bluuebunny/crossref_metadata_2025 huggingface dataset:
Agricultural Work Safety Efforts by Wisconsin Extension Agricultural Agents
Authors: Chapman Larry J. , Schuler Ronald T. , Skjolaas Cheryl A. , Wilkinson Terry L.
Published: April 2008

Abstract: This study investigated the agricultural work‐related safety and health programming of county‐level cooperative extension agents who work through land grant universities to provide a range of educational programs to agricultural producers. A questionnaire was designed and administered to all 89 Wisconsin agriculture and agribusiness extension county faculty. The questionnaire obtained valid responses from 98.9 percent of the agents. Ninety percent of all agents conducted some occupational safety and health promotion programming in the last year. These activities occupied an average of 4.8 days per agent per year. Most of the reported activities were group programs for the agricultural labor force that involved other extension agents and included the use of videotapes. The greatest barrier to more programming was lack of time on the part of both the agricultural workforce and the agents. Most extension agents placed greater emphasis on training in how to work safely around hazards than on how to recognize and permanently correct hazards. For future programs agents requested more short format materials to use in programming, such as fact sheets, videotapes, and farm hazard inspection checklists. Agents are important training delivery resources for controlling farm‐related injury and disease. Agents could be more effective with more time, better materials, and with more emphasis on hazard correction in workplace safety programs.
The Interactive Effects of Race and Ethnicity and Mother's Residence on the Adequacy of Prenatal Care
Authors: Miller Michael K. , Clarke Leslie L. , Albrecht Stan L. , Farmer Frank L.
Published: April 2008

Abstract: Adequate prenatal care is known to reduce the risks of low birth weight and neonatal death, yet nearly one quarter of all women giving birth in the United States receive delayed, inadequate or no prenatal care. This suboptimal use of prenatal care has contributed to rates of low birth weight and neonatal mortality higher than those in most other industrialized nations. This paper examines the relationships among race/ethnicity, residence, maternal sociodemographic and medical risk characteristics, and use of prenatal care in the United States. Using data from the National Maternal and Infant Health Survey, this study found important differences in prenatal care use by race/ethnicity and residence, as well as interactive effects of these variables. Single marital status, non metropolitan residence, poverty, low level of education, and no insurance were more strongly associated with inadequate prenatal care for whites and Hispanics than for blacks. Nonmetropolitan residents were more likely to receive inadequate care, regardless of race/ethnicity or sociodemographic characteristics. Predicted probabilities of prenatal care use by race/ethnicity and residence showed that, regardless of risk, nonmetropolitan Hispanic women had the highest probability of obtaining inadequate prenatal care. Results highlight the continued importance of race/ethnicity and rural residence in determining prenatal care use and the need to design interventions targeted to these populations.
Residential Differences in the Use of Pharmacies by Older Adults and Their Communication Experiences with Pharmacists
Authors: Ranelli Paul L. , Coward Raymond T.
Published: April 2008

Abstract:This investigation compares adults (65 and older) living in two different types of communities on the characteristics of the pharmacies they use and their patterns of communicating with pharmacists. Telephone interviews were conducted with a random sample (N=400) of respondents, half residing in six nonmetropolitan counties (containing no towns of more than 4,000) and the other half in a single city (population approximately 130,000) located within a metropolitan county. Elders living in the sparsely populated nonmetropolitan areas were more apt to purchase their medications from an independent neighborhood pharmacy than their counterparts who lived in the large city. These pharmacies, however, were more likely to be located in another town. Differences between residential groups were also observed in the communication patterns that older patients had with their pharmacists. Elders residing in sparsely populated areas reported more frequent conversation with their pharmacists about general topics, although not about medicines or other health‐related topics. The elders living in small and remote places also reported that they talked with their pharmacists longer, that communication about medications were more often initiated by the pharmacist, and that they were more likely to talk about their medications directly with their pharmacist rather than a non‐pharmacist employee. The overall greater frequency of contact and communication between nonmetropolitan elders and their pharmacists would seem to be precursors to establishing a positive provider‐client relationship and may increase the probability of more personal, medication‐related discussions. Further research is needed, however, to determine if these potentials are transformed into realities and if they lead to more positive medical outcomes for older persons.
Prevalence of Abnormal Pap Smears in Rural Family Practice
Authors: Miller Karl S. , Yunger Jamie , Single Nancy , Kunz Jerry
Published: April 2008

Abstract: The purpose of this study was to examine the prevalence of abnormal Pap smears in rural family practice, to compare this to the published literature, and to determine if the prevalence of abnormalities is higher in the younger age group (≤ 35 years of age). A retrospective chart audit was performed on all Pap smears from four rural family practice sites during a 12‐month period. Data collected were Pap smear result, patient's age, and interval since previous Pap smear. Statistical analysis was used to determine if the prevalence of abnormal Pap smears was consistent among the practices as well as similar to the three larger published studies. Also, chi‐square analysis was used to compare the prevalence of abnormal Pap smears in the younger (≤ 35 years of age) versus the older (>35 years of age) age groups. There were 2,891 Pap smears reviewed, with 782 (27%) recorded as abnormal. The prevalence of cervical intraepithelial neoplasia (CIN) (76 or 2.6%) was compared to the published literature and was found to be statistically significantly higher (chi square=772.194, P=0.000). The prevalence of abnormal Pap smears was higher in the younger than age 35 group when compared to the older than age 35 group (chi square=20.953, P=0.000). Pap smear interval and age varied between the four practice sites, but the prevalence of CIN was not statistically different (chi square=3.154, P=0.368). The results of this study suggest that rural family physicians may encounter abnormal Pap smears at rates similar to those reported in the literature. This study also suggests that the prevalence of abnormal Pap smears may be higher in the younger groups in this population.
Implementation of an Inpatient Case Management Program in Rural Hospitals
Authors: Bertram Dennis A. , Thompson Mary Carla , Giordano Dianne , Perla Jeanne , Rosenthal Thomas C.
Published: April 2008

Abstract: The objective of the study was to identify factors that affected the implementation of an inpatient case management program in rural hospitals. The hospitals studied were from the Western New York Rural Health Care Cooperative. Five of the hospitals implemented the program in 1992. A qualitative evaluation was conducted by analyzing tape‐recorded inter‐views with nurses and chief executive officers to identify obstacles to and facilitators of program implementation. Many obstacles to implementation could be traced to workload and time constraints, physician autonomy concerns, and limited nursing staff and physician participation. Implementation was facilitated foremost by the effort and supportive attitudes of nursing leaders and hospital chief executive officers. This study concluded that it should be possible to successfully implement conceptually sound managed care and case management programs in rural hospitals, but it will require a relatively long period of support, especially from hospital administration and nursing leaders.
Telecommunications and Rural Health Care
Authors: Whitener Lynn
Published: April 2008

“Research Reviews” are a regular feature of The Journal of Rural Health, presenting current research on a particular them or topic of interest.
Identifying Health Care Needs of Rural Ohio Citizens: An Evaluation of a Two‐stage Methodology
Authors: Birdwell Stephen W. , Calesaric Heather
Published: April 2008

Abstract: The purpose of this study was to determine the health care needs of rural Ohio from the perspectives of health care providers and consumers using a two‐stage methodology. In stage one, 12 focus groups were conducted in six rural areas: six groups of consumers and six groups of health care providers. A total of 53 consumers and 53 health care providers participated in the sessions. The participants identified 124 health care issues. In stage two, a questionnaire was developed to determine the importance of all issues identified in the focus group sessions. The questionnaire was mailed to all focus group participants and also to individuals invited to participate in the focus groups who were unable to attend. Individuals were asked to rate the importance of each health care issue in their community on an 11‐point scale (0=not important, 10=extremely important. A total of 207 (56.9%) usable questionnaires were re‐turned. Mean (+ S.D.) values were calculated for each health care issue, and the most important were (1) issues related to the financing and cost of health services and insurance, and (2) concerns associated with characteristics and behaviors of rural residents. The two‐stage methodology provides a mechanism for identifying the concerns of providers and consumers and allows for these perspectives to be considered in the planning and development of strategies to address issues surrounding rural health care.
Providing Birthing Services in Rural Health Networks: Coping with Change in New York State
Authors: Rosenthal Thomas C. , Ferrara Elysa , Hesler Elizabeth
Published: April 2008

Abstract: Making prenatal and birthing services accessible in rural communities no longer able to support a local full‐service hospital and the introduction of managed care cost control has led to consideration of alternative models. One such model, the freestanding birth center located in an isolated rural community, challenges the guidelines of several state and professional organizations directed at assuring adequate emergency response, including cesarean sections. An extensive review of freestanding birth centers and their effect on birth outcomes revealed little outcomes data about birth centers distant from full‐service hospitals. Most states have modeled their birth center regulations on recommendations from the National Association of Childbearing Centers, but others, such as New York, have more rigidly defined transport parameters that exclude many rural locations. A consensus panel convened by the New York State Rural Health Council concluded that demonstrations projects featuring a rural birthing center farther than 20 minutes from a full‐service hospital and operated within a networked rural health system should be developed. Consumers would need to be fully informed about the implications of their choice of birth services and all qualified providers, including midwives, should be included in a team approach to care giving.
Dementing Illnesses in Rural Populations: The Need for Research and Challenges Confronting Investigators
Authors: Keefover Robert W. , Rankin Eric D. , Keyl Penelope M. , Wells Jane C. , Martin Joye , Shaw Jennifer
Published: April 2008

Abstract: Expansion of the world's elderly populations has increased concerns about aging‐related medical disorders like Alzheimer's disease and other dementias. In the United States, one fourth of those older than age 65 and at greatest risk for developing dementia live in rural environments that may influence its manifestation. The objectives of this study were to determine the need for and potential benefits of further epidemiological research concerning dementia and similar disorders in rural U.S. populations and to identify pertinent methodological issues related to rural dementia research. This study employed a National Library of Medicine (MEDLINE) document search based on the key words “cognitive disorders,”“dementia,”“Alzheimer's disease,” and “rural,” followed by recovery of literature resources referenced in the bibliographies of selected articles.

Nineteen studies focusing on dementia or related disorders in rural settings have been reported from around the world. While four of these were conducted in the United States, only one rural dementia prevalence study has been undertaken in this country. Because of methodological variability, comparisons of prevalence estimates between these rural studies, as well as with those from urban investigations, is difficult. Nonetheless, there is reason to believe that certain potentially dementing illnesses are more common in rural populations. There is also evidence to suggest that the screening instruments commonly used in such studies tend to misclassify rural elders as “false positive” dementia cases.

Information regarding dementing disorders, particularly Alzheimer's disease, in rural populations is scarce. Preliminary observations that dementia may be more common in rural settings and that rural families are more likely to maintain their dementing elders in the community imply that further rural dementia research could yield important insights into the risk factors for these illnesses, the variables influencing their course, and the methods by which they can be more effectively managed. A determination of the reliability and validity of commonly used dementia screening instruments in rural populations would represent an important advancement in this area of research.
Barriers to Preventive Health Services for Minority Households in the Rural South
Authors: Strickland Jay , Strickland David L.
Published: April 2008

Abstract: Health values, behaviors, and status are shaped by place of residence, region, race, and socio‐economic status, among other social factors. Consequently, this article examines barriers to preventive health services for lower‐income blacks in five rural counties in Georgia. Qualitative and quantitative data were collected through 281 household, 51 community leader, and six focus group interviews. Female respondents who had been pregnant were most Iikely to have received pregnancy‐related services and all respondents least likely to have received vision and dental screenings. Six of the seven types of services inquired about were most likely to have been received in a private practice setting. Primary barriers to preventive service utilization included ability to pay, perception of need, service availability, accessibility of services, and the perception of racism. The relationship between structural and nonstructural barriers, their impact on preventive service utilization, and research recommendations also were developed and presented.
The Mobile Hospital Technology Industry: Focus on the Computerized Tomography Scanner
Authors: Hartley David , Moscovice Ira
Published: April 2008

Abstract: This study of firms offering mobile hospital technology to rural hospitals in eight northwestern states found that several permanently parked computerized tomography (CT) units were found where mobile routes had atrophied due to the purchase of fixed units by former mobile CT hospital clients. Based on a criterion of 140 scans per month per unit as a threshold of profitable production, units owned by larger firms (those that operate five or more units) were more likely to be profitable than units owned by smaller firms (71% versus 20%, P=0.03). A substantial number of rural hospitals lose money on mobile CT due to low Medicare reimbursement. In some areas, mobile hospital technology is a highly competitive industry. Evidence was found that several firms compete in some geographic areas and that some firms have lost hospital clients to competing vendors.
Rural Mental Health Care
Authors: Whitener Lynn
Published: April 2008

“Research Reviews” are a regular feature of The Journal of Rural Health, presenting current research on a particular theme or topic of interest.
Rural Physician Satisfaction: Its Sources and Relationship to Retention
Authors: Pathman Donald E. , Williams Eric S. , Konrad Thomas R.
Published: April 2008

Abstract:This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention.

Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty‐nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full‐time teaching positions.

Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor‐patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified.

These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.
State Legislation and Policy Affecting Rural Hospital Conversion and Closure
Authors: AIexander Jeffrey A. , Succi Melissa J.
Published: April 2008

Abstract: Many rural hospitals have closed or converted to organizations that provide health services other than general, acute inpatient care. However, little is known about why rural hospitals convert rather than close. This study evaluates the relationship between state policy and rates of rural hospital conversion relative to rates of rural hospital closure. The expectation was that the relationship among state policies and rates of conversion and rates of closure differs as a function of whether a state policy facilitates rural hospital transition to alternative models of care or supports them in their existing form. National data were analyzed for all rural hospitals from 1984 to 1991. Results indicate that state policies have done little to facilitate widespread adoption of conversion among rural hospitals. Despite these findings, results also indicate that some state policies have resulted in an increase in the rate of rural hospitals conversions as an alternative to closure.
Skin Cancer Prevention and Detection Practices in a Michigan Farm Population Following an Educational Intervention
Authors: Mullan Patricia B. , Gardiner Joseph C. , Rosenman Kenneth , Zhu Zhiwei , Swanson G. Marie
Published: April 2008

Abstract: Farmers face an increased risk of skin cancer, presumed to be secondary to their increased occupational exposure to sunlight. This study examines skin cancer prevention and detection beliefs and practices among adult farmers in defined control and comparison farming communities in four contiguous counties of Michigan, before and after a community‐based educational intervention. The educational intervention included mailing packets containing information on skin cancer risks and community sources for screening, disseminating articles in local newspapers on skin cancer prevention and control measures, and providing information and screening at local county fairs and agricultural community fairs. The responses of 2,999 survey participants were analyzed to identify the interrelationships among their beliefs and their descriptions of their (primary preventive) self‐care and professional medical care seeking (for detection and treatment) practices. Factors associated with the likelihood of skin cancer screening and with measures of knowledge and practices associated with medical care of skin cancer were examined. The intervention appeared to improve the practice of preventive behaviors and seeking medical care.
Lengthening Spells of Uninsurance and Their Consequences
Authors: Mueller Keith J. , Patil Kashinath , Ullrich Fred
Published: April 2008

Abstract: The lengths of time adults are without health insurance have increased since 1988, as shown by data from 1,235 household interviews completed during 1992 in Nebraska. Rural residents without insurance have experienced longer such spells than their urban counterparts. Thus, while rates of uninsurance are nearly the same between urban and rural residents, important differences exist. The relationship between insurance status and physician utilization is consistent during the five years (1989 to 1993) covered in this study. Continuously insured persons have the most physician visits, followed by those intermittently insured, followed by those continuously uninsured. The number of physician visits was expected to increase when respondents moved from uninsured to insured status. However, among urban respondents, the number of visits declined; among residents in rural frontier counties (fewer than six persons per square mile) and for respondents in rural nonfrontier counties, there was no significant difference. This study points out some differences between rural and urban populations regarding insurance status, even when the overall rates of uninsurance are equal.
Meeting the Challenges of Workload and Building a Practice: The Perspectives of 10 Rural Physicians
Authors: Bowman Robert C. , Crabtree Benjamin F. , Petzel Janis B. , Hadley Terry S.
Published: April 2008

Abstract: This qualitative study used in‐depth interviews to identify and describe factors regarding the retention of rural physicians. A purposeful sample of 10 established rural physicians from counties of fewer than 10,000 people participated in the study. Analysis of the interview transcripts identified the increased workload involved in building a rural practice to be a major concern of the physicians. The physicians expressed this difficulty in the form of two challenging dilemmas: (1) Towns with only a few physicians presented excellent opportunities for a building practice, but the lack of physicians resulted in more difficult working conditions; and (2) building a practice was described as primarily competitive, but staying in rural practice involved working cooperatively with various competitors. The demands of family, practice, and community interact in a complex fashion. The smallest health systems, those in counties with populations of fewer than 10,000, one hospital, and fewer than five physicians, may represent situations where it is difficult to find a workable solution
Returns to Nursing Education: Rural and Nonrural Practice
Authors: Pan Shihua , Straub LaVonne
Published: April 2008

Abstract: This study uses data from a national sample of registered nurses to compare earnings of nurses in rural and nonrural practice. The comparisons, conditioned by the nurses' educational level, are analogous to the concept of “returns to human capital investment” used in labor economics. A general linear model is applied within a framework of labor economics analysis. Results show that nurses with more education receive less for their investment if they practice in rural areas. Work experience and employment setting are also related to lower annualized earnings for rural practice. One exception to the otherwise consistent findings is that returns to advanced practice nursing are higher in rural areas. Results and policy implications are discussed.
The Effects of Physician In‐migration to Rural Colorado (1992 to 1995)
Authors: Jr. George E. Fryer , Stine Curtis , Vojir Carol , Miyoshi Thomas , Miller Marie
Published: April 2008

Abstract: This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in‐migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three‐year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from non‐metropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants
Factors Influencing Exposure of Children to Major Hazards on Family Farms
Authors: Lee Barbara C. , Jenkins Louise S. , Westaby James D.
Published: April 2008

Abstract: On family farms, parents are usually knowledgeable of high‐risk activities, yet they allow their children to be active participants in (or bystanders to) hazardous work for reasons not well‐documented. A two‐phase descriptive study, based on the theory of planned behavior and using mail survey research methods, was carried out to understand factors that influence parents' decisions to expose children to major hazards on family farms. A representative sample of 1,255 Wisconsin dairy farm fathers provided data about factors that influence their decisions to expose children younger than 14 years to risks of injury. Multivariate analyses revealed that attitudes, subjective norms, and perceived control accounted for up to three‐fourths of the variance in fathers' behavioral intentions. Fathers' attitudes were stronger predictors of behavioral intentions than subjective norms (i.e., perceived social pressure) or perceived control. Grandparents and mothers exerted a limited influence. Other groups, such as health care providers, 4‐H, Future Farmers of America, and insurers, exerted only a modest influence on fathers' feelings of social pressure. Few demographic characteristics of the family or farm were predictive of fathers' intentions to expose children to hazards
A Typological Approach to the Study of Rural HIV Service Delivery Networks
Authors: Berry David E. , McKinney Martha M. , Marconi Katherine M.
Published: April 2008

Abstract: Despite the rapid growth of AIDS cases in nonmetropolitan areas, little is known about the characteristics and needs of HIV‐positive rural residents or how rural areas are responding to the epidemic. This paper proposes a typology for distinguishing among rural environments and examining variations in HIV service networks. The typology identifies three dimensions that have a major effect on the development of rural HIV service networks: degree of rurality, the prevalence of AIDS, and the epidemiological and demographic characteristics of the infected populations. Data from four case studies are used to illustrate how variations in rural environments can affect the organization and delivery of HIV/AIDS care. The typology contributes to public policy discussions by identifying key attributes of rural environments that influence program planning and implementation and the transferability of service delivery models
How Rural Physicians Compare on Cost and Quality Measures for Medicaid Ambulatory Care Episodes
Authors: Bronstein Janet M. , Johnson Victoria A. , Jr. Crayton A. Fargason
Published: April 2008

ABSTRACT: This study compares the costs and quality of episodes of care for two common childhood illnesses, urinary tract infections (UTI) and otitis media (OM), across providers practicing in rural, small town, and urban counties in Alabama in 1992. The data source is Medicaid claims data for children under age 8 who were treated for these conditions. The study found that episodes cared for by rural providers were less expensive than episodes cared for in other locations, both because fewer rural episodes included outpatient facility charges and because fewer ancillary services were provided in rural settings. Researchers also found that, even controlling for physician characteristics and patient demographic and utilization factors, rural episodes were significantly less likely to include two process measures of quality of care: fewer rural UTI episodes included urine cultures, and fewer rural OM episodes included follow‐up visits. This study suggests that, as a group, rural physicians may have a favorable cost profile but a potentially unfavorable care content profile, compared with other physicians. Both practice profile data and explicit care recommendations need to be available to physicians so they can monitor, defend, or alter their clinical practices
Importing Employer‐based Managed Care Initiatives to Rural Areas: The Experience of the South Dakota State Employees Group
Authors: Christianson Jon B. , Hart I. Patrick
Published: April 2008

ABSTRACT: In urban areas, employers are frequently in the forefront of efforts to implement managed care initiatives at the community level, either individually or through coalitions. While employer‐driven managed care initiatives also exist in rural areas, they are less common and much less is known about them. This article describes and analyzes the early experience of a large rural employer—the state of South Dakota—in its attempt to develop and implement a managed care initiative. Several aspects of that experience suggest that employer‐driven man‐aged care models in urban sites may require reexamination and redefinition for implementation in rural areas
The Composition of Rural Hospital Medical Staffs: The Influence of Hospital Neighbors
Authors: Krein Sarah L. , Christianson Jon B. , Chen Mei‐Mei
Published: April 2008

ABSTRACT: The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closest rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.
Interdisciplinary Student Health Teams: Combining Medical Education and Service in a Rural Community‐based Experience
Authors: Hamilton Charles B. , Smith C. Alex , Butters Janice M.
Published: April 2008

ABSTRACT:Several initiatives have been introduced over the years to address the maldistribution of health care professionals and to improve access to care for underserved rural populations. One of these is the sponsorship of community‐based, service‐oriented teams comprised of students from various health disciplines. This study investigated extramural training as a complement to traditional hospital‐based experiences. The specific objective of the study was to determine the extent to which the nation's medical schools combine training with a rural community‐based experience in the form of an interdisciplinary student health team program. In the fall of 1994, a 32‐item questionnaire was mailed to the chief academic or clinical affairs administrators of the nation's 126 allopathic medical schools. A total of 104 (82.5%) medical schools responded to the survey. Eighty‐six of the respondents (82.7%) reported some type of rural training or public service activity; 22 (21.2%) acknowledged the sponsorship of an inter‐disciplinary student health team program. Small rural communities, those with populations of 5,000 or fewer, were the focus of 76 percent of the reporting programs. Nearly two‐thirds of the reporting programs were located in the South, the region with the nation's lowest physician‐topopulation ratio. The nursing and medical professions were most frequently represented, although a wide range of disciplines were identified as participating on the student health teams. Activities of the teams included both ambulatory care and community outreach services. The majority of the programs used team‐building exercises to enhance team effectiveness. Extramural training programs offer students a realistic examination of the social, cultural, economic, and political forces that influence both individual and community health. Rural community‐based programs, such as interdisciplinary student health teams, should be valued because they can strengthen the link between the sponsoring institution's educational mission and its public service obligation.
What is Rural? A Focus on Urban Influence Codes
Authors: Baer Leonard D. , Johnson‐Webb Karen D. , Gesler Wilbert M.
Published: April 2008

ABSTRACT: Classification of U.S. counties into metropolitan and nonmetropolitan masks a high degree of variation in population size, density, and relationship between urban and rural areas. This article reviews the urban influence county coding system and illustrates how it applies to U.S. counties. The urban influence codes can be useful for analysis of rural health policy.
Rural and Urban Nonphysician Providers in Georgia
Authors: Strickland W. Jay , Strickland David L. , Garretson Cornelius
Published: April 2008

Abstract: Nonphysician providers make valuable contributions to health care in rural areas. This study examines provider and practice characteristics, location preference, and reasons for location preference among Georgia nurse practitioners (NPs), certified nurse midwives, and physician assistants (PAS) (N=1,079). Data collected through a statewide survey revealed that providers were concentrated in urban areas. Rural providers tended to be older, less educated, possess fewer specialty credentials, and were employed longer than urban providers. NPs were significantly more likely to prefer smaller communities, and PAS were significantly more likely to prefer larger communities. Providers who preferred smaller communities were likely to practice in rural and urban areas, but providers who preferred larger communities were substantially more likely to practice in urban areas. Providers who preferred smaller communities were significantly more likely to mention the importance of community dynamics, while providers who preferred larger communities were significantly more likely to mention professional context.
A Comparison of Practice Characteristics Among Physician Assistants in HMO and Non‐HMO Settings
Authors: Geller Jack M. , Weier Andrew , Muus Kyle J. , Hart L. Gay
Published: April 2008

Abstract: Health maintenance organizations (HMOs) have continued to grow in both number and enrollment. A major goal of HMOs and other managed care structures is the containment of health care costs. The utilization of physician assistants (PAS) would seem to nicely mesh with these organizations. This study examines the roles, productivity, and clinical autonomy of PAS in HMO settings. In this examination, PAS working with HMOs are compared with PAS working in non‐HMO settings, both urban and rural. The results of the study document that PAS working in HMO environments primarily focus on ambulatory care, with few inpatient or administrative responsibilities. Further, PAS working in HMO settings have a highly autonomous practice with approximately 70 percent of patient visits never being discussed with a supervising physician. Lastly, the results suggest that many of the attributes of an HMO practice are found in rural practice as well. Consequently, as HMOs reach out farther into rural America, PAS in rural settings will have fewer practice modifications to make than urban PAS in their transition to practice in an HMO modality.
The Use of Health Care Services by People With Diabetes in Rural Areas
Authors: Dansky Kathryn H. , Dirani Riad
Published: April 2008

Abstract: Current standards of health care support the view that diabetes can be managed in an outpatient setting, thereby preventing costly hospitalization. Yet, recent studies on access to care suggest that rural residents do not receive the same services for diabetes care as their urban counterparts. This study identifies differences in use for three types of services‐hospital care, home health visits, and physician office visits—by geographical location. Using a sample of 6,698 Medicare beneficiaries, the authors performed multivariate analysis of variance to test the influence of geographical differences on each type of service use after controlling for the other types of service use and individual factors. Results showed significant differences among the geographical categories, with diabetic individuals in the most sparsely populated communities reporting fewer physician office visits and more home health visits than their urban counterparts. Because this pattern may have a negative impact on health outcomes, additional research is needed to determine the optimal array of services necessary to manage chronic diseases, such as diabetes, in rural areas.
Determinants of the Quality of Life of Rural Families
Authors: Garrison M.E. Betsy
Published: April 2008

Abstract: Drawing from human ecology theory, the purpose of this study was to examine socioeconomic‐demographic determinants of the quality of life of rural families. In the study, computer‐aided telephone interviewing via random digit dialing procedures were used to collect data in the spring of 1996. The participants included 510 rural (both farm and nonfarm) respondents. Quality of life was measured by five subscales: finances; home, family, and friends; household; community; and environment. The results of the regression analyses indicated that the independent variables—gender, race, marital status, employment status, residence, age, family income, and household size, differentially affected the quality of life sub‐scales. Among the independent variables, household size—not a commonly used determinant in quality of life studies—was the most important predictor of subjective Well‐being. The findings of this study lend support for the dimensional, rather than global, measurement of subjective well‐being.
United Health Care of North Carolina
Authors: Casey Michelle , Wellever Anthony
Published: April 2008

Physicians. While many of the rural physicians interviewed in North Carolina would prefer not to deal with HMOs at all, they are generally positive about their relationships with United Healthcare of North Carolina. These physicians chose to contract with the HMO to obtain new patients and to retain existing patients. They are satisfied that their participation has accomplished these goals. Their reimbursement arrangements are easy to understand, and most view the payment amounts as satisfactory. The physicians regard the size of the HMOs provider network and the open‐access structure of the HMO as positive features that allow them to make referrals without the restrictions imposed by some other HMOs.

To date, participation in United Healthcare of North Carolina has imposed few burdens on rural physicians. They are reimbursed on a fee‐for‐service basis, and their financial risk has been limited. They do not perceive that the HMO has had a significant impact on the way they practice medicine. This situation may change in the future if enrollees from United Healthcare of North Carolina and other HMOs constitute a greater proportion of their practices and if these HMOs move toward capitated reimbursement. The attitudes of rural physicians toward United Healthcare of North Carolina also may change if the HMO attempts to more actively manage the care provided to its enrollees.

United Healthcare of North Carolina plans to eliminate physician risk sharing (in the form of withholds) and replace it with bonus payments. As one HMO executive said, the plan wants to “put incentives where they belong.” If rewarding good performance instead of punishing poor performance yields intended consequences, it may provide United Healthcare of North Carolina with a competitive advantage in rural areas. First, because such a change offers an opportunity to augment a physician's income instead of diminishing it, physicians might prefer to contract with the HMO rather than with other HMOs. Second, because bonus payments depend on performance, United Healthcare of North Carolina providers may produce outcomes that allow reductions in premium prices or expansions of benefits compared with the HMOs competitors.

Hospitals. Rural hospitals cited similar motivations (attracting and retaining business) for participating in United Healthcare of North Carolina and similar levels of satisfaction with their relationships. In their experiences, the HMO has been fair in its negotiations and reimbursement. Although they contract with multiple HMOs, these rural hospitals do not perceive that HMO participation has had a significant impact on hospital operations. Because these hospitals, like many rural hospitals, rely heavily on Medicare (and, to a lesser degree, on Medicaid) as revenue sources, the future impact of managed care on their operations will depend in large part on the extent to which significant proportions of their Medicare and Medicaid patients enroll in HMOs.
Medical Associates HMO
Authors: Wellever Anthony , Christianson Jon
Published: April 2008

Medical Associates HMO is based on a multi specialty group practice located in a small metropolitan area. That group practice regards the HMO as an important strategy for maintaining and increasing patient referrals. A substantial portion of the HMOs service area is rural; therefore, the HMOs relationships with rural providers are important because they affect its ability to attract enrollees from rural areas and, potentially, non‐HMO referrals as well. During the past few years, the competition for patients and for HMO enrollees has intensified in the HMOs market area. A major challenge facing this HMO is how to protect and enhance its market share while maintaining constructive, cordial relationships with providers in surrounding rural areas.
Residential Differences in Attitudes About Barriers to Using Community‐based Services Among Older Adults
Authors: Schulenburg Nancy E. , Coward Raymond T.
Published: April 2008

Abstract: Despite poorer health, rural elders tend to use fewer community‐based services than their urban or suburban counterparts. Researchers have speculated that residential differences in the receipt of community‐based services may be attributable to, among other factors, the attitudes of older adults toward such services. Twelve focus groups were conducted to explore residential variation in the attitudes of older adults toward the use of community‐based services, specifically emphasizing perceived barriers to the use of services. While both rural and urban residents expressed overall satisfaction with the services that they had received in the past or currently receive and both groups noted insufficient community‐based services, residential differences emerged in both the nature of the perceived barriers and the frequency in which they were mentioned. Rural elders more frequently highlighted barriers that diminished their use of community‐based services. Such barriers included a lack of awareness of services, inadequate transportation, and perceived rigid program eligibility standards. Urban older adults mentioned far fewer and different barriers to the receipt of services, but those barriers seemed to be consistent with the community context in which they lived. While these findings support speculations that differences in attitudes may account for some of the residential variation in the use of community‐based services that has been observed, the conclusion also can be drawn that, regardless of residence, older adults face substantial barriers to services, resulting in unmet needs.
Physician and Clinical Integration Among Rural Hospitals
Authors: Alexander Jeffrey A. , Morrisey Michael A. , Burns Lawton R. , Johnson Victoria
Published: April 2008

Abstract: The pressures for closer alignment between physicians and hospitals in both rural and urban areas are increasing. This study empirically specifies independent dimensions of physician and clinical integration and compares the extent to which such activities are practiced between rural and urban hospitals and among rural hospitals in different organizational and market contexts. Results suggest that both rural and urban hospitals practice physician integration, although each emphasizes different types of strategies. Second, urban hospitals engage in clinical integration with greater frequency than their rural counterparts. Finally, physician integration approaches in rural hospitals are more common among larger rural hospitals, those proximate to urban facilities, those with system affiliations, and those not under public control.