bluuebunny/crossref_metadata_2025 huggingface dataset:
Boundary Maintenance as a Barrier to Mental Health Help‐seeking for Depression Among the Old Order Amish
Authors: Reiling Denise M.
Published: April 2008

This paper describes “boundary maintenance” as a barrier to help‐seeking for depression within an Old Order Amish enclave. Observations and qualitative interview data were collected from 50 members of the Old Order Amish enclave and from the 8 mental health providers in their rural community. The Amish reported fairly high levels of depression, concomitantly high levels of reluctance to seek treatment for depression from mental health providers, and very low levels of service utilization. The functionality of boundary maintenance to group cohesion was discovered to be a significant barrier to help‐seeking for depression from outside providers. Boundary maintenance was achieved through two social control mechanisms: religious‐based stigmatization of depression and the construction of mental health providers as illegitimate help agents. Suggestions have been made to assist providers in achieving cultural competence among the Amish, in order to reduce the threat that the Amish perceive to their cultural boundaries.
Hispanic Farmworker Interpretations of Green Tobacco Sickness
Authors: Rm Painela , Quandt Sara A. , A.Arcury Thomas
Published: April 2008

This paper describes the explanatory model of green tobacco sickness (GTS) held by migrant and seasonal farmworkers in North Carolina and compares it with a research‐based biobehauioral model. GTS is a form of acute nicotine poisoning that affects individuals who work in wet tobacco fields. It is characterized by nausea, voimting, headache, and dizziness. There are no standard diagnostic criteria for GTS; clinicians must diagnose it based on a combination of symptoms and exposure risk. GTS resembles pesticide poisoning, but treatment is quite different. Many farrnworkers in tobacco today are Spanish‐speaking immigrants from Mexico with limited experience in tobacco work. In‐depth interviews about GTS were conducted with 23 Hispanic farmworkers in central North Carolina to explore their understanding of the problem. Workers generally attributed the symptoms to other aspects of working in tobacco, suck as pesticides or heat, rather than nicotine. They cited many of the same risk factors identified in the biobehavioral model, such as wt work conditions and inexperience with tobacco work. Prevention and treatment include a combination of exposure midance and common medications. The symptoms of most importance to farmworkers wre insomnia and anorexia, both of which impaired the ability to work. This jeopardized their inconze, as well as their work security. lf health care providers understand the explanatory model held by farmworkers, they will be more effective at diagnosing and treating GTS and be better prepared to teach patients how to prevent future episodes.
Colorectal Cancer Incidence and Mortality in Texas 1990–1992: A Comparison of Rural Classifications
Authors: Hawley Sarah Tropman , Chang Shine , Risser David , Zhang Qing
Published: April 2008

Although cancer incidence and mortality rates are known to be higher in urban populations, more unstaged tumors and later staged cancer are diagnosed in rural populations. Most investigators have used a dichotomous definition of urban and rural in studying these populations, and they have not considered whether a more detailed categorization of rural areas could influence their findings. The objective of this study was to evaluate colorectal cancer incidence and mortality rates in Texas from 1990 to 1992 by using a dichotomous definition (Metropolitan Area vs. Nonmetropolitan Area [MA/non‐MA]) and two, more detailed rural classifications (the Rural‐Urban Continuum Code [RUCC] and the Urban Influence Code [UICI). Cancer data were obtained from the Texas Cancer Registry for 1990 to 1992 and supplemented with data from the Texas State Department of Vital Statistics (mortality), the U.S. Census Bureau (age, gender, race) and the Area Resource File (rural and urban definitions). Incidence and mortality rates, age‐adjusted to the 1970 U.S. standard population, were calculated for non‐Hispanic White, African American, and Hispanic males and females. Results revealed a nonlinear relationship between rural category and colorectal cancer incidence or mortality for all races. Applying the MA definition yielded rates in the middle of the ranges obtained with using RUCC or UIC classifications and most closely reflected the result for non‐Hispanic Whites using the more detailed scales. Our results suggest that a dichotomous definition of rural and urban may mask important variation in colorectal cancer incidence and mortality rates within rural areas.
Rural Health Research and Rural Health in the 21st Century: The Future of Rural Health and the Future of Rural Health Services Research
Authors: Ricketts Thomas C.
Published: April 2008

Rural health research is a unique field. It is neither a nested subcategory under general health services research nor a separate field of policy analysis or advocacy. Rural health research faces three potential crises: of content, of applicability, and of credibility. The content of the field is driven often by funds, its applicability is thus limited by its purview as well as its special constituency, and its credibility is challenged by its findings, sometimes contrary to accepted positions in the larger health services field. Rural health research can strength its position by accepting the paradoxes it presents, especially the paradox of continuing disparity in the face of substantial investment to eliminate differences, and by seeking to answer why this occurs across the rural‐urban spectrum. Rural health research can answer questions about why the distribution of resources is unfair without depending solely on pure definitions of rural.
Rural Public Health: Policy and Research Opportunities
Authors: Berkowitz Bobbie , Ivory Janet , Morris Tom
Published: April 2008

Changes in the health care system, medicine, and technology as well as in the characteristics of rural communities raise issues that impact the responsiveness of the rural public health system to emerging threats to health. These issues, which are systemic in nature and primarily involve the infrastructure of public health, include the capacity of rural public health to manage population health, utilize information technology, monitor performance of the essential public health functions, develop leadership and the public health workforce, and promote the interaction and integration of public health and health care. This article provides an overview of policy and research implications, and it suggests that each of these issues contributes to the capacity of public health to effectively improve the outcomes of health in rural communities.
Rural Health Care Providers in the United States
Authors: Hart L. Gary , Salsberg Edward , Phillips Debra M. , Lishner Denise M.
Published: April 2008

One of the most recalcitrant problems of the rural health landscape is the uneven distribution and relative shortage of medical care providers. Despite considerable efforts by federal and state governments over the past three decades to address these problems, rural provider distribution and shortage issues have persisted. The purpose of this article is to identify the challenges for rural health research and policy regarding health provider supply in the first decade of the 21st century. While the emphasis in this article is on physicians, workforce concerns pertaining to nurses, nurse practitioners, and physician assistants are briefly described. Physician supply, geographic and specialty distribution, age, gender, quality of care, recruitment and retention, training, productivity and income, reimbursement aid managed care, federal and state ameliorative programs, safety net, and telehealth are discussed. Also highlighted are issues concerning rural health care workforce research, methods, and data as well as a series of policy‐relevant questions. Solutions to rural health personnel problems can only be successfully addressed through multifaceted approaches. No vision of the future of rural health can come to fruition if it does not promote stable, rewarding, and fulfilling professional and personal lives for rural health care providers.
Public Health Protecting Rural Communities From Terrorism: A Statewide, Community‐based Model
Authors: Clawson Art , Brooks Robert C.
Published: April 2008

Abstract: Given the number of Americans who live in rural areas and the unique challenges they face in the provision of health care services, special attention to planning for and responding to terrorist acts is warranted. After September 11, 2001, Florida developed a statewide, community‐based model that applies the public health principles of assessment, policy development, and assurance. This model can serve as a possible framework for other states and communities.
Brief Report Evaluation of a Childhood Lead Questionnaire in Predicting Elevated Blood Lead Levels in a Rural Community
Authors: Muñiz Marco A. , Dundas Robert , Mahoney Martin C.
Published: April 2008

Abstract: The accuracy of a lead screening questionnaire in predicting elevated blood lead levels was examined in a pediatric practice in a rural part of New York state. A retrospective chart review was used to collect data on children ages 9 to 24 months who presented for well‐child visits. Children with both questionnaire and lead level results available in the chart were included in the study (n = 171). The mean blood lead level among all children was 1.6 μg/dl (median = 2.0 μg/dl, range 0 to 24 μg/dl). Four children (2.3%) had elevated lead levels (greater than 10 μg/dl), with levels for two of these children being greater than 20 μg/dl. Although our lead screening questionnaire was expanded from the standard 1991 CDC questionnaire by the inclusion of six additional items, it was not especially useful in predicting elevated blood lead levels above 10 μg/dl. However, the questionnaire exhibited some utility in predicting marked elevations in blood lead levels (over 20 μg/dl). Although results in other geographic areas might differ, the lead questionnaire may have value by enhancing parents' awareness of potential lead hazards in their children's environment and may prove to be more useful in areas of high risk to lead exposure.
AHEC in West Virginia: A Case Study
Authors: Nottingham Lamont D. , Lewis Michael J.
Published: April 2008

Abstract: This case study describes the area health education centers (AHEC) program in West Virginia, spanning 30 years from a first‐generation project at Charleston in 1972 (AHEC 1) to a newly funded statewide program (AHEC 2). The outcome is an evolving universitycommunity partnership designed to meet changing workforce and community health needs in the heart of rural Appalachia. West Virginia University's (WVU's) application of the original Carnegie Commission AHEC recommendations (1970) resulted in the Charleston AHEC, now part of the Robert C. Byrd Health Sciences Center of WVU. AHEC today trains more than 135 residents and interns, and one‐third of the third‐year and fourth‐year WVU medical students. Charleston offers clinical and continuing education for nurses, dentists, pharmacists, and allied health professionals. A health sciences library, distance learning, and a neiwork of primary care clinics help define Charleston's unique AHEC role. This AHEC hub continues to meet the classic Carnegie goals of recruiting and retaining health professionals, and providing access to care in the original service area and statewide. Based on the Charleston experience, four new federally funded AHECs are being developed to link rural primary care residencies with the state‐funded West Virginia rural health education partnerships. These rural consortia AHECs are applying the concept of community competency, a performance‐based methodology, to integrate learning while achieving the goals of Healthy People 2010.
A Cohort Study of Family Practice Residency Graduates in a Predominantly Rural State: Initial Practice Site Selection and Trajectories of Practice Movement
Authors: Frisch Larry , Kellerman Rick , Ast Terry
Published: April 2008

Abstract: Limited information is available on long‐term patterns of practice location choice among family physicians, although these patterns will significantly affect the quantity, quality, and continuity of health care provided in rural areas. From 1992 through 2000, five biennial surveys were administered to graduates of three family practice residency programs. Graduates were asked the location of their current and previous practice site locations, specific practice information, and global satisfaction with family practice. Identifiable practice sites were assigned a U. S. Department of Agriculture rural‐urban continuum code based on the county in which the practice was located. The use of ruralurban continuum codes as a measure of rurality was believed to be particularly applicable to the small rural and frontier counties typical of the Great Plains region. For purposes of this study, practice locations were considered rural if they were in rural‐urban continuum codes 7, 8, or 9. Of 593 graduates, 514 (87%) returned at least one questionnaire. Overall, about one‐third of graduates had chosen their first practice sites in counties with rural‐urban continuum codes of 7, 8, or 9. While most graduates remained in their initial practice site, almost half moved at least once. Those who left nonmetropolitan practices tended to move to less rural locations, though a few moved against this gradient. Moves away from the initial practice site occurred after a median of 3 years, and the likelihood of a first move decreased rapidly 5 to 6 years after graduation. Much remains to be learned about decisions to enter or leave practice in rural‐urban continuum code 7, 8, and 9 counties.
Rural Nonphysician Providers' Perspectives on Palliative Care Services in Northwestern Ontario, Canada
Authors: Kelley Mary Lou , Sellick Scott , Linkewich Barb
Published: April 2008

Abstract: Most palliative care in rural remote areas is provided by nonphysicians. This paper reports a survey of interdisciplinary rural health service providers (not including physicians) to identify the strengths and weaknesses in palliative care service delivery in a rural and remote region in northwestern Ontario, Canada. Questionnaires were sent to 156 nurses, homemakers, social workers, and pastoral care workers who care for terminally ill persons and their families, and 122 were completed and returned (response rate 78%). Consistent with practice in most rural areas, 90% of respondents were generalists. Respondents identified several problems with palliative care services, including inadequate training for caregivers, inadequate support services for family and professional caregivers, inadequate human resources, and lack of organized volunteer programs. Suggestions for improvements included better education for service providers; better availability of palliative care services; more counseling and support services for patients, family members, and professionals; and greater availability of respite beds. Overall, respondents rated clients' needs as being better met than their own. The most frequently reported problems for care providers were related to the lack of supports for care provision.
Veterans' System‐of‐care Preferences for Percutaneous Transluminal Coronary Angioplasty in a Rural Setting
Authors: Weeks William B. , O'Rourke Daniel J. , Ryder Lisa B. , Straw Michelle M.
Published: April 2008

Abstract: Context: In the Veterans Health Administration (VHA), regionalization of high‐technology health care services may influence veterans who live far from referral centers to obtain care locally, through the private sector. Purpose: To understand veterans' system‐of‐care preferences for a high‐technology regionalized service. Methods: The charts of 142 veterans who were referred for percutaneous transluminal coronay angioplasty PTCA) by their VHA cardiologists were reviewed. Findings: Fifty two percent of these veterans obtained the procedure outside the VHA system. Insurance coverage and out‐of‐pocket costs were strongly associated with veterans' obtaining PTCA outside of the VHA system; travel distance was not. Conclusions: As the VHA begins to understand veterans' use of multiple systems of care, it will be important to understand the relationship between out‐of‐pocket costs and the system of care used for high‐technology health care services.
The Role of Federally Funded Health Centers in Serving the Rural Population
Authors: Regan Jerrilynn , Schempf Ashley H. , Yoon Jean , Politzer Robert M.
Published: April 2008

Abstract: Context: Federally funded health centers attempt to improve rural health by reducing and eliminating access barriers to primary care services. Purpose: This study compares rural health center patients with people in the general rural population for indicators of access to preventive services and health outcomes. Methods: Data from the annual reporting system for federally funded health centers, the 1999 Uniform Data System, and published national census data were used to provide sociodemographic comparisons. Selected health status indicators, preventive services utilization, and health outcomes were obtained from a survey of health center patients, and the results were compared with the National Health Interview Survey and National Vital Statistics. Findings: Unlike the nation's rural population, the majority of rural health center patients are of minority race/ethnicity, live at or below poverty, and are either uninsured or on Medicaid. Despite having higher prevalence of traditional access barriers than the general rural population, rural health center patients are significantly more likely to receive certain preventive services and also to experience lower rates of low birthweight, particularly for African American infants. However, rural health center patients are not more likely to have received influenza vaccination or up‐to‐date mammogram screening. Conclusions: Health centers provide access to essential preventive care for many of the most vulnerable rural residents. A national strategy to expand the rural health center network will likely help to ensure improved health for the considerable proportion of rural residents who still lack access to appropriate services.
Impact of Conversion to Critical Access Hospital Status for Oklahoma's Rural Hospitals
Authors: Lawler Mary K. , Doeksen Gerald A. , Schott Val
Published: April 2008

Abstract: Context: The Medicare Rural Hospital Flexibility Grant Program established a new hospital category, the Critical Access Hospital, designed to provide financial stability to small rural hospitals that were losing money after changes in the Prospective Payment System implemented by Medicare. Purpose: This article describes the impact of conversion to Critical Access Hospital (CAH) status for 15 small rural hospitals in Oklahoma. Objectives of the study were to identify how conversion to CAH affected hospital utilization and finances for the first year after conversion. Methods: A telephone survey was used to collect information from hospital administrators. Fifteen of 16 eligible hospitals participated in the study. Findings: In general, services and patient census declined slightly with conversion to CAH. All 15 hospitals had reported losses prior to conversion, totaling $6 985 033. Ten hospitals reported losses after conversion. After converting to CAH status, the hospitals reported total losses of $3 094 547. The hospitals had a net change of $4 293 040 Conclusions: Most of the 15 study hospitals greatly improved their financial situation in the first year after conversion to CAH status, but in aggregate still operated at a loss.
Calculating Multirace Categories and Race‐specific Rates: A Cautionary Note to Rural Health Researchers and Analysts
Authors: Hodgson Todd W. , Farmer Frank L.
Published: April 2008

Abstract: Context: Revised federal standards for racial and ethnic data have resulted in 57 new self‐selected multirace categories that cannot be directly compared with traditional “one‐race‐only” categories. “Bridge methods” are available, but each produces different estimates of single‐race populations, raising concern about the potential influence on calculated rates for rural and nonmetropolitan areas. Purpose: to examine the potential impact of several bridge methods when calculating race‐specific mortality rates. Methods: Population and mortality data were collected for 75 counties in Arkansas, and race‐specific mortality rates were calculated using 3 deterministic bridging methods: (1) Equal Fractions, (2) Largest Group, and (3) Largest Group Other Than White. The mortality rates were compared at the state and metropolitan/nonmetropolitan levels, as well as for 4 rural substate regions. Findings: Variable rates were obtained from different methods. Estimated mortality rates for the largest single‐race groups, White and Black, varied only slightly by method at the state and nonmetropolitanl metropolitan levels. The rural substate regions with the smallest Black populations showed the greatest variation between method‐estimated rates for Blacks. Conclusions: The results suggest that the smallest minority race categories are exceedingly susceptible to the impact of bridge method selection, especially in nonmetropolitan substate regions.
Characteristics of Rural Elderly People Who Bypass Local Pharmacies
Authors: Xu K. Tom , Borders Tyrone F.
Published: April 2008

Abstract:Context:The bypassing of local pharmacies by consumers is an indicator of limited accessibility and, possibly, compromised quality of rural pharmacy services.Purpose:The objective of this study was to identify the characterisitcs of rural consumers who bypassed local pharmacies for their medication needs.Methods:The sample was derived from the Texas Tech 5000, a longitudinal survey in West Texas, and pharmacy data from the Texas State Board of Pharmacy. The sample included 1062 people aged 65 or older who lived in rural counties and had at least one community pharmacy in town. Bivariate and multivariate analyses were performed to investigate the demographic, financial, nonfinancial, prescription and over‐the‐counter drug use, and health characteristics that were associated with the probabilities of the subjects' using local community pharmacies, nonlocal community pharmacies, and amil‐order pharmacies.Findings:In the sample, 70.8%, 13.7%, and 15.5% of elderly people primarily used local pharmacies, nonlocal pharmacies, and mail‐order pharmacies, respectively. The oldest subjects, women subjects, subjects with no employer‐provided or other fedral insurance, subjects who had a regular doctor, and subjects living within city limits and in areas with a higher density of community pharmacies had lower probabilities of chooosing nonlocal pharmacies over local pharmacies. Insurance covarage for prescriptions was one of the most important determinants in choosing mail‐order pharmacies over local community pharmacies.Conclusions:Additional research is warranted to furhter understand the choices made by older people, as well as by younger people who use medications. In particular, further investigation of the potential differences between services provided by rural‐community, urbancommunity, and mail‐order pharmacies is needed to identify other reasons for bypassing local pharmacies.
The Experience of Native Peer Facilitators in the Campaign Against Type 2 Diabetes
Authors: Struthers Roxanne , Hodge Felicia Schanche , Cora Lorelei De , Geishirt‐Cantrell Betty
Published: April 2008

Abstract:Context:The use of peer facilitators in health programs has great potential. One important application is prevention and control of type 2 diabetes among American Indians.Purpose:To explore the experience of American Indian facilitators in a culturally appropriate intervention (Talking Circles) on 2 Northern Plains reservations. The Talking Circles offered a forum for educational dialogue on diabetes risk factors and the management of type 2 diabetes.Methods:Phenomenology, a qualitative research approach, was used to answer the research question: “What did Native Talking Circle facilitators experience?” Participants were 4 lay health workers from the intervention reservations who had been trained to present a diabetes curriculum while coordinating and guiding the group discussion. During open‐ended, taped interviews, the facilitators shared their experiences conducting the Talking Circles. Analysis categorized the experiences into common themes to explain the phenomena and cultural construction of oral discussions (Talking Circles) of diabetes.Findings:Themes included the concept of “a calling” to do the work, which included a self‐growth process, a blending of 2 worldviews as a diabetes intervention strategy, the importance of translating educational materials in a liaison role, and commitment to tribal people and communities.Conclusions:The experience of the facilitators was positive because they were knowledgeable about American Indian culture and worldview and were trained in both Talking Circle facilitation and type 2 diabetes.
Understanding Rural Hospital Bypass Behavior
Authors: Radcliff Tiffany A. , Brasure Michelle , Moscovice Ira S. , Stensland Jeffrey T.
Published: April 2008

Abstract: Context: Though many rural hospitals offer a broad array of services, local residents may choose more distant facilities for inpatient care services. Depending on the extent of the bypass phenomenon, hospitals may experience financial distress, reduced service offerings, or closure

Purpose:This study provides a descriptive analysis of rural hospital bypass behavior in 7 states. Methods: We examine hospital discharge data for calendar years 1991 and 1996 to determine the extent to which patients admitted from rural areas are bypassing local facilities. We also assess whether there are trends in bypass patterns over time. Our primary specification of bypass is defined as a discharge from a hospital between 15 and 1000 miles from the closest facility.

Findings: We found an overall bypass rate of 30%. This overall rate changed little between 1991 and 1996. Subgroups of patients, defined by payer and diagnosis, had differing propensities to bypass local rural facilities. Patients with managed care or commercial insurance had higher bypass rates compared to patients who relied on other payer sources. Medicare and uninsured (self‐pay) patients had lower bypass rates. Payer type differences persisted when cases were divided into emergent and scheduled categories. Patients seeking general medical or obstetrical care had lower bypass rates than patients discharged with a diagnosis related group (DRG) related to complex medical, general surgery, or specialty sergery services. With the exception of normal delivery, DRG codes frequently associated with bypass discharges involved procedures or surgery that may not be offered by smaller rural facilities

Conclusions:Our results indicate that rural patients, or their admitting physicians, perceive local rural hospitals as a viable option for many inpatient care services but prefer other facilities for treatments beyond the scope of general medical or surgical treatment
Rural Demographics Racial/Ethnic Diversification in Metropolitan and Nonmetropolitan Population Change in the United States: Implications for Health Care Provision in Rural America
Authors: Murdock Steve H. , Hoque Md. Nazrul , Johnson Kenneth , McGehee Mary A.
Published: April 2008

Abstract: The diversification of the rural population of the United States provides substantial challenges to the current and to future health care systems in rural areas. Because of a variety of historical, discriminatory, and other factors, minority populations have had lower levels of access to health care in rural as well as urban areas and higher rates of both mortality and morbidity than nonminority populations. Although minority health issues have often been seen as primarily urban issues, this article demonstrates that minority population growth has become a major component of total population growth in rural areas in the past several decades (accounting for nearly 62% of the net growth in the nonmetropolitan population of the United States in the 1980s and for nearly 42% in the 1990s), that future US population growth is likely to be largely a product of minority population growth (nearly 89% of US net population growth from 2000 to 2100 is projected to be due to minority population growth), and that the incidence of diseases and disorders in the US population will come to increasingly involve minority populations (by 2050 roughly 43% of all disease/disorder incidences would involve minority population members). The growth of younger minority populations with disproportionately impoverished socioeconomic characteristics will pose challenges for rural areas and health care systems, which also are likely to face health issues created by disproportionately older populations
Brief Report: Quality Improvement in Critical Access Hospitals: Addressing Immunizations Prior to Discharge
Authors: Ellerbeck Edward F. , Totten Bonnie , Markello Samuel , Patterson Kelly , Sipe Thomas R. , Tilden Chris
Published: April 2008

Abstract: Context: Many patients hospitalized in critical access hospitals (CAHs) are at high risk for influenza and pneumonia. These hospitalizations may represent a missed opportunity to address immunizations. Addressing these missed immunizations could provide an opportunity for CAHs to gain practical experience in data‐driven quality improvement. Purpose: To improve documentation and delivery of influenza and pneumococcal immunizations prior to hospital discharge and provide CAHs with quality improvement experience. Methods: We recruited 17 CAHs in Kansas to participate in a rapidcycle quality improvement project to address inpatient immunizations. Each hospital identified patient discharges on a monthly basis and abstracted medical records to see if the patient's immunization status had been assessed and if patients had been vaccinated prior to discharge. Findings: Documentation of influenza immunization status improved from 17% of admissions at baseline to 62% at follow‐up (P<0.001). Documentation of pneumococcal immunization status increased from 36% at baseline to 51% at follow‐up (P<0.001). Documentation of immunizations was significantly higher among the 8 hospitals that developed standard charting forms for recording immunization status (P<0.01). Despite improved documentation of immunization status, at remeasurement only 3.4% received an influenza vaccination and 1.3% received a pneumococcal vaccination prior to discharge. Conclusions: Critical access hospitals can effectively participate in quality improvement activities, but increased involvement of medical staff or standing immunization orders may be needed to improve actual vaccine administration prior to discharge.
“Bottoming Out?” Among Rural African American Women Who Use Cocaine
Authors: Brown Emma J. , Trujillo Teresa Henehan
Published: April 2008

Abstract: Context: Studies have explored the spiraling‐down effect of losing individual, familial, and social resources among African Americans who use drugs, but there is a gap in knowledge about this “bottoming‐out” phenomenon among rural African American women. Purpose: The study was conducted to better understand the phenomenon of bottoming out among rural African American women who use cocaine. Methods: Using an ethnographic approach, researchers drew on multiple qualitative and quantitative data collection methods. Data derived from qualitative interviews, field notes, and demographic profiles describe the phenomenon or lack thereof of bottoming out among 25 southeastern rural African American women who use cocaine. Data collection took place in a rural county of north Florida with a population between 11 000 and 15 000. Twenty‐five African American females 18 years or older who used either powder or crack cocaine at the time of enrollment and resided in the rural county participated in the study. Findings: Respondents used 6 major strategies that delayed or prevented them from bottoming out: (1) taking advantage of their social environment and community ties, (2) utilizing various sources of income, (3) accessing family resources, (4) maintaining some degree of discipline over spending for drugs, (5) maintaining routine drug use locations, and (6) renting cheap housing and/or house pooling. Conclusion: Unlike studies of similar populations in urban settings, most respondents continued to work after numerous years of drug use, tended not to lose legal custody of their children, maintained a support system of nonusers as well as users over time, and secured food, clothing, and shelter for themselves and in many instances their children using legal or illegal means
A Method for Identifying Places in Rural America at Risk of Not Being Able to Support Adequate Health Services
Authors: Mueller Keith J. , Stoner Julie A. , Shambaugh‐Miller Michael D. , Lucas Woodrow O. , Pol Louis G.
Published: April 2008

Abstract: Context: Public policymakers and their advisers struggle with the problem of specifying criteria by which health care providers in rural areas are eligible for special consideration in payment policies and for special grant programs. A means of designating places can provide a basis for assistance and can help target public resources for any providers who deliver services in those places. Purpose: This paper provides the details underlying a place‐based approach to identifying rural areas that are at risk for not being able to provide requisite health services. Methods: A population size criterion is utilized first to eliminate metropolitan areas and other large agglomerations from consideration. Any territory not included in a place of 3500 or more people, including a 25‐mile buffer around that place, is a priori considered to be at risk. All places, including buffers, that have populations between 3500 and 100 000 are further analyzed using population compositional data and principal components analysis. Findings: In 10 states and 24 bordering states selected for developing and testing the method, there were 1907 block groups outside the boundaries of any place with a population of at least 3500. In addition, the analysis suggested that 66 out of 236 places and buffers with populations between 3500 and 100 000 also should be classified as vulnerable. Conclusions: The results are discussed in regard to how a place‐based approach can advance the study of rural health needs. By focusing on the needs of the people residing in a defined area, as determined from the aggregate characteristics of the population, a model is generated that can be used to predict special circumstances confronting any service provider. The public policy implications of the findings are also considered. Special payment policies could be written on the basis of place instead of provider characteristics, and grant programs providing technical assistance could be targeted to places of greatest need
The Rural Physician Workforce in Florida: A Survey of US‐ and Foreign‐Born Primary Care Physicians
Authors: Brooks Robert G. , Mardon Russell , Clawson Art
Published: April 2008

Abstract: Context: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. Purpose: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. Methods: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. Findings: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign‐born and trained, a National Health Service Corps member, or a J‐1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign‐born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. Conclusions: Recruiting and retaining doctors in rural areas can be best supported through a mission‐driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J‐1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.
Emergency Medical Services in Rural Areas: The Supporting Role of State EMS Agencies
Authors: Knott Astrid
Published: April 2008

Abstract: Context: EMS is an integral part of health care and is especially important in less densely populated areas. What is known about EMS in rural areas is limited because of fragmentation in the system and rudimentary data collection efforts. Purpose: The goal of this study is to identify important issues faced by rural EMS systems and describe the support of rural EMS providers by state EMS agencies. Methods: A telephone survey of state EMS directors (response rate 95.7%) asked questions regarding issues in medical direction, programs, and initiatives by state EMS agencies that target rural and volunteer EMS providers, integration initiatives, and anticipated effects of the new Medicare fee schedule. Findings: Medical direction in rural EMS was identified as a major issue for a majority of states. Integration in EMS is seen as a possible solution but does not occur very commonly. The survey found substantial variation in the state approach to EMS issues. Less than a third of the states in the study have a statewide EMS plan. State EMS agencies address rural EMS provider needs in a limited manner. EMS state agencies focus on regulation and funding of EMS providers, with only approximately a third providing technical assistance to EMS providers. Conclusions: The range in approaches to EMS issues at the state level will need to be taken into account in formulating national EMS policy. The limited provision of technical assistance leaves a void that may be addressed by other agencies and organizations in some states. In the absence of major federal funding initiatives, the development of EMS has become a state and local issue. A new national initiative may help address EMS issues and stimulate the development of EMS as a system beyond its current fragmented state.
Promoting Pneumococcal Immunizations Among Rural Medicare Beneficiaries Using Multiple Strategies
Authors: Johnson Elizabeth A. , Harwell Todd S. , Donahue Peg M. , Weisner M'liss A. , Mclnerney Michael J. , Holzman Greg S. , Helgerson Steven D.
Published: April 2008

Abstract: Context: Vaccine‐preventable diseases among adults are major contributing causes of morbidity and mortality in the United States. However, adult immunizations continue to be underutilized in both urban and rural areas. Purpose: To evaluate the effectiveness of a community‐wide education campaign and mailed reminders promoting pneumococcal immunizations to rural Medicare beneficiaries. Methods: We implemented a community‐wide education campaign, and mailed reminders were sent to Medicare beneficiaries in 1 media market in Montana to increase pneumococcal immunizations. In a second distinct media market, mailed reminders only were sent to beneficiaries. Findings: The proportion of respondents aged 65 years and older aware of pneumococcal immunizations increased significantly from baseline to follow‐up among respondents both in the education‐plus‐reminder (63% to 78%, P = 0.04) and the reminder‐only (64% to 74%, P = 0.05) markets. Overall from 1998 to 1999, there was a 3.7‐percentage‐point increase in pneumococcal immunization claims for Medicare beneficiaries in the education‐plus‐reminder market and a 1.5‐percentage‐point increase in the reminder‐only market. Medicare beneficiaries sent reminders in the education‐plus‐reminder market compared to those in the reminder‐only market were more likely to have a claim for pneumococcal immunization in 1999 (odds ratio 1.18, 95% confidence interval 1.08 to 1.28). The results suggest that these quality improvement strategies (community education plus reminders and reminders alone) modestly increased pneumococcal immunization awareness and pneumococcal immunization among rural adults. Mailed reminder exposure was associated with an increased prevalence of pneumococcal immunizations between 1998 and 1999 and was augmented somewhat by the education campaign.
Transforming the Delivery of Rural Health Care in Georgia: State Partnership Strategy for Developing Rural Health Networks
Authors: Minyard Karen J. , Lineberry Isiah C. , Smith Tina Anderson , Byrd‐Roubides Tracy
Published: April 2008

Abstract: Since 1996, 19 networks covering 74 of the 117 rural counties in Georgia have emerged. This grassroots transformation of rural health care occurred through a series of partnerships launched by state government officials. These partnerships brought together national and state organizations to pool resources for investment in an evolving long‐term strategy to develop rural health care networks. The strategy leveraged resources from partners, resulting in greater impact. Change was triggered and accelerated using an intensive, flexible technical assistance effort amplified by developmental grants to communities. These grants were made available for structural and organizational change in the community that would eventually lead to improved access and health status. Georgia's strategy for developing rural health networks consisted of 3 elements: a clear state vision and mission; investment partnerships; and proactive, flexible technical assistance. Retrospectively, it seems that the transformation occurred as a result of 5 phases of investment by state government and its partners. The first 2 phases involved data gathering as well as the provision of technical assistance to individual communities. The next 3 phases moved network development to a larger scale by working with multiple counties to create regional networks. The 5 phases represent increasing knowledge about and commitment to the vision of access to care and improved health status for rural populations
Anti‐O6‐Methylguanine‐Methyltransferase (MGMT) Immunohistochemistry in Glioblastoma Multiforme: Observer Variability and Lack of Association with Patient Survival Impede Its Use as Clinical Biomarker*
Authors: Preusser Matthias , Charles Janzer Robert , Felsberg Jörg , Reifenberger Guido , Hamou Marie‐France , Diserens Annie‐Claire , Stupp Roger , Gorlia Thierry , Marosi Christine , Heinzl Harald , Hainfellner Johannes A , Hegi Monika
Published: April 2008

Silencing of O6‐methylguanine‐DNA methyltransferase (MGMT) protein expression because of MGMT gene promoter hypermethylation is considered to be associated with postoperative chemoradiotherapy benefits in glioblastoma multiforme (GBM) patients. The objective of this study was to clarify the usability of MGMT immunohistochemistry (IHC) as a clinical biomarker.

We immunostained a tissue microarray containing biopsy samples of 164 GBM patients from the European Organization for Research and Treatment of Cancer and the National Cancer Institute of Canada (EORTC/NCIC) trial 26981/22981 using two commercial anti‐MGMT antibodies (clones MT3.1 and MT23.2). Immunostaining results were semiquantitatively evaluated by four observers from three neuropathological laboratories using a predefined algorithm. We analyzed (i) inter‐ and intraobserver agreement on MGMT expression (kappa statistics); (ii) correlation of MGMT expression with MGMT promoter methylation status (kappa statistics); and (iii) correlation of MGMT expression with patient outcome (log‐rank test). Interobserver agreement on MGMT expression varied from slight to almost perfect, whereas intraobserver agreement ranged from substantial to almost perfect. MGMT expression showed poor to moderate correlation with MGMT promoter methylation status. We found no significant association of MGMT expression with patient outcome. In our hands, observer variability as well as lack of association with the MGMT promoter methylation status and patient survival impeded the use of anti‐MGMT immunohistochemistry as a clinical biomarker for routine diagnostic purposes.
Pressure Buildup Mechanism in a Textured Inlet of a Hydrodynamic Contact
Authors: Cupillard Samuel , Cervantes Michel J. , Glavatskih Sergei
Published: April 2008

A flow analysis is carried out for an inclined slider bearing with the aim of showing the governing mechanism at conditions where an optimum in load carrying capacity is achieved. The effects of surface texture on pressure buildup and load carrying capacity are explained for a textured slider bearing geometry. Numerical simulations are performed for laminar, steady, and isothermal flows. The energy transferred to the fluid from the moving wall is converted into pressure in the initial part of the converging contact and into losses in the second part. The convergence ratio can be increased, in order to get the greatest pressure gradient, until the limiting value where flow recirculation begins to occur. The texture appears to achieve its maximum efficiency when its depth is such that the velocity profile is stretched at its maximum extent without incurring incoming recirculating flow. The wall profile shape controlling the velocity profile can be optimized for many hydrodynamic contacts.
Free Surface Thin Layer Flow on Bearing Raceways
Authors: van Zoelen M. T. , Venner C. H. , Lugt P. M.
Published: April 2008

In this paper, the effects of rotation on the distribution of a layer of oil on a bearing raceway are analyzed in relation to the geometry of the raceway. The research is motivated by the need to understand the behavior of grease lubricated bearings. Some specific aspects of grease lubrication can be understood by approximating the contact as a starved lubricated elastohydrodynamic lubrication contact. In such a contact, the shape and thickness of the inlet layer of oil, supplied to the contact on the running track, are of crucial importance to the film formation and contact performance. Small changes in the distribution of lubricant on the rolling track, as a result of reflow or redistribution, may have a large (local) effect on the film thickness inside the contact. Starting from the Navier–Stokes equations, the free surface thin layer flow equation for axisymmetric rotating surfaces is derived. For the case of bearing applications, it is shown that a simple quasilinear equation can be derived for the layer thickness, as a function of location and time, which can be solved analytically. Experiments have been carried out, measuring the changes of a layer of oil on rotating raceways in time in relation to the rotational speed and the raceway geometry. It is shown that the simplified model accurately predicts the thin layer flow, except in a region near the outflow boundary, where the effect of the boundary condition on the layer shape is crucial. This is further illustrated by results of numerical simulations.