Prevention research in rural communities: overview and concluding comments

Connecting to Community: Violence Prevention Barriers, Geography, and Preventionist Perceptions of Community Leadership and Opportunities

Violence is a public health concern, negatively impacting individual and community health and safety. Although violence can be prevented, prevention efforts are complex in part because they require addressing community factors. Despite an increase in funding and support for community violence prevention, relatively little is known about what prevention practice barriers may be related to community factors. This study addressed this gap by surveying a statewide sample of violence preventionists. We explored if coordination and logistical barriers and rural geography are associated with perceptions of two community factors: community opportunities and leadership quality. As part of a statewide assessment of violence and prevention efforts, 130 violence preventionists completed surveys. Results showed that both perceived coordination barriers and rural geography were negatively associated with perceptions of existing community opportunities, representative/influential leadership, and leadership commitment. Perceived logistical barriers were positively associated with perceived leadership commitment. Findings suggest that support reducing community coordination barriers in particular-and to support rural violence prevention work more broadly-is needed.

Decreasing sugar-sweetened beverage consumption in the rural adolescent population

Adolescent consumption of sugar-sweetened beverages (SSBs) has increased drastically with detrimental effects such as weight gain, weakened bones, dental caries, and associated higher levels of type II diabetes in this population. While in the clinical setting, rural family nurse practitioner (FNP) students, using Kellogg-funded Smart Phones, screened adolescents aged 13 to 17 years for SSB consumption in the previous 24 hours. Adolescents initially were provided with a pamphlet and related oral teaching concerning SSBs by the FNP students, as well as a water bottle to encourage healthy fluid intake. Screening SSB information was loaded onto Smart Phones, which resulted in immediate access by the primary investigator sometimes even hundreds of miles distant. After 30 days, FNP students completed follow-up phone interviews to reassess SSB consumption in the previous 24 hours. Results concerning decreased SSB consumption were statistically significant. Additionally, Smart Phones were instrumental in high-speed data transfer. Both advantages and disadvantages were encountered when using this evolving technology.

Successful research recruitment strategies in a study focused on abused rural women at risk for sexually transmitted infections

INTRODUCTION

The purpose of this article is to describe the successful recruitment methods of a study focused on a pilot intervention for rural women who were experiencing abuse and who also were at risk for sexually transmitted infections. Initial recruitment into the study was the primary challenge, and strategies to overcome recruitment difficulties are discussed.

METHODS

Eighty-seven women were screened, and 20 women were recruited from clinics into a 1-group pretest/posttest pilot study. The main inclusion criterion for the intervention was a past-year history of intimate partner violence (IPV).

RESULTS

After 1 month of recruitment, only 10 women agreed to be screened for IPV. Several creative strategies were utilized in the revision of the recruitment plan, with the most successful being knitting by the research staff and incentives to participants for screening. An additional 77 women agreed to be screened for study participation within 3 months of implementing the recruitment changes.

DISCUSSION

Personal involvement by the research staff and a nonthreatening and welcoming environment were necessary components for timely recruitment. Researcher flexibility and reevaluation allowed for changes to the recruitment plan that ultimately proved successful.

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy

OBJECTIVE

A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth.

METHOD

A 2 x 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9-17 years included the Child Behavior Checklist and out-of-home placements.

RESULTS

A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%).

CONCLUSIONS

Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments.

On becoming a practitioner-researcher in remote northern Australia: personal commitment and resources compensate for structural deterrents to research

AIM

This study critically explores the experience of one clinician who developed the practitioner-researcher role in a remote hospital.

PARTICIPANT

One occupational therapist working in rehabilitation who had never previously done or been trained for research but who completed and published a randomized controlled trial.

SETTING

Government hospital rehabilitation ward in remote northern Australia.

METHOD

Data from a reflective journal and project records were content analysed using a conceptual framework of the metropolitan practitioner-researcher experience.

RESULTS

The participant's experience was similar to that of metropolitan practitioner-researchers as it was not just a matter of doing research, but rather one of role change from practitioner to researcher. The remote context created structural conditions that discouraged and hindered research and made the task of researcher role development challenging with high personal costs. Research deterrents included a lack of: Research-related infrastructure (such as information technology), research development policy, research accommodations in job descriptions, dedicated funding to support research time release and training, and research support networks. These deterrents were a consequence of the remote setting. Investment of substantial personal time, money and use of pro bono city research advisers was required to compensate for structural deterrents to ensure project completion.

CONCLUSION

Researcher role development was central to project success, the remote context dominated role development processes and personal resources were needed to compensate for structural research deterrents

Opportunities to meet challenges in rural prevention research: findings from an evolving community-university partnership model

Various rural prevention research challenges have been articulated through a series of sessions convened since the mid 1990s by the National Institutes of Health, particularly the National Institute on Drug Abuse. Salient in this articulation was the need for effective collaboration among rural practitioners and scientists, with special consideration of accommodating the diversity of rural areas and surmounting barriers to implementation of evidence-based interventions. This paper summarizes the range of challenges in rural prevention research and describes an evolving community-university partnership model addressing them. The model entails involvement of public school staff and other rural community stakeholders, linked with scientists by Land Grant University-based Extension system staff. Examples of findings from over 16 years of partnership-based intervention research projects include those on engagement of rural residents, quality implementation of evidence-based interventions, and long-term community-level outcomes, as well as factors in effectiveness of the partnerships. Findings suggest a future focus on building capacity for practitioner-scientist collaboration and developing a network for more widespread implementation of the partnership model in a manner informed by lessons learned from partnership-based research to date.

The ARC organizational and community intervention strategy for implementing evidence-based children's mental health treatments

This paper reviews the implications of organizational and community intervention research for the implementation of effective mental health treatments in usual community practice settings. The paper describes an organizational and community intervention model named ARC for Availability, Responsiveness and Continuity, that was designed to support the improvement of social and mental health services for children. The ARC model incorporates intervention components from organizational development, interorganizational domain development, the diffusion of innovation, and technology transfer that target social, strategic, and technological factors in effective children's services. This paper also describes a current NIMH-funded study that is using the ARC intervention model to support the implementation of an evidence-based treatment, Multisystemic Therapy (MST), for delinquent youth in extremely rural, impoverished communities in the Appalachian Mountains of East Tennessee.

Challenges to HIV Prevention in Young Adults in the English-Speaking Caribbean: The Case in Rural Eastern Jamaica

This article presents findings from qualitative interviews with persons involved with HIV/AIDS prevention and youth development initiatives in rural Eastern Jamaica. Key informants were asked to describe the HIV/AIDS prevention strategies being employed in the region. Informants were also asked to share perspectives on challenges to HIV prevention with young adults in this setting. HIV/AIDS prevention strategies included: peer education, HIV talks and condom use demonstrations at family planning centers and the local health clinic, information dissemination at community events, and guest lectures with follow-up discussions during youth meetings and social development programs. Preoccupation with economic survival versus personal protection, denial of risk, fatalistic attitude, and ongoing struggle with low self-esteem, particularly among young adult females, were identified as reasons the message of prevention and willingness to practice personal protection was often rejected.

Community entry in conducting rural focus groups: process, legitimacy, and lessons learned

This article explores the value of community collaboration in a qualitative study of diabetes. In 1999, the Appalachian Diabetes Coalition of West Virginia University's Prevention Research Center employed a statewide effort to conduct focus groups in West Virginia to elicit cultural perspectives on diabetes and its management. The success of this research depended on community participation at many levels, particularly because of the rural, often geographically isolated community structure of the state. The researchers' entry into small communities and the involvement of local residents in focus groups was possible with the collaboration of the West Virginia Rural Health Education Partnerships program and the West Virginia University Extension Service, both of which played primary roles as community gatekeepers in helping the research team access and involve rural areas. This collaboration reinforced the value of a two-tiered approach in enlisting local resources. These relationships resulted in beneficial outcomes to all partners. Researchers benefited by gaining entry to communities, and the community organizations benefited by gaining a better understanding of the diabetic population to assist in planning programs. Working with well-established community groups with strong community ties is crucial when gaining entry for research and interventions. The identification and involvement of trusted, accessible members of rural communities gives research local legitimacy, ensures adequate participation and effective data collection, and permits entry into remote communities.

A rural mental health research agenda: defining context and setting priorities

This article provides a brief overview of research perspectives on rural mental health services and suggests the importance of building an agenda to bring coherence to studies in this area. The need for sound theory and methodology to guide research is emphasized. The importance of better conceptualization of the rural context as a focus of research is addressed, and 14 propositions concerning issues the authors think will advance rural research are presented. This article is intended to stimulate discussion about a research agenda that will lead to better understanding of rural needs for mental health services as well as more responsive service models.

Emerging behavioral strategies for the prevention of HIV in rural areas

HIV/AIDS prevention efforts have been concentrated in urban areas, despite increases in HIV in nonmetropolitan areas. This study reviews behavioral prevention programs initiated in rural areas and programs that could be adapted for rural contexts. Outcomes from these interventions demonstrate that preventive interventions at the population, community, targeted populations subgroups, and small group levels can reduce high-risk behavior in rural environments and are cost effective to deliver.

Perceptions of community nutrition and health needs in the Lower Mississippi Delta: a key informant approach

OBJECTIVE

Key informants' perceptions of nutrition and health needs in their southern rural communities were assessed prior to nutrition intervention planning.

DESIGN

This cross-sectional survey used in-person interviews.

SUBJECTS/SETTINGS

A sample of 490 individuals from 12 professional and lay roles in 8 community sectors in 36 counties in Arkansas, Louisiana, and Mississippi was chosen.

STATISTICAL ANALYSES PERFORMED

Factor analysis was carried out on reported food, nutrition, and health problems and contributing factors. The General Linear Models procedure identified within- and between-subject effects for factors. Tukey's post hoc tests identified differences between sectors and states. Frequencies and weighted rankings were computed for health problems.

RESULTS

Key informants rated individual-level factors (food choices, education, willingness to change, health behavior) as more important than community-level factors (food and health care access, resources) with regard to nutrition and health problems and contributors to problems. The number one health problem was hypertension.

IMPLICATIONS

Key informants are knowledgeable about nutrition and health problems, contributing factors, and available resources. Individual factors were perceived as more important contributors to nutrition and health problems providing valuable information for planning nutrition interventions.

Work attitudes, employment barriers, and mental health symptoms in a sample of rural welfare recipients

Most of the extant research on welfare reform has neglected to consider the experiences of families in rural settings. Fifty women receiving welfare for their dependent children in a rural community were interviewed about their work experiences and aspirations, barriers to employment and service use, as well as mental health and social support. The findings indicate that the majority of participants were connected to the labor force and expressed positive attitudes about work. Barriers to employment (lack of available jobs, child care) and service use (transportation, inconvenient office hours) were endorsed. Perceived social support was negatively related to depression symptoms and positively related to self-efficacy and self-esteem. The importance of understanding the life experiences of welfare recipients in different contexts is discussed.