"If only someone had told me…": lessons from rural providers

PURPOSE

Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers' knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains.

METHODS

Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, "What are the 3 things you wish someone would have told you about delivering health care in rural areas?" were thematically coded.

FINDINGS

Emergent themes coalesced into 3 overarching themes addressing practice-related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner.

CONCLUSION

Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.

Training needs of healthcare providers related to Centers for Disease Control and Prevention core competencies for fetal alcohol spectrum disorders

BACKGROUND

Fetal alcohol spectrum disorders (FASDs) are birth defects directly linked to consumption of alcohol during pregnancy and hence completely preventable. Many health and allied health professionals are in prime positions for primary prevention of FASDs through work with women of childbearing age and secondary prevention through work with affected individuals whose lives can be greatly improved via tailored intervention.

OBJECTIVES

To develop educational guidelines for FASD prevention.

METHODS

Interviews were conducted with 26 individuals representing eight health or allied health professions. Participants were asked about professional groups with which they had sufficient experience to describe FASD-related competencies and educational needs for the given group(s). For each group, participants were asked for their perceptions of group members' FASD awareness, knowledge, and skills application as related to the seven core competencies for FASD practice developed by the Centers for Disease Control and Prevention (CDC).

RESULTS

Findings revealed that competence, especially when viewed separately in terms of knowledge versus capacity for application of information, in the area of FASDs is unevenly distributed among and throughout healthcare provider groups.

CONCLUSION

Based on this information, recommendations are offered for optimal health and allied health education efforts to prevent and treat FASDs, framed along FASD core competencies recommended by the CDC.

Community-Based Participatory Research for Improved Mental Health

Community-based participatory research (CBPR) focuses on specific community needs, and produces results that directly address those needs. Although conducting ethical CBPR is critical to its success, few academic programs include this training in their curricula. This paper describes the development and evaluation of an online training course designed to increase the use of CBPR in mental health disciplines. Developed using a participatory approach involving a community of experts, this course challenges traditional research by introducing a collaborative process meant to encourage increased participation by special populations, and narrow the parity gap in effective mental health treatment and services delivery.

Brief motivational interventions for HIV/STI risk reduction among individuals receiving alcohol detoxification

This HIV/STI risk reduction clinical trial implemented in short-term alcohol detoxification employed a randomized block design to evaluate three intervention conditions for feasibility, safety, and potential for changing sexual risk attitudes, motivations, and behavior: (a) nonintervention control (standard HIV information dissemination), (b) brief motivational intervention (BMI) for resolution of ambivalence and sex risk reduction planning, and (c) BMI with biological feedback based on testing for sexually transmitted infections (STIs). Findings revealed that BMI can be feasibly implemented during detoxification treatment with individuals with significant substance impairment. BMI, whether coupled with biological feedback or not, enhanced motivation for increasing behaviors that protect from STI. Sexual risk behavior did not change in any of the groups to a statistically significant degree; however, additional analyses suggest negative biological feedback may have resulted in slightly increased level of sexual activity, undoing behavioral effects of increased motivation for sexual risk reduction, perhaps by distorting participants' perception of risk.

Childhood Abuse History and Substance Use Among Men and Women Receiving Detoxification Services

According to data collected from women and adolescents, a strong link exists between childhood abuse history and substance abuse. Using a sample of 274 women and 556 men receiving detoxification services, we explored whether the same pattern emerged across genders and types of abuse. Results revealed 20% of men and more than 50% of women reported childhood physical or sexual abuse. Sexual or physical abuse had negative sequelae, regardless of gender. Individuals with abuse history reported earlier age of onset of drinking, more problems associated with use of alcohol/drugs, more severe psychopathology, and more lifetime arrests, arrests related to substance use, and arrests related to mental health. Prevention and proactive intervention activities are crucial to prevent negative sequelae of childhood victimization.

Barriers to healthcare as reported by rural and urban interprofessional providers

The research literature is replete with reports of barriers to care perceived by rural patients seeking healthcare. Less often reported are barriers perceived by the rural healthcare providers themselves. The current study is an extensive survey of over 1,500 healthcare providers randomly selected from two US states with large rural populations, Alaska and New Mexico. Barriers consistently identified across rural and urban regions by all healthcare professionals were Patient Complexity, Resource Limitations, Service Access, Training Constraints, and Patient Avoidance of Care. Findings confirmed that rural areas, however, struggle more with healthcare barriers than urban and small urban areas, especially as related to Resource Limitations, Confidentiality Limitations, Overlapping Roles, Provider Travel, Service Access, and Training Constraints. Almost consistently, the smaller a provider's practice community, the greater the reports of barriers, with the most severe barriers reported in small rural communities.

When providers and patients come from different backgrounds: perceived value of additional training on ethical care practices

Fostering the therapeutic alliance, safeguarding confidentiality, gaining informed consent, and enhancing treatment adherence are critical aspects of patient care. We examined whether multidisciplinary health care providers perceive additional training on these areas as helpful in their work with patients from different ethnic backgrounds than the provider. Data are drawn from a National Institute on Drug Abuse-funded survey of 1555 providers in 8 disciplines in New Mexico and Alaska. Clinicians viewed additional training as moderately helpful for ensuring treatment adherence, establishing the therapeutic alliance, safeguarding confidentiality, and engaging in informed consent processes, in that order. Women were more receptive than men to additional training. Modest differences were detected between behavioral and physical health providers and between minority and majority providers. Implications of providers' only modest interest in such training are discussed.

Adaptations to health care barriers as reported by rural and urban providers

Barriers to ethical and effective health care in rural communities have been well-documented; however, less is known about strategies rural providers use to overcome such barriers. This study compared adaptations by rural and urban health care providers. Physical and behavioral health care providers were randomly selected from licensure lists for eight groups to complete a survey; 1,546 (52%) responded. Replies indicated that health care providers from small rural and rural communities were more likely to integrate community resources, individualize treatment recommendations, safeguard client confidentiality, seek out additional expertise, and adjust treatment styles than were providers from small urban and urban communities. Behavioral health care providers were more likely than physical health care providers to integrate community resources, individualize treatment recommendations, safeguard client confidentiality, and adjust their treatment styles; physical health care providers were more likely than behavioral health care providers to make attempts or have options to seek out additional expertise.

Receiver Operating Characteristics for the Brief Symptom Inventory Depression, Paranoid Ideation, and Psychoticism Scales in a Large Sample of Clinical Inpatients

A commonly used screening tool for psychopathology, the Brief Symptom Inventory, provides normative data for assessing current mental functioning across multiple domains. Using data from 654 psychiatric inpatients, receiver operating characteristic (ROC) analyses were conducted for three scales, Depression, Paranoid Ideation, and Psychoticism. t ratios identified significant group differences on the Depression scale between patients diagnosed with or without depression but no differences on the Paranoid Ideation and Psychoticism scales between patients diagnosed with or without schizophrenia. Area under the curve for Depression was .65, indicating that the scale improved diagnostic prediction somewhat beyond chance; for Paranoid Ideation, the area was .52 and for Psychoticism, the area was .53, indicating that these two scales did not significantly improve diagnostic prediction beyond chance.

Ethical disparities: challenges encountered by multidisciplinary providers in fulfilling ethical standards in the care of rural and minority people

CONTEXT

Health care disparities are well documented for people living in rural areas and for people who are members of ethnic minorities.

PURPOSE

Our goal was to determine whether providers report greater difficulty in providing care for rural than urban residents and for ethnic minorities than patients/clients in general in 4 practice areas of ethical relevance: attaining treatment adherence, assuring confidentiality, establishing therapeutic alliance, and engaging in informed consent processes.

METHODS

We received survey responses from 1,558 multidisciplinary medical and behavioral providers across rural and non-rural areas of New Mexico and Alaska in 2004 to assess a wide range of issues in providing health care.

FINDINGS

Providers reported some difficulties in fulfilling various ethical practices for all types of patients, but not more difficulty when caring for minority compared to nonminority patients/clients. However, they do report more frequent additional problems related to the practice issues of treatment adherence, therapeutic alliance, informed consent, and confidentiality with minority patients than others. Difficulties and more frequent additional problems are greater for providers in rural than in non-rural areas. Results generalize across both Alaska and New Mexico with few differences.

CONCLUSIONS

We obtained evidence for disparity in care for patients/ clients who were minority group members, and clear evidence of disparity for people residing in rural compared to non-rural areas of 2 states with large rural areas.

Psychiatric symptomatology among individuals in alcohol detoxification treatment

The coexistence of psychiatric symptomatology among individuals receiving longer-term treatment for alcohol use disorders has been well-established; however, less is known about comorbidity among individuals receiving alcohol detoxification. Using the Brief Symptom Inventory [BSI; Derogatis, L. R. (1992). BSI: Administration, scoring, and procedures manual--II. Towson, MD: Clinical Psychometric Research], we compared psychiatric symptomatology among 815 individuals receiving short-term detoxification services with normative data from non-patients, psychiatric patients, and out-of-treatment individuals using street drugs. Findings revealed that individuals in the current sample reported a wide range of psychiatric symptoms with over 80% meeting BSI criteria for diagnosable mental illness. These BSI scores were significantly more severe than those reported by out-of-treatment individuals using street drugs and most closely resembled BSI scores reported for adult psychiatric inpatients. Findings suggest that routine screening for severe mental health symptoms appears warranted in detoxification units. Such screening would greatly increase the chance that coexistence of substance use and other psychiatric disorders would be properly addressed in ongoing treatment.

Hearing consumer voices: planning HIV/sexually transmitted infection prevention in alcohol detoxification

The literature has provided ample evidence that individuals abusing or dependent upon alcohol are at high risk for contracting HIV and other sexually transmitted infections (STIs). Despite the documented need of this vulnerable group for targeted HIV/STI prevention efforts, no prior research has explored the efficacy and feasibility of HIV/STI prevention for individuals in alcohol detoxification. The current study sought the voices of consumers of such services to get their guidance about successful and necessary features of HIV/STI prevention programs targeted to their needs. Two focus groups conducted yielded exceptionally helpful information. Consumers clearly want to be educated about HIV/STI, seeing this as crucial to their physical well-being and safety. They voiced preferences for nonjudgmental counselors who meet with them on an individual basis in contexts that protect consumer privacy. A clear set of guidelines emerged for an intervention structure that, if carefully honored, has strong likelihood of success in protecting individuals in alcohol detoxification from HIV/STI.

Survey return rates as a function of priority versus first-class mailing

Prior research indicates survey procedures that signal significance and individualized mailings have higher response rates. Thus, it was hypothesized that surveys delivered via Priority mail would result in higher return rates than surveys delivered via First-Class. 260 surveys were sent to individuals randomly selected from lists of licensed physical and behavioral healthcare providers in Alaska and New Mexico. Half of the selected individuals were assigned randomly to receive mailings using Priority mail, the other half received First-Class mailings. Return rate was 39% for First-Class and 35% for Priority. Z tests of proportion indicated no statistically significant differences between methods. Given increased costs with no resultant increase in response rate, sending surveys to potential participants via Priority mail does not appear warranted.

Exploring differences in caseloads of rural and urban healthcare providers in Alaska and New Mexico

OBJECTIVES

Although it is commonly accepted that rural healthcare providers face demands that are both qualitatively and quantitatively different from those faced by urban providers, this conclusion is based largely on data from healthcare consumers and relies on qualitative work with small sample sizes, surveys with small sample sizes, theoretical reviews and anecdotal reports. To enhance our knowledge of the demands faced by rural healthcare providers and to gain the perspectives of healthcare providers themselves, this study explored the caseloads of rural providers compared with those of urban providers.

METHOD

An extensive survey of over 1500 licensed clinicians across eight physical and behavioural healthcare provider groups in Alaska and New Mexico was undertaken to explore differences in caseloads based on community size (small rural, rural, small urban, urban), state (Alaska, New Mexico) and discipline (health, behavioural).

RESULTS

Findings indicated numerous caseload differences between community sizes that were consistent across both states, with complex case presentations being described most commonly by small rural and rural providers. Substance abuse, alcohol use, cultural diversity, economic disadvantage and age diversity were issues faced more often by providers in rural and small rural communities than by providers in small urban and urban communities. Rural, but not small rural, providers faced challenges around work with prisoners and individuals needing involuntary hospitalization. Although some state and discipline differences were noted, the most important findings were based on community size.

CONCLUSIONS

The findings of this study have important implications for provider preparation and training, future research, tailored resource allocation, public health policy, and efforts to prevent 'burnout' of rural providers.

Depression as measured by the Beck Depression Inventory-II among injecting drug users

This study conducts a confirmatory factor analysis of the Beck Depression Inventory-II (BDI-II) with a sample of 598 individuals who reported recent injecting drug use. Findings indicate that out of four models tested, the best model for this sample is a three-factor solution (somatic, affective, and cognitive) previously reported by Buckley, Parker, and Heggie. The findings that nearly 50% of participants provided BDI-II scores indicating significant depressive symptomatology reveals that these individuals are in need of treatment for their psychiatric symptoms as well as substance use. Somatic symptoms are endorsed more strongly than affective or cognitive symptoms of depression, suggesting a possible, but yet poorly defined, relationship between depressive symptomatology and drug use that centers on shared somatic symptomatology.

Rural-urban health care provider disparities in Alaska and New Mexico

Compared to their urban counterparts, rural residents face numerous disparities in obtaining health care, including limited access to care providers. We assessed disparities in provider availability in rural versus urban Alaska and New Mexico, with emphasis on professionals likely to provide mental health care. Using lists of licenses, we categorized physical and mental health care providers into rural versus urban and calculated rural versus urban disparity ratios. Rural residents had significantly less access to health care providers and discrepancies grew with level of required provider education and specialization. Addressing disparities via creative strategies is crucial to improving rural care delivery.

Preferences of Alaska and New Mexico psychiatrists regarding professionalism and ethics training

OBJECTIVE

To identify the preferences of practicing licensed psychiatrists in two rural states regarding ethics training.

METHOD

All licensed psychiatrists in Alaska and New Mexico were mailed a survey exploring differences in ethical and practice issues between rural and urban health care providers. Data were collected from 97 psychiatrists.

RESULTS

Findings indicated a moderate level of interest in training related to a diverse set of ethics topics. Although women expressed greater interest in most topics than did men, ranking of topics was similar across genders. Level of interest in training was inversely related to number of years in practice.

CONCLUSIONS

The psychiatrists in this study indicated some interest in professionalism and ethics training, but did not express the level of need or enthusiasm documented in many studies of physicians-in-training. Creating continuing medical education initiatives that are attuned to the distinct needs and preferences of psychiatrists in clinical practice thus poses many challenges. This may be particularly true for certain aspects of practice, such as ethics and professionalism, that have long been recognized as vital to clinical care, but now are viewed as core competency areas.

Patient requests and provider suggestions for alternative treatments as reported by rural and urban care providers

OBJECTIVES

Explored the relationship between different types of care providers' willingness to suggest alternative and complementary treatments (CAM), patients' requests for CAM, and provider perceptions about CAM as barriers to effective healthcare.

DESIGN

Large survey.

SETTING

Alaska and New Mexico.

MAIN MEASURES

Survey responses from 1528 physical and behavioral healthcare providers.

RESULTS

Over 97% of providers suggested CAM; over 97% reported patients asked for CAM. Providers were more likely to suggest CAM than perceived CAM as a barrier to care. Healthcare providers who were female, from small rural areas, or specializing in behavioral healthcare were more likely to suggest CAM and less likely to perceive CAM as a barrier. Patients of physical healthcare providers asked for CAM more often than patients of behavioral healthcare providers, yet physical care providers suggested CAM less frequently.

CONCLUSIONS

Healthcare providers of all disciplines, regions, and gender are sensitive to patients' desire for CAM and do not perceive CAM as a barrier to care.

Moderating Effects of Control on the Relationship Between Stress and Change

Given the well-documented impact of stress on employees, it is important to understand moderating factors, especially in behavioral health treatment settings, where constant change occurs. Staff members at four mental health (n=663) and four substance abuse (n=256) treatment agencies completed questionnaires inquiring about perceptions of direct and indirect agency changes, stress experienced due to changes, and control and input into the changes. Results revealed that as direct and indirect change increased, stress increased; as level of control and input into changes increased, stress decreased. Control and input served as a moderating variable between stress and direct change, but not for indirect change.

Ethical considerations in rural health care: a pilot study of clinicians in Alaska and New Mexico

To investigate differences in the experiences of rural versus non-rural clinicians, we surveyed caregivers in New Mexico and Alaska regarding ethical aspects of care provision. Consistent with past literature, rural compared to non-rural clinicians perceived patients as having less access to health care resources. They reported more interaction with patients and less awkwardness in relationships with their patients outside of work. Rural clinicians also reported their patients expressed more concern about knowing them in both personal and professional roles, had more concerns over confidentiality, and experienced more embarrassment concerning stigmatizing illnesses. Ethical issues and implications of these results for providing care in rural areas are discussed.

Validity of injecting drug users' self report of hepatitis A, B, and C

OBJECTIVE

To test the validity of drug users self-reports of diseases associated with drug use, in this case hepatitis A, B, and C.

DESIGN

Injecting drug users (n = 653) were recruited and asked whether they had been diagnosed previously with hepatitis A, B, and/or C. These self-report data were compared to total hepatitis A antibody, hepatitis B core antibody, and hepatitis C antibody seromarkers as a means of determining the validity of the self-reported information.

SETTING

Anchorage, Alaska.

PARTICIPANTS

Criteria for inclusion included being at least 18-years old; testing positive on urinalysis for cocaine metabolites, amphetamine, or morphine; having visible signs of injection (track marks).

INTERVENTION

Serological testing for hepatitis A, B, and C.

MAIN OUTCOME

Findings indicate high specificity, low sensitivity, and low kappa coefficients for all three self-report measures.

RESULTS

Subgroup analyses revealed significant differences in sensitivity associated with previous substance abuse treatment experience for hepatitis B self-report and with gender for hepatitis C self-report.

CONCLUSION

Given the low sensitivity, the validity of drug users, self-reported information on hepatitis should be considered with caution.