per se does not necessarily lead to rural-urban disparities, but may exacerbate the effects of socio-economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions. Programs to improve rural health will be most effective when based on policies which target all risk determinants collectively contributing to poor rural health outcomes. Focusing solely on 'area-based' explanations and responses to rural health problems may divert attention from more fundamental social and structural processes operating in the broader context to the detriment of rural health policy formulation and remedial effort.     

Perceptions of practice among rural family physicians--is there a gender difference?

BACKGROUND: Women physicians are relatively less likely to practice in rural areas. The purpose of this study was to describe differences in perceptions of rural practice between male and female physicians currently in rural practice. METHODS: A questionnaire was developed from interviews with rural family physicians and mailed to 118 randomly selected board-certified family physicians in rural towns of the northwestern United States. RESULTS: Responses from 63 physicians were analyzed quantitatively and qualitatively. Female family physicians were more likely than their male counterparts to agree they had been attracted by the availability of part-time work and by opportunities for their personal partner. Compared with men, women were more likely to expect to earn less in rural than in urban practice. On open-ended questions analyzed using qualitative methods, women were more likely to report discouragement by professional isolation and by potential lack of privacy in rural areas. CONCLUSIONS: These responses suggest that during recruitment efforts rural communities might be able to attract more female physicians by offering flexible schedules, spouse or partner opportunities, role boundaries, and professional or personal support networks.     

The closure of rural hospitals in Saskatchewan: method or madness?

On April 14, 1993 the Minister of Health of the Province of Saskatchewan announced the closure of 52 of the 112 small hospitals using the criteria of: size, utilization for two consecutive years and distance to the nearest-neighbouring hospital. Amazingly, that government was re-elected. This study compared two models of reasons for hospital closure: the government criteria; and historical population, resource, and utilization factors, gathered for the year prior to closure and a decade earlier. Of the 112 small hospitals in Saskatchewan, the 10 hospitals in the frontier area were not included. Hospitals in the settled part of the province were divided into two distinct zones. The Northern zone, with 53 hospitals is characterized by rich dark soil and prosperous trade centres and the Southern zone, with 49 hospitals is characterized by light brown sandy soil and oil and gas exploration centres. Two discriminant models were developed. The government model consisted of size, two years of utilization and distance. The historical model consisted of population, resource, and utilization factors for the years 1981/1982 and 1991/1992. The dependent variable for both models was hospital status (open = 1 and closed = 0). The government model accurately predicted 91.18% of the closure decisions. The historical model had a classification accuracy of 95.10% for the whole of settled Saskatchewan, 96.23% for the Northern zone, and 95.92% for the Southern zone. The historical model was more accurate than the government model. Closing a hospital is a sad event. The manner in which the government closed nearly half of the small hospitals in Saskatchewan and gained re-election is an important account of responsible public policy. The historical model developed to examine this story takes public policy one step further in that it is possible for governments to recognize signals that indicate when communities should undertake orderly transitions in the operation of their health services facilities.     

Do the learning needs of rural and urban general practitioners differ?

INTRODUCTION: The challenges of rural general practice have given rise to a separate rural training stream and a separate rural professional body. The differences are characterised by the nature of the work undertaken by rural GPs and reflected in the continuing medical education topic choices made when surveyed. METHODS: In 2001 a survey was designed and distributed by the Royal Australian College of General Practitioners and Divisions of General Practice in South Australia and Northern Territory. The survey utilised a list of 104 topics. The topic choices of rural and urban GPs were compared. RESULTS: The survey was distributed to approximately 1762 GPs and yielded 578 responses (33%). Rural GPs were more likely to select the following topics: Anaesthetics, Aboriginal Torres Strait Islander health, Population Health, Renal medicine, Cardiology, Teaching skills, Obstetrics, Neonates, Arrhythmias, Fracture management, Tropical medicine and Therapeutics. Urban GPs were more likely to select Menopause, Travel medicine and Palliative care (P < 0.05). DISCUSSION: Many of the areas of difference reflected aspects of rural general practice. There were also many similarities in topic choices between these two groups.     

Health-related quality of life of “left-behind children”: a cross-sectional survey in rural China

Purpose  

To estimate the prevalence of children in rural China without constant parental guardians (i.e., “left-behind”), to examine whether left-behind children were associated with lower health-related quality of life (HRQOL) than their counterparts (“non-left-behind”) .     

Why does a rural background make medical students more likely to intend to work in rural areas and how consistent is the effect? A study of the rural background effect

Objective: Evidence indicates that medical graduates with a rural background are more likely to become rural doctors than those with an urban background (the rural background effect (RBE)). Exactly why this is so has rarely been studied. This study sought to identify the role of social, environmental and economic factors in addition to isolation characterising rural environments that either explain or modify the association between rural background and becoming a rural doctorrural practice intention. Design and setting: Secondary analysis of linked databases from the Medical Schools Outcomes Database (MSOD), Australian Bureau of Statistics and other government sources. Participants: Seven thousand four hundred twenty‐two commencing medical students who took part in the MSOD survey and for whom external data could be linked. Results: No social, environmental or economic factor studied or isolation significantly contributed to explaining the RBE, although there is some evidence that areas of more attractive climate strengthen the RBE. However, even when the RBE is at its weakest, it remains a strong, positive predictor of attraction to rural practice. Conclusion: Why the RBE occurs remains unexplained. Evidence was found of a reduced RBE under certain climatic conditions and personal circumstances, but further work is required to better understand why rural background is so strongly related with rural medical intention and practice.     

"Remnants of feudalism"? Women's health and their utilization of health services in rural China

Almost five decades ago, the Chinese Communist Party wished to abolish all "remnants of feudalism," including the patriarchal social order. Just one year after the revolution, the Marriage Law endorsed women's rights within the family, but no operative measures were taken to enforce it. Some of the economic reforms since independence even strengthened patrilocality and, possibly, patriarchal values. The purpose of this study was to explore the degree to which patrilocality served to maintain the traditional patriarchal stratification among women in the household by exploring women's health patterns and utilization of health services. Data were collected from 3859 women residing in rural Hebei, and variation in health and help seeking of six categories of relation to household head--mothers, wives, daughters, daughters-in-law, family heads, and other relatives--were explored. Utilization of health services is not dependent on women's position in the household, but primarily on per-capita income. Health patterns seem to indicate that mothers of the head of the household still have a considerable power to define their roles and share of household work. Women head of family, most of whom are married, appear to be under strain, which could be a result of their culturally "deviant" position. We conclude that old patriarchal values are intertwined with values of equality in current rural China.     

Are rural adolescents necessarily at risk of poorer obstetric and birth outcomes?

OBJECTIVE: The purpose of the present study were to describe the sociodemographic and clinical characteristics of adolescent women giving birth at Wagga Wagga Base Hospital, and compare these with those with all adolescents in New South Wales. DESIGN: An investigative approach. Main outcome measures: Obstetric complications, delivery intervention and adverse infant outcomes. SETTING: Wagga Wagga Base Hospital. Participants: One hundred and sixteen adolescents aged 15-19 years. RESULTS: In relation to obstetric complications and infants with complications, the study sample was found to be representative of New South Wales adolescents. However, for type of delivery there was a higher rate of forceps delivery (12.3% (15) vs 4.7% (415) P = 0.0001), forceps rotation (4.1% (5) vs 0.9% (80) P = 0.004) and fewer normal vaginal deliveries (67.2% (82) vs 80.8% (7108) P = 0.006) at Wagga Wagga Base Hospital. CONCLUSION: These findings suggest that rural adolescents are at risk of delivery complications and are less likely to have a normal vaginal delivery. More research is required into obstetric and birth outcomes for the rural adolescent population.     

The acceptability of yoghurt‐cereal mixtures to a rural community in Mexico

A dried yoghurt‐cereal mixture was produced with a final protein content of around 17 per cent, and an amino‐acid spectrum close to the FAO/WHO standard; lysine and threonine were the limiting values. Feeding trials with rats confirmed this slight deficiency, in that the mixture had a PER value of 2.3 (casein—2.5) and an NPU value of 61.2 compared with 62 for casein.

The acceptability of the product was tested by substituting the mixture for rice flour in a typical Mexican food, Atole. This gruel is widely consumed in rural communities, particularly by children, and the yoghurt‐based equivalent was readily drunk by mothers and children alike. Flavoured gruels, especially strawberry and vanilla, proved most popular. It was concluded that the production of yoghurt‐cereal flours could be a valuable method of preventing losses of liquid milk in rural areas, and that the material could form a useful dietary adjunct, especially for pre‐school children.     

‘HIV is an enemy of childbearers’: the construction of local epidemiology in rural Malawi

In the sub-Saharan African AIDS epidemic there is no shortage of formal messages about HIV distributed through health clinics, NGOs and the media. These messages, however, do not always address the issues that are of most importance for people living in the epidemic and learning how to navigate it safely. In rural Malawi, one message that has been absent concerns the implications of HIV for childbearing. Using data from in-depth interviews, this paper argues that rural Malawians socially constructed their own belief system and came to believe strongly that pregnancy and childbirth would negatively impact the disease progression of HIV-positive women. Through the recursive processes of selective observation, interpretation of formal public health messages and discussion within social networks, rural Malawians concluded that HIV and childbearing did not go together. In an uncertain world, social constructive processes such as these that are fluid and responsive to local circumstances are particularly important for making sense of the seemingly senseless and for developing tools to navigate unsettled times.     

Health‐related quality of life for rural American Indians in New Mexico

Objectives. To determine health‐related quality of life for rural American Indians using an economical telephone surveillance system.

Design. We interviewed 618 American Indians by telephone about health‐related quality of life using an adaptation of the Behavioral Risk Factor Surveillance System questionnaire.

Results. A smaller proportion of rural New Mexico American Indians (50.7%) reported their general health as ‘excellent’ or ‘very good’ compared to the overall New Mexico (58.2%) and US populations (57.9%). American Indians reported a mental health limitation more frequently than the New Mexico and the US populations. However, 13% fewer rural New Mexico American Indians reported a limitation in usual activities. Most limitations were due to musculoskeletal conditions or diabetes mellitus. Survey respondents were found to be representative of the rural American Indian population as reported by the 1990 US Census Bureau by tribal group affiliation and age, but were not representative by income, education, and gender.

Conclusions. Health‐related quality of life for rural American Indians differs little from that of other New Mexicans and the general US population; however, when physical and mental health was rated as poor, fewer American Indians reported a limitation in usual activities. A telephone survey focusing on New Mexico American Indians is an efficient method by which to conduct surveillance of health‐related quality of life.