Mental health service use and cost by Australian women in metropolitan and rural areas

INTRODUCTION

The use and costs of mental health services by rural and remote Australian women are poorly understood.

OBJECTIVE

To examine the use of the Better Access Scheme (BAS) mental health services across geographical areas.

DESIGN

Observational epidemiology cohort study using a nationally representative sample of 14 247 women from the Australian Longitudinal Study on Women's Health born 1973-1978, linked to the Medical Benefits Schedule dataset for use of BAS services from 2006 to 2015. The number and cost of BAS services were compared across metropolitan and regional/remote areas for women using the mental health services.

FINDINGS

31% of women accessed a BAS mental health service, 12% in rural populations. Overall, 90% of women with estimated high service need had contact with professional services (83% rural vs 92% metropolitan regions). Mean mental health scores were lower for women accessing a BAS service in remote areas compared with metropolitan, inner and outer regional areas (61.9 vs 65.7 vs 64.8 vs 64.2, respectively). Higher proportion of women in remote areas who were smokers, low/risky drinkers and underweight were more likely to seek treatment. Compared with metropolitan areas, women in inner, outer regional and remote areas accessed a lower mean number of services in the first year of diagnosis (6.0 vs 5.0 vs 4.1 vs 4.2, respectively). Actual mean overall annual costs of services in the first year of diagnosis were higher for women in metropolitan areas compared with inner, outer regional or remote areas ($733.56 vs $542.17 vs $444.00 vs $459.85, respectively).

DISCUSSION

Women in rural/remote areas not accessing services need to be identified, especially among those with the highest levels of distress. In remote areas, women had greater needs when accessing services, although a substantial proportion of women who sought help through the BAS services lived in metropolitan areas.

CONCLUSION

Regardless of lower cost to services in rural/remote areas, geographic and economic barriers may still be major obstacles to accessing services.

Factors influencing nursing and allied health recent graduates' rural versus urban preferred principal place of practice: A cross-sectional data linkage study

INTRODUCTION

Disparities between metropolitan and non-metropolitan health workforce must be addressed to reduce inequities in health care access. Understanding factors affecting early career practitioners' choice of practice location can inform workforce planning.

OBJECTIVE

To investigate influences on rural practice location preferences of recent graduates.

DESIGN

Cross-sectional analysis linked university enrolment, Graduate Outcomes Survey (GOS) and Australian Health Professional Regulation Agency (Ahpra) principal place of practice (PPP) for 2018 and 2019 nursing and allied health graduates from two Australian universities. Chi-squared tests and logistic regression compared rural versus urban PPP and locational preference.

FINDINGS

Of 2979 graduates, 1295 (43.5%) completed the GOS, with 63.7% (n = 825) working in their profession and 84.0% of those (n = 693) in their preferred location. Ahpra PPP data were extracted for 669 (81.1%) of those working in their profession. Most reported influences were 'proximity to family/friends' (48.5%), 'lifestyle of the area' (41.7%) and 'opportunity for career advancement' (40.7%). Factors most influential for rural PPP were 'cost of accommodation/housing' (OR = 2.26, 95% CI = 1.23-4.17) and 'being approached by an employer' (OR = 2.10, 95% CI = 1.12-3.92). Having an urban PPP was most influenced by 'spouse/partners employment/career' (OR = 0.53, 95% CI = 0.30-0.93) and 'proximity to family/friends' (OR = 0.41, 95% CI = 0.24-0.72).

DISCUSSION

While the findings add strength to the understanding that graduates who originated from a rural area are most likely to take up rural practice in their preferred location, varied social and professional factors are influential on decision-making.

CONCLUSIONS

It is imperative to recruit students from non-metropolitan regions into health professional degrees, as well as addressing other influences on choice of practice location.

Medical treatment decision-making in rural cancer patients: A qualitative systematic review and meta-synthesis

OBJECTIVE

Rural cancer patients have unique care needs which may impact upon treatment decision-making. Our aim was to conduct a qualitative systematic review and meta-synthesis to understand their perspectives and experiences of making treatment decisions.

METHODS

A systematic search of MEDLINE, PsycINFO, CINAHL and RURAL was conducted for qualitative studies in rural cancer patients regarding treatment decision-making. Articles were screened for relevance, and data from the included articles were extracted and analysed using meta-thematic synthesis.

RESULTS

Twelve studies were included, with 4 themes and 9 subthemes identified. Many studies reported patients were not given a choice regarding their treatment. Choice, if given, was influenced by personal factors such as finances, proximity to social supports, convenience, and their personal values. Patients were also influenced by the opinions of others and cultural norms. Finally, it was reported that patients made choices in the context of seeking the best possible medical care and the patient-clinician relationship.

CONCLUSIONS

In the rural context, there are universal and unique factors that influence the treatment decisions of cancer patients.

PRACTICAL IMPLICATIONS

Our findings are an important consideration for clinicians when engaging in shared decision-making, as well as for policymakers, to understand and accommodate the unique rural perspective.

Factors influencing medical radiation science graduates' early career principal place of practice: a retrospective cohort study

INTRODUCTION

While studies have investigated influences on graduate practice locations of other health professionals, especially medicine, none have investigated practice locations of medical radiation science (MRS) graduates. This study aimed to explore factors influencing the registered principal place of practice (PPP) of diagnostic radiography, radiation therapy and nuclear medicine graduates from the University of Newcastle (UON), Australia, in their second post-graduate year.

METHODS

Data were extracted from the UON enrolment and clinical placement databases and linked to Australian Health Practitioners Regulation Agency (Ahpra) registration data for PPP location in 2019 for 187 graduates who completed their studies in 2017. Explanatory variables included age at enrolment, gender, MRS discipline, location of origin, socio-economic index for location of origin, and locations and duration of undergraduate professional placements. Descriptive statistics, tests of association and logistic regression compared rural and non-rural origin, and professional placement locations with Ahpra PPP.

RESULTS

Factors related to non-metropolitan PPP were location of origin (P = 0.002), number (P = 0.002) and duration (P = 0.007) of rural placements, and MRS discipline (P = 0.033). Controlling for other variables, location of origin and MRS discipline remained significant. Graduates of rural origin had up to 3.54 (95%CI = 1.51-8.28) times the odds of a rural PPP. Diagnostic radiography graduates had up to 5.46 (95%CI = 1.55-19.20) times the odds of nuclear medicine of a rural PPP.

CONCLUSION

To help reduce the gap between rural and metropolitan medical radiation service availability, there is a need for targeted recruitment of rural origin students. Further investigation of the effect of rural undergraduate MRS placements is justified.

Rationale and protocol for the Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study: a large-scale longitudinal investigation of graduate practice destinations

INTRODUCTION

Inequitable distribution of health workforce limits access to healthcare services and contributes to adverse health outcomes. WHO recommends tracking health professionals from their points of entry into university and over their careers for the purpose of workforce development and planning. Previous research has focused on medical students and graduates' choice of practice location. Few studies have targeted nursing and allied health graduates' practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is investigating factors affecting Australian nursing and allied health students and graduates' choice of graduate practice location over the course of their studies and up to 10 years after graduation by linking multiple data sources, including routinely collected university administrative and professional placement data, surveys of students and graduates, and professional registration data.

METHODS

By using a prospective cohort study design, each year a new cohort of about 2000 students at each participating university (Deakin University, Monash University and the University of Newcastle) is tracked throughout their courses and for 10 years after graduation. Disciplines include medical radiation practice, nursing and midwifery, occupational therapy, optometry, paramedicine, pharmacy, physiotherapy, podiatry and psychology. University enrolment data are collected at admission and professional placement data are collected annually. Students' practice destination intentions are collected via questions added into the national Student Experience Survey (SES). Data pertaining to graduates' practice destination, intentions and factors influencing choice of practice location are collected in the first and third years after graduation via questions added to the Australian Graduate Outcomes Survey (GOS). Additionally, participants may volunteer to receive a NAHGOT survey in the second and fourth-to-tenth years after graduation. Principal place of practice data are accessed via the Australian Health Practitioner Regulation Agency (Ahpra) annually. Linked data are aggregated and analysed to test hypotheses comparing associations between multiple variables and graduate practice location.

RESULTS

This study seeks to add to the limited empirical evidence about factors that lead to rural practice in the nursing and allied health professions. This prospective large-scale, comprehensive study tracks participants from eight different health professions across three universities through their pre-registration education and into their postgraduate careers, an approach not previously reported in Australia. To achieve this, the NAHGOT study links data drawn from university enrolment and professional placement data, the SES, the GOS, online NAHGOT graduate surveys, and Ahpra data. The prospective cohort study design enables the use of both comparative analysis and hypothesis testing. The flexible and inclusive study design is intended to enable other universities, as well as those allied health professions not regulated by Ahpra, to join the study over time.

CONCLUSION

The study demonstrates how the systematic, institutional tracking and research approach advocated by the WHO can be applied to the nursing and allied health workforce in Australia. It is expected that this large-scale, longitudinal, multifactorial, multicentre study will help inform future nursing and allied health university admission, graduate pathways and health workforce planning. Furthermore, the project could be expanded to explore health workforce attrition and thereby influence health workforce planning overall.

Destinations of nursing and allied health graduates from two Australian universities: A data linkage study to inform rural placement models

OBJECTIVE

Combined, nursing and allied health constitute most of the Australian health workforce; yet, little is known about graduate practice destinations. University Departments of Rural Health have collaborated on the Nursing and Allied Health Graduate Outcomes Tracking to investigate graduate entry into rural practice.

DESIGN

Data linkage cohort study.

SETTING

Monash University and the University of Newcastle.

PARTICIPANTS

Graduates who completed their degree in 2017 across seven disciplines.

MAIN OUTCOME MEASURE(S)

The outcome variable was Australian Health Practitioner Regulation Agency principal place of practice data. Explanatory variables included discipline, age, gender, location of origin, and number and duration of rural placements.

RESULT

Of 1130 graduates, 51% were nurses, 81% females, 62% under 21 years at enrolment, 23% of rural origin, 62% had at least one rural student placement, and 23% had over 40 cumulative rural placement days. At the time of their second Australian Health Practitioner Regulation Agency registration, 18% worked in a 'Rural principal place of practice.' Compared to urban, rural origin graduates had 4.45 times higher odds ratio of 'Rural principal place of practice.' For graduates who had <20 cumulative rural placement days, compared to zero the odds ratio of 'Rural principal place of practice' was the same (odds ratio = 1.10). For those who had 20-40 rural placement days, the odds ratio was 1.93, and for >40 rural placement days, the odds ratio was 4.54).

CONCLUSION

Rural origin and more rural placement days positively influenced graduate rural practice destinations. Outcomes of cumulative placements days may compare to immersive placements.

Profile and rural exposure for nursing and allied health students at two Australian Universities: A retrospective cohort study

Objective

Linking enrolment and professional placement data for students' from 2 universities, this study compares characteristics across universities and health disciplines. The study explores associations between students' location of origin and frequency, duration and type of placements.

Design

Retrospective cohort data linkage.

Setting

Two Australian universities, Monash University and the University of Newcastle.

Participants

Students who completed medical radiation science, nursing, occupational therapy, pharmacy or physiotherapy at either university between 2 February 2017 and 28 February 2018.

Interventions

Location of origin, university and discipline of enrolment.

Main outcome measure(s)

Main measures were whether graduates had multiple rural placements, number of rural placements and cumulative rural placement days. Location of origin, discipline and university of enrolment were the main explanatory variables. Secondary dependent variables were age, sex, socio‐economic indices for location of origin, and available placements.

Results

A total of 1,315 students were included, of which 22.1% were of rural origin. The odds of rural origin students undertaking a rural placement was more than 4.5 times greater than for urban origin students. A higher proportion of rural origin students had multiple rural placement (56.0% vs 14.9%), with a higher mean number of rural placement days. Public hospitals were the most common placement type, with fewer in primary care, mental health or aged care.

Conclusions

There is a positive association between rural origin and rural placements in nursing and allied health. To help strengthen recruitment and retention of graduates this association could be further exploited, while being inclusive of non‐rural students

Comparative use of cancer therapies in Australian farm, rural nonfarm and urban residents aged 45 years and older

Objectives and importance of the study: To determine whether use of selected therapies for prostate, breast and colorectal cancer in farm residents differs from that in rural nonfarm and urban counterparts. Little is known about cancer therapies used by farm residents.

STUDY TYPE

Data linkage cohort study.

METHODS

Baseline survey information from the Sax Institute's 45 and Up Study cohort was linked with data from the New South Wales Admitted Patient Data Collection for 2006-2012. Adjusted odds of receiving surgery, chemotherapy, radiotherapy and/or brachytherapy for each cancer were compared between groups, controlling for selected variables.

RESULTS

Differences in the likelihood of surgery for breast and colorectal cancer between groups were not significant. However, for prostate cancer, farm men had 35% greater odds of prostatectomy than rural nonfarm men (odds ratio [OR] 1.35; 95% CI 1.05, 1.72). Urban men were most likely to have had brachytherapy, with three times greater odds of treatment than farm men (OR 2.90; 95% CI 1.51, 5.56). Urban women were most likely to have had chemotherapy for breast cancer, having twice the odds of receiving this treatment as farm women (OR 2.24; 95% CI 1.25, 4.04). The odds of chemotherapy for colorectal cancer among rural nonfarm residents were two-thirds the odds among urban men (OR 0.62; 95% CI 0.44, 0.90) and urban women (OR 0.57; 95% CI 0.37, 0.88). Age, distance, income and health insurance factors contributed to differences in nonsurgical care between groups.

CONCLUSIONS

Cancer-related surgical services for breast and colorectal cancer were comparable between groups. Farm and rural nonfarm residents may have been disadvantaged in relation to nonsurgical therapies for prostate, breast and colorectal cancer compared with urban counterparts.

Comparison of cancer incidence in Australian farm residents 45 years and over, compared to rural non-farm and urban residents - a data linkage study

BACKGROUND

It is not known if the incidence of common cancers in Australian farm residents is different to rural non-farm or urban residents.

METHODS

Data from farm, rural non-farm and urban participants of the 45 and Up Study cohort in New South Wales, Australia, were linked with state cancer registry data for the years 2006-2009. Directly standardised rate ratios for cancer incidence were compared for all-cancer, prostate, breast, colorectal cancer, melanoma and non-Hodgkin Lymphoma (NHL). Proportional hazards regression was used to generate incidence hazard ratios for each cancer type adjusted for relevant confounders.

RESULTS

Farm women had a significantly lower all-cancer hazard ratio than rural non-farm women (1.14, 1.01-1.29). However, the lower all-cancer risk observed in farm men, was not significant when compared to rural non-farm and urban counterparts. The all-cancer adjusted hazard ratio for combined rural non-farm and urban groups compared to farm referents, was significant for men (1.08,1.01-1.17) and women (1.13, 1.04-1.23). Confidence intervals did not exclude unity for differences in risk for prostate, breast, colorectal or lung cancers, NHL or melanoma. Whilst non-significant, farm residents had considerably lower risk of lung cancer than other residents after controlling for smoking and other factors.

CONCLUSIONS

All-cancer risk was significantly lower in farm residents compared to combined rural non-farm and urban groups. Farm women had a significantly lower all-cancer adjusted hazard ratio than rural non-farm women. These differences appeared to be mainly due to lower lung cancer incidence in farm residents.

Farmers' knowledge of Q fever and prevention approaches in New South Wales

OBJECTIVE

To identify what New South Wales (NSW) farmers know about Q fever to inform preventive approaches.

DESIGN

Thematic analysis of qualitative data gathered through semi-structured individual interviews, focus groups and a community meeting.

SETTING

Rural communities in NSW, Australia.

PARTICIPANTS

A total of 25 farmers participated in individual interviews (n = 4) or three focus groups, each with seven participants (n = 21). A further 27 persons, were involved in a community meeting.

MAIN OUTCOME MEASURES

Themes derived from the interviews, focus groups and community meeting.

RESULTS

Knowledge variations regarding Q fever risk and transmission highlight a need for improved risk communication. Vaccination was viewed as the preferred prevention approach; barriers were raised including time, costs, access to screening/vaccination and General Practitioner (GP) knowledge about Q fever. Local vaccination initiatives were supported.

CONCLUSIONS

Strengthening existing GP knowledge and services leading to expanded provision of screening/vaccination could improve the coverage of Q fever vaccine in endemic NSW farming and rural communities.

A review of prostate cancer incidence and mortality studies of farmers and non-farmers, 2002-2013

OBJECTIVES

To review the recent literature on the incidence and mortality of prostate cancer in farmers compared to non-farmers.

METHODS

Searches were conducted in seven electronic databases for observational studies published from 2002 to 2013. Studies were assessed against eligibility criteria and a narrative summary of findings presented.

RESULTS

Eighteen primary research articles were included in the review. Four of ten mortality studies and two of nine incidence studies reported statistically significant increases in prostate cancer risk in farmers. However, nearly half of all studies reported non-significant reductions in farmers' risk. Additionally, one study reported significantly increased and decreased risk using different outcome measures. Results varied considerably by geographic region, study design and degree of control for confounders, affecting comparability and strength of findings.

CONCLUSIONS

The overall evidence for increased prostate cancer risk in farmers was weak.

Safe play areas on farms in New South Wales

OBJECTIVE

To assess the prevalence and security of fenced house yards on NSW farms and rural properties with a view to providing information to increase the development of safe play areas on farms.

DESIGN

A cross-sectional stratified study using computer-assisted telephone interviewing.

SETTING

Interviews were conducted in the four rural Area Health Services throughout February to December 2008.

PARTICIPANTS

Randomly selected sample of 1117 adults living on a farm or rural property in the study areas.

MAIN OUTCOME MEASURES

Self-reported issues involving fenced house yards or safe play areas for children.

RESULTS

Overall, 79.8% of farm respondents reported that they had a fenced house yard or safe play area. For those respondents with a fenced house yard, 66.6% reported that it was secure enough to prevent /make it difficult for a young child to wander away unsupervised. Based on these figures, it is estimated that only 53.1% of all farms or rural properties have a secure fenced house yard or safe play area. There were statistically significant variations between geographic locations, with the North Coast (37.7%) being lower.

CONCLUSIONS

This study illustrates a need across rural NSW to further promote, install or upgrade secure fenced house yards or safe play areas. While all geographic regions of the state could improve provision to protect children, there may also be some that are in need of more intensive intervention programs to enhance compliance. Such a proposition may also be relevant on a national level.

Mortality patterns of Australian male farmers and farm managers

OBJECTIVE

To compare the all-cause and specific-cause death rates of Australian male farmers and farm managers aged 25-74 years, with other Australian men.

METHODS

Data were extracted from the Australian Bureau of Statistics Death Registration Collection covering the calendar years of 1999-2002. Denominator data for male farmers and farm managers were drawn from the 2001 Australian Population Census. Direct age-standardized death rates were calculated and compared with the general Australian male population.

RESULTS

The 4025 male farmers or farm managers who died in this period represented 3.35% of all male deaths in the 25-74 year age range. The all-cause death rate for farmers and farm managers (730/100,000) was 33% higher than that of the Australian male population of the same age (549/100,000) (standardized mortality ratio (SMR)=1.33). Causes of death related to neoplasms (SMR=1.37), circulatory disease (SMR=1.40) and all external causes (SMR=1.37), were all statistically higher than the comparison population. Within these groupings, ischaemic heart disease (SMR=1.39), other circulatory disease (SMR=1.42), prostate cancer (SMR=2.40), lymphohaematopoietic cancer (SMR=1.80) and transport injuries (SMR=2.06), were all significantly higher.

CONCLUSION

These data indicate that Australian male farmers and farm managers are a disadvantaged group in terms of health status. The elevated rates of all-cause and specific-cause mortality compared with the Australian comparison population, illustrate both the need and scope for further investigation of these issues.

Hearing screening program impact on noise reduction strategies

The objective of this study was to determine the impact of the New South Wales Rural Hearing Conservation Program on the implementation of personal hearing protection (PHP) and noise management strategies among farmers who had participated in this program in New South Wales, Australia. A follow-up survey of a random sample of people screened through the New South Wales Rural Hearing Conservation Program was linked to their baseline data. The use of PHP at baseline was compared to use at follow-up in four specific scenarios: use with non-cabbed tractors, with chainsaws, with firearms, and in workshops. For non-cabbed tractors, the net gain in PHP use was 13.3%; the net gain was 20.8% for chainsaws, 6.7% for firearms, and 21.3% for workshops. Older farmers and those with a family history of hearing loss were less likely to maintain or improve PHP use. Those with severe hearing loss, males, and participants reporting hearing problems in situations where background noise was present were more likely to maintain or improve PHP use. Forty-one percent of farmers had initiated other strategies to reduce noise exposure beyond the use of PHP, which included engineering, maintenance, and noise avoidance solutions. The early (hopefully) identification of hearing deficit in farmers and farm workers can help promote behavior change and help reinforce a farm culture that supports hearing conservation. The continuation and expansion of hearing screening programs such as these should be encouraged as basic public health strategy in farming communities.

An evidence-consultation base for developing child injury prevention priorities for Australian farms

ISSUE ADDRESSED

Child injury on farms is a significant public health problem. This article describes the evidence and consultation base for development of a national strategy for child safety on farms in Australia.

METHODS

A data profile describing farm child injury was compiled, with evidence for the effectiveness of solutions being defined and the strength of recommendations determined. Representative working groups played a key role in assessing the evidence and advising on the best ways to communicate prevention messages within the farming community.

RESULTS

The main risks identified were drowning; farm vehicle and machinery injury; and injury associated with motorbikes and horses. Prevention recommendations were: (1) creating effective safe play areas on farms; (2) use of seatbelts/restraints in farm vehicles, (3) prevention of children riding as passengers on tractors, ATVs or the back of utilities; and (4) use of helmets when riding horses and motorbikes.

CONCLUSIONS

Evidence on key injury risks and solutions has been a cornerstone to set the agenda for child safety on farms. An evidence-consultation base has achieved credibility with potential partners at all levels for adopting priority child safety messages.

Factors Affecting Farm Noise During Common Agricultural Activities

Hearing injury due to exposure to excessive noise during common farming activities is a significant problem for farmers. The aim of this study was to investigate factors that affect the level of risk to hearing caused by common farming activities. Noise levels on farms were measured across a range of activities and producer groups, and situational factors that effect noise levels were also investigated. Older tractors were found to be 6 dB louder than newer tractors. Cabs reduced noise to the operator by 16 dB, which was halved to 8 dB if a door was open. Radios added between 3 and 5 dB to the noise in the cab. These variables significantly affect the noise level at the ear of operators and others in the workplace, and affect the subsequent exposure limits that are considered safe. Situational factors need to be considered in assessing the level of risk to farmers' hearing and in choosing noise management strategies on the farm. This information has been incorporated into material about hearing and discussions with farmers who participated in field day hearing screening programs in Australia.

Farm Noise Emissions During Common Agricultural Activities

Noise injury in agriculture is a significant yet often unrecognized problem. Many farmers, farm workers, and family members are exposed to noise levels above recommended levels and have greater hearing loss than their non-farming contemporaries. The aim of this study was to gather up-to-date information on farm noise levels and to enhance the quality of information available to assist farmers in reducing noise exposure and meeting Occupational Health and Safety (OHS) regulations regarding noise management. Farm visits were conducted on 48 agricultural establishments that produce a range of commodities. Noise levels were measured at the ears of operators and bystanders involved in typical activities on farms. The average and peak noise levels were measured for 56 types of machinery or sites of farming activity, totaling 298 separate items and activities. Common noise hazards identified included firearms, tractors without cabs, workshop tools, small motors (e.g., chainsaws, augers, pumps), manual handling of pigs, shearing sheds, older cabbed tractors, and heavy machinery such as harvesters, bulldozers, and cotton module presses. We found that use of firearms without hearing protection presents a pressing hearing health priority. However, farming activities involving machinery used for prolonged periods also present significant risks to farmers' hearing health. Noise management strategies on the farm are essential in order to prevent noise injury among farmers.