Effect of rural practice observation on the anxiety of medical students

INTRODUCTION

The aim of this study is to identify the level and causes of anxiety of sixth year medical students related to working in a rural area and the effect of a 1-day mobile rural health service observation on their anxiety.

METHODS

In the Ondokuz Mayis University Medical School in Samsun, Turkey, 212 students participated in a 1-day mobile rural health service led by a family physician. Between June 2011 and June 2013, during their family medicine internship, each student completed a structured questionnaire and a State-Trait Anxiety Inventory (STAI) before and after the observation.

RESULTS

A total of 85.8% of the students preferred to work in an urban area compared to 14.2%, who preferred a rural area. Currently, 89.6% of the students live in an urban area while 84.4% had lived in an urban area during most of their childhood. A total of 18.5% had no opinion about living conditions in a rural area, 71.7% thought they would be able to deal with the challenges, and 52.4% said the idea of working in a rural area made them anxious. Those students who had lived in a rural area as a child were found to be less anxious about working in a rural area. The association between the preferred work area and the student's anxiety about working in a rural area was statistically significant (p<0.001). Of the students, 76.8% thought that rural areas are more difficult places to work; a major reason for this as stated by 76.4% was the desire to have access to easy transportation. Difficult living conditions was noted by the students as their main reason for not wanting to work in a rural areas. Of the students, 77.8% answered that the 1-day rural health service observation positively affected their perspective on working in a rural area. There were 102 (48.1%) anxious students before the observation and the total decreased to 87 (41%) after the observation.

CONCLUSIONS

Difficult living conditions were the main reason for students' anxiety about working in a rural area. Most of the students answered that the curriculum positively affected their perspective. Medical schools should provide students with the rural primary care environment experience, which would decrease their anxiety.

A checklist approach to caring for women seeking pregnancy testing: effects on contraceptive knowledge and use

OBJECTIVE

To assess how a checklist reminding clinicians to deliver a bundled intervention affects contraceptive knowledge and use 3 months after women seek walk-in pregnancy testing.

METHODS

Pre-intervention, an inner-city family planning clinic provided unstructured care; during the intervention period, clinic staff used a checklist to ensure women received needed services. Women seeking walk-in pregnancy testing who wished to avoid pregnancy for at least 6 months were asked to complete surveys about their contraceptive knowledge and use immediately after and 3-months after visiting the study clinic. To assess the significance of changes over time, we used logistic regression models.

RESULTS

Between January 2011 and May 2013, over 1500 women sought pregnancy testing from the study clinic; 323 completed surveys (95 pre-intervention and 228 during the intervention period). With this checklist intervention, participants were more likely to receive emergency contraception (EC) (22% vs. 5%, [aOR 4.66 (1.76-12.35)], [corrected] have an intrauterine device or implant placed at the time of their clinic visit (5% vs. 0%, p=0.02), or receive a contraceptive prescription (23% vs. 10%, p<0.001). Three months after visiting the study clinic, participants from the intervention period were more knowledgeable about intrauterine and subdermal contraception and were more likely to report at 3-month follow-up a method of contraception more effective than the method they used prior to seeking pregnancy testing from the study clinic (aOR=2.02, 95% CI=1.03-3.96). The authors would like to apologize for any inconvenience caused. [corrected].

CONCLUSIONS

Women seeking walk-in pregnancy testing appear more likely to receive EC and to have switched to a more effective form of birth control in the 3 months following their visit when clinic staff used a 3-item checklist and provided scripted counseling.

IMPLICATIONS

A checklist reminding clinic staff to assess pregnancy intentions, provide scripted counseling about both emergency and highly-effective reversible contraception, and offer same-day contraceptive initiation to women seeking walk-in pregnancy testing appears to increase use of more effective contraception.

The use of early immobilization in the management of acute soft-tissue injuries of the knee: results of a survey of emergency physicians, sports medicine physicians and orthopedic surgeons

BACKGROUND

Evidence-based guidelines on the use of immobilization in the management of common acute soft-tissue knee injuries do not exist. Our objective was to explore the practice patterns of emergency physicians (EPs), sports medicine physicians (SMPs) and orthopedic surgeons (OS) regarding the use of early immobilization in the management of these injuries.

METHODS

We developed a web-based survey and sent it to all EPs, SMPs and OS in a Canadian urban centre. The survey was designed to assess the likelihood of prescribing immobilization and to evaluate factors associated with physicians from these 3 disciplines making this decision.

RESULTS

The overall response rate was 44 of 112 (39%): 17 of 58 (29%) EPs, 7 of 15 (47%) SMPs and 20 of 39 (51%) OS. In cases of suspected meniscus injuries, 9 (50%) EPs indicated they would prescribe immobilization, whereas no SMPs and 1 (5%) OS would immobilize (p = 0.002). For suspected anterior cruciate ligament injuries, 13 (77%) EPs, 2 (29%) SMPs and 5 (25%) OS said they would immobilize (p = 0.005). For lateral collateral ligament injuries, 9 (53%) EPs, no SMPs and 6 (32%) OS would immobilize (p = 0.04). All respondents would prescribe immobilization for a grossly unstable knee.

CONCLUSION

We found that EPs were are more likely to prescribe immobilization for certain acute soft-tissue knee injuries than SMPs and OS. The development of an evidenced- based guideline for the use of knee immobilization after acute soft-tissue injury may reduce practice variability.

"It just happens": a qualitative study exploring low-income women's perspectives on pregnancy intention and planning

OBJECTIVE

Unintended pregnancy is common and disproportionately occurs among low-income women. We conducted a qualitative study with low-income women to better typologize pregnancy intention, understand the relationship between pregnancy intention and contraceptive use, and identify the contextual factors that shape pregnancy intention and contraceptive behavior.

STUDY DESIGN

Semistructured interviews were conducted with low-income, African-American and white women aged 18-45 recruited from reproductive health clinics in Pittsburgh, PA, to explore factors that influence women's pregnancy-related behaviors. Narratives were analyzed using content analysis and the constant comparison method.

RESULTS

Among the 66 participants (36 African-American and 30 white), we identified several factors that may impede our public health goal of increasing the proportion of pregnancies that are consciously desired and planned. First, women do not always perceive that they have reproductive control and therefore do not necessarily formulate clear pregnancy intentions. Second, the benefits of a planned pregnancy may not be evident. Third, because preconception intention and planning do not necessarily occur, decisions about the acceptability of a pregnancy are often determined after the pregnancy has already occurred. Finally, even when women express a desire to avoid pregnancy, their contraceptive behaviors are not necessarily congruent with their desires. We also identified several clinically relevant and potentially modifiable factors that help to explain this intention-behavior discrepancy, including women's perceptions of low fecundity and their experiences with male partner contraceptive sabotage.

CONCLUSION

Our findings suggest that the current conceptual framework that views pregnancy-related behaviors from a strict planned behavior perspective may be limited, particularly among low-income populations.

IMPLICATIONS

This study identified several cognitive and interpersonal pathways to unintended pregnancy among low-income women in Pittsburgh, PA, including perceptions of low reproductive control, perceptions of low fecundity and male partner reproductive coercion.

Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training

PURPOSE

The study explored optimal intraprofessional collaboration between physicians in the emergency department (ED) and those from general internal medicine (GIM). Prior to the study, a policy was initiated that mandated reductions in ED wait times. The researchers examined the impact of these changes on clinical practice and trainee education.

METHOD

In 2010-2011, an ethnographic study was undertaken to observe consults between GIM and ED at an urban teaching hospital in Ontario, Canada. Additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments as well as formal one-on-one interviews with 12 physicians. Data were coded and analyzed using concepts of institutional ethnography.

RESULTS

Participants perceived that efficiency was more important than education and was in fact the new definition of "good" patient care. The informal label "failure to cope" to describe high-needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency. This resulted in tension during consults as well as reduced opportunities for education.

CONCLUSIONS

The authors suggest that the emphasis on wait times resulted in more importance being placed on "getting the patient out" of the ED than on providing safe, compassionate, person-centered medical care. Resource constraints were hidden within a discourse that shifted the problem of overcrowding in the ED to patients with complex chronic conditions. The term "failure to cope" became activated when overworked physicians tried to avoid assuming care for high-needs patients, masking institutionally produced stress and possibly altering the way patients are perceived.

Chaperones for intimate examinations in family medicine: findings from a pilot study in Melbourne, Australia

BACKGROUND

The use of medical chaperones during clinical examinations is important whether one practises as a specialist, nurse, medical student or generalist. Chaperone use in general practice remains largely unknown in most countries across the world and, what is known is limited to a handful of countries. Their use in Australian general practice remains unknown.

OBJECTIVE

To explore the attitudes and practices of a cohort of general practitioners in urban Melbourne regarding the use of chaperones in their daily clinical practice.

METHODS

Self-administered postal questionnaire to pilot group of general practitioners in urban Melbourne, Australia.

MAIN OUTCOME MEASURES

Frequency of chaperone use; views on chaperone use itself; preferred choice for the role of chaperone; main reasons for using chaperones.

RESULTS

The majority (95% respondents) had never or occasionally used a chaperone. The use of chaperones correlated with general practitioner gender - male general practitioners were more likely to use a chaperone. General practitioners preferred choice as chaperone was the practice nurse. There was no association found between chaperone use and the respondents' age, practice size or the availability of a practice nurse. The most highly rated influence by general practitioners for using a chaperone was because of anticipated patient embarrassment and/or distress.

CONCLUSION

This is the first step in understanding attitudes and experiences of general practitioners in general practice in Australia. The results of a larger, national study would provide further insight into this important issue taking into account the realities of general practice in Australia and relationship between general practitioners and patients.

Health workforce equity in urban community health service of China

Objectives

To reveal the equity of health workforce distribution in urban community health service (CHS), and to provide evidence for further development of community health service in China.

Methods

A community-based, cross-sectional study was conducted in China from September to December 2011. In the study, 190 CHS centers were selected from 10 provinces of China via stratified multistage cluster sampling. Human resources profiles and basic characteristics of each CHS centers were collected. Lorenz curves and Gini Coefficient were used to measure the inequality in the distribution of health workforce in community health service centers by population size and geographical area. Wilcoxon rank test for paired samples was used to analyze the differences in equity between different health indicators.

Results

On average, there were 7.37 health workers, including 3.25 doctors and 2.32 nurses per 10,000 population ratio. Significant differences were found in all indicators across the samples, while Beijing, Shandong and Zhejiang ranked the highest among these provinces. The Gini coefficients for health workers, doctors and nurses per 10,000 population ratio were 0.39, 0.44, and 0.48, respectively. The equity of doctors per 10,000 population ratio (G = 0.39) was better than that of doctors per square kilometer (G = 0.44) (P = 0.005). Among the total 6,573 health workers, 1,755(26.7%) had undergraduate degree or above, 2,722(41.4%)had junior college degree and 215(3.3%) had high school education. Significant inequity was found in the distribution of workers with undergraduate degree or above (G = 0.52), which was worse than that of health works per 10000 population (P<0.001).

Conclusions

Health workforce inequity was found in this study, especially in quality and geographic distribution. These findings suggest a need for more innovative policies to improve health equity in Chinese urban CHS centers.

Intra-facility linkage of HIV-positive mothers and HIV-exposed babies into HIV chronic care: rural and urban experience in a resource limited setting

Introduction

Linkage of HIV-infected pregnant women to HIV care remains critical for improvement of maternal and child outcomes through prevention of maternal-to-child transmission of HIV (PMTCT) and subsequent chronic HIV care. This study determined proportions and factors associated with intra-facility linkage to HIV care and Early Infant Diagnosis care (EID) to inform strategic scale up of PMTCT programs.

Methods

A cross-sectional review of records was done at 2 urban and 3 rural public health care facilities supported by the Infectious Diseases Institute (IDI). HIV-infected pregnant mothers, identified through routine antenatal care (ANC) and HIV-exposed babies were evaluated for enrollment in HIV clinics by 6 weeks post-delivery.

Results

Overall, 1,025 HIV-infected pregnant mothers were identified during ANC between January and June, 2012; 267/1,025 (26%) in rural and 743/1,025 (74%) in urban facilities. Of these 375/1,025 (37%) were linked to HIV clinics [67/267(25%) rural and 308/758(41%) urban]. Of 636 HIV-exposed babies, 193 (30%) were linked to EID. Linkage of mother-baby pairs to HIV chronic care and EID was 16% (101/636); 8/179 (4.5%)] in rural and 93/457(20.3%) in urban health facilities. Within rural facilities, ANC registration <28 weeks-of-gestation was associated with mothers' linkage to HIV chronic care [AoR, 2.0 95% CI, 1.1–3.7, p = 0.019] and mothers' multi-parity was associated with baby's linkage to EID; AoR 4.4 (1.3–15.1), p = 0.023. Stigma, long distance to health facilities and vertical PMTCT services affected linkage in rural facilities, while peer mothers, infant feeding services, long patient queues and limited privacy hindered linkage to HIV care in urban settings.

Conclusion

Post-natal linkage of HIV-infected mothers to chronic HIV care and HIV-exposed babies to EID programs was low. Barriers to linkage to HIV care vary in urban and rural settings. We recommend targeted interventions to rapidly improve linkage to antiretroviral therapy for elimination of MTCT.

[Response of primary care teams to manage mental health problems after the 2010 earthquake]

BACKGROUND

Thirty to 50% of people exposed to a natural disaster suffer psychological problems in the ensuing months.

AIM

To characterize the activities in mental health developed by Primary Health Care centers after the earthquake that affected Chile on february 27th, 2010.

MATERIAL AND METHODS

A cross-sectional study analyzing 16 urban centers of Maule Region, was carried out. A questionnaire was developed to know the preparatory and supportive activities directed to the community and the training and self-care activities directed to Health Care personnel that were made during the 12 months following the catastrophe. In addition, a questionnaire evaluating structural aspects was designed.

RESULTS

Only 1/3 of the centers made some preparatory activity and none of them made a diagnosis of population vulnerability. The average of protective Mental Health interventions coverage reached 35% of the population estimated to be most affected. The activities lasted 31 to 62% of the optimal duration standards set by experts (according to the type of action). Important differences between centers in economic and geographical accessibility, construction and professional resources were found.

CONCLUSIONS

This study shows the difficulties faced by urban centers of Maule Region to deal with mental health problems caused by the earthquake, which were attributable to the absence of local planning and drills, and to the lack of intra and inter sectorial coordination.

Assessment of patient care indicators at community pharmacies in Bandung City, Indonesia

Community pharmacies supply medications; therefore are involved in the patient care process. The objective of this study was to study the quality of patient care given by these pharmacies. We conducted a cross sectional study of 13 community pharmacies in Bandung City, Indonesia. Data collected were patient care indicators whose standard is defined by the World Health Organization (WHO). These were assessed by observing 1961 subjects who presented to the studied pharmacies to receive their medication. The average dispensing time was 62 seconds. Ninety-six percent of the prescribed medicine was dispensed correctly and 99% of the prescribed medication was sufficiently labeled. Only 88% of patients were able to repeat the correct dosage regimen of their prescribed medicines. Although the average dispensing time was greater than the recommended 60 seconds, the dispensing time ranged from 3 to 435 seconds. Greater attention should be focused on making sure the patient understands the dosage regimen correctly to ensure patient compliance with the correct regimen.

"Civil unrest does not stop ovulation": women's prenatal and family planning services in a 1960s Detroit neighborhood clinic

In 1965, Nancy Milio established a prenatal and family planning clinic in Detroit, Michigan, to address health disparities and limited access to care among low-income, African American, urban women. Women's health disparities persist today nationally and internationally. Using historical methods, this research analyzes how Milio provided women's health services in the context of the social and political environment. Milio empowered neighborhood women to direct, plan, and participate in the care they received. Successful methods to address disparities in access to family and planning and prenatal care should include empowered participation from the women these programs are intending to serve.

Abortion services for sex workers in Uganda: successful strategies in an urban clinic

Sex workers' need for safe abortion services in Uganda is greater than that of the population of women of reproductive age because of their number of sexual contacts, the inconsistent use of contraception and their increased risk of forced sex, rape or other forms of physical and sexual violence. We sought to understand sex workers' experiences with induced abortion services or post-abortion care (PAC) at an urban clinic in Uganda. We conducted nine in-depth interviews with sex workers. All in-depth interviews were audiotaped, transcribed, translated, computer recorded and coded for analysis. We identified several important programmatic considerations for safe abortion services for sex workers. Most important is creating community-level interventions in which women can speak openly about abortion, creating a support network among sex workers, training peer educators, and making available a community outreach educator and community outreach workshops on abortion. At the health facility, it is important for service providers to treat sex workers with care and respect, allow sex workers to be accompanied to the health facility and guarantee confidentiality. These programmatic elements help sex workers to access safe abortion services and should be tried with all women of reproductive age to improve women's access to safe abortion in Uganda.

Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya

BACKGROUND

The World Health Organization (WHO) and the Government of Kenya alike identify a well-performing health workforce as key to attaining better health. Nevertheless, the motivation and retention of health care workers (HCWs) persist as challenges. This study investigated factors influencing motivation and retention of HCWs at primary health care facilities in three different settings in Kenya - the remote area of Turkana, the relatively accessible region of Machakos, and the disadvantaged informal urban settlement of Kibera in Nairobi.

METHODS

A cross-sectional cluster sample design was used to select 59 health facilities that yielded interviews with 404 health care workers, grouped into 10 different types of service providers. Data were collected in November 2011 using structured questionnaires and a Focus Group Discussion guide. Findings were analyzed using bivariate and multivariate methods of the associations and determinants of health worker motivation and retention.

RESULTS

The levels of education and gender factors were lowest in Turkana with female HCWs representing only 30% of the workers against a national average of 53%. A smaller proportion of HCWs in Turkana feel that they have adequate training for their jobs. Overall, 13% of the HCWs indicated that they had changed their job in the last 12 months and 20% indicated that they could leave their current job within the next two years. In terms of work environment, inadequate access to electricity, equipment, transport, housing, and the physical state of the health facility were cited as most critical, particularly in Turkana. The working environment is rated as better in private facilities. Adequate training, job security, salary, supervisor support, and manageable workload were identified as critical satisfaction factors. Family health care, salary, and terminal benefits were rated as important compensatory factors.

CONCLUSIONS

There are distinct motivational and retention factors that affect HCWs in the three regions. Findings and policy implications from this study point to a set of recommendations to be implemented at national and county levels. These include gender mainstreaming, development of appropriate retention schemes, competitive compensation packages, strategies for career growth, establishment of a model HRH community, and the conduct of a discrete choice experiment.

Postpartum contraception utilization among low-income women seeking immunization for infants in Mumbai, India

OBJECTIVE

The objective was to examine postpartum contraception utilization among Indian women seeking immunization for their infants in three low-income communities in Mumbai, India.

STUDY DESIGN

We conducted a cross-sectional questionnaire of low-income postpartum women seeking immunization for their infants at three large urban health centers in Mumbai. Contraceptive utilization data were collected as part of a larger study focused on the impact of postpartum domestic violence on maternal and infant health. Descriptive, bivariate and multivariate analyses were conducted to describe and identify predictors of postpartum contraceptive utilization.

RESULTS

Postpartum women aged 17-45 years (N=1049) completed the survey; 44.5% (n=467) reported resuming sexual relations with their husbands. Among these women, the majority (65.3%; n=305) reported not currently using contraception. In multivariate analyses, women who did not discuss postpartum family planning with their husbands, had not used contraception previous to the recent birth, and had experienced physical violence or forced sex were more likely to not use postpartum contraception (adjusted odds ratios=1.47-1.77). Among the 162 women using contraception, the most common time to initiation of contraception was 5 weeks postpartum, and the most common method used was condoms 77.8% (n=126).

CONCLUSION

Contraception nonuse was common among urban, low-income postpartum women in India. This study highlights the importance of developing interventions to increase use of highly effective contraceptive methods postpartum, and that spousal violence and lack of marital communication may present barriers to postpartum contraception utilization. Infant immunization may represent an opportunity for provision of contraceptives and contraceptive counseling.

IMPLICATIONS

This original research study is a unique contribution to the literature because it presents data regarding the nonuse of postpartum contraception among women seeking immunizations for their infants in urban centers in a developing country. It also reveals barriers to not using postpartum contraception and provides data for future interventions.

Effectiveness of the Epley's maneuver performed in primary care to treat posterior canal benign paroxysmal positional vertigo: study protocol for a randomized controlled trial

BACKGROUND

Vertigo is a common medical condition with a broad spectrum of diagnoses which requires an integrated approach to patients through a structured clinical interview and physical examination. The main cause of vertigo in primary care is benign paroxysmal positional vertigo (BPPV), which should be confirmed by a positive D-H positional test and treated with repositioning maneuvers. The objective of this study is to evaluate the effectiveness of Epley's maneuver performed by general practitioners (GPs) in the treatment of BPPV.

METHODS/DESIGN

This study is a randomized clinical trial conducted in the primary care setting. The study's scope will include two urban primary care centers which provide care for approximately 49,400 patients. All patients attending these two primary care centers, who are newly diagnosed with benign paroxysmal positional vertigo, will be invited to participate in the study and will be randomly assigned either to the treatment group (Epley's maneuver) or to the control group (a sham maneuver). Both groups will receive betahistine. Outcome variables will be: response to the D-H test, patients' report on presence or absence of vertigo during the previous week (dichotomous variable: yes/no), intensity of vertigo symptoms on a Likert-type scale in the previous week, total score on the Dizziness Handicap Inventory (DHI) and quantity of betahistine taken.

DISCUSSION

Positive results from our study will highlight that treatment of benign paroxysmal positional vertigo can be performed by trained general practitioners (GPs) and, therefore, its widespread practice may contribute to improve the quality of life of BPPV patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01969513.

Patient satisfaction with community pharmacy: comparing urban and suburban chain-pharmacy populations

BACKGROUND

Patient satisfaction with pharmaceutical care can be a strong predictor of medication and other health-related outcomes. Less understood is the role that location of pharmacies in urban or suburban environments plays in patient satisfaction with pharmacy and pharmacist services.

OBJECTIVES

The purpose of this study was to serve as a pilot examining urban and suburban community pharmacy populations for similarities and differences in patient satisfaction.

METHODS

Community pharmacy patients were asked to self-administer a 30-question patient satisfaction survey. Fifteen questions addressed their relationship with the pharmacist, 10 questions addressed satisfaction and accessibility of the pharmacy, and five questions addressed financial concerns. Five urban and five suburban pharmacies agreed to participate. Data analysis included descriptive statistics and chi-square analysis.

RESULTS

Most patients reported high levels of satisfaction. Satisfaction with pharmacist relationship and service was 70% or higher with no significant differences between locations. There were significant differences between the urban and suburban patients regarding accessibility of pharmacy services, customer service and some patient/pharmacist trust issues.

CONCLUSIONS

The significant differences between patient satisfaction in the suburban and urban populations warrant a larger study with more community pharmacies in other urban, suburban and rural locations to better understand and validate study findings.

Urban health: it's time to get moving!

The global health community should mainstream urban health and implement urban health programs to address the triple health burden of communicable diseases, noncommunicable diseases, and injuries in low- and middle-income countries.

How social accountability can be incorporated into an urban community-based medical education program: an Australian initiative

BACKGROUND

Medical schools play a role in ensuring that their outcomes ultimately have positive effects on the health status of communities. We describe an initiative that translates this broad intent into meaningful activities that foster positive attitudes to social accountability among medical students in the context of an already full curriculum.

METHODS

Faculty members from an urban community-based medical education program undertook broad consultation with its community groups. Medical students then undertook activities designed to assist in the well-being of socio-economically disadvantaged adolescents through near-peer counselling and health education.

RESULTS

Early evaluation from medical students, secondary students, community organisations and faculty indicates that the activities undertaken to-date have been of value to stakeholders.

DISCUSSION

This initiative is intended to develop one model for incorporating social accountability into the medical curriculum with sustainable activities that benefit the community and medical students. Further research and evaluation of the impact of this initiative on both the community group involved and on medical students is essential.

A guide to understanding the variation in premiums in rural health insurance marketplaces

Key Findings. (1) State-level decisions in implementing the Patient Protection and Affordable Care Act of 2010 (ACA) have led to significant state variation in the design of Health Insurance Marketplace (HIM) rating areas. In some designs, rural counties are grouped together, while in others, rural and urban counties have been deliberately mixed. (2) Urban counties have, on average, approximately one more firm participating in the marketplaces, representing about 11 more plan offerings, than rural counties have. (3) The highest-valued "platinum" plan types are less likely to be available in rural areas. Thus, the overall mix of plan types should be factored into the reporting of average premiums. (4) Levels of competition are likely to have a greater impact on the decisions of firms considering whether to operate in higher-cost areas or not, as those firms must determine how they can pass such costs on to consumers, conditional on the market share they are likely to control.