Nonmetropolitan Settings Research Articles

Gastrostomy tube (g-tube) placement timing and clinical outcomes in patients with locally advanced squamous cell carcinoma of the head and neck (HNSCC) receiving definitive chemoradiation.

37 Background: Patients with HNSCC who undergo definitive chemoradiation (dCRT) frequently require nutritional support via G-tubes; despite this, the factors associated with the timing of G-tube placement remain poorly understood. Methods: We performed a retrospective analysis of patients with HNSCC who received dCRT and required G-tube placement between 01/2018 – 01/2024. We segregated G-tube timing into two groups as determined by the intent of the treating clinician: “prophylactic” placement (ordered in anticipation of dCRT start) or “reactive” placement (ordered in response to weight loss or other adverse clinical indicators). We then evaluated associated clinical variables (patient, disease, treatment) and outcomes (weight loss, G-tube duration, healthcare utilization). Differences across G-tube groups were assessed using t-tests or Wilcoxon Rank Sum tests for continuous measures and Fisher’s exact tests or logistic regression for binary variables. Results: We identified 86 patients; 59 (69%) prophylactic and 27 (31%) reactive G-tubes were placed. At baseline, patients had a mean age of 63, BMI of 28 kg/m 2 , and Charlson Comorbidity Index of 4. Patients were 12% non-White, 2% non-English speaking, and 10% unhoused; 27% had a non-metropolitan address, 67% had public insurance, 31% were smokers and 26% had a history of alcohol dependence. The most common site was the oropharynx (66%; 75% HPV+). Across HNSCC types, 38% had stage IV disease and 60% had preexisting dysphagia/odynophagia. Most received weekly (83%) cisplatin (84%) and bilateral (95%) radiation (RT). We collected RT dose data (parotids, esophagus, pharyngeal constrictors) and found no association between RT dose and G-tube group. Patients with prophylactic G-tubes were significantly more likely to have preexisting odynophagia/dysphagia (69% vs 41%, p = 0.017). Compared to the prophylactic group, reactive G-tube placement occurred more often among patients living in non-metropolitan settings (44% vs 19%, p = 0.018) and was associated with a trend towards a higher mean percent weight loss (12% vs 10%; p = 0.128) and cachexia (per int’l criteria; 89% vs 74%, p = 0.159). We observed no difference in the median G-tube duration or in the rate of persistent G-tube use at last follow-up or death. Notably, we found that patients with reactive G-tubes were hospitalized more frequently (74% vs 36%, p = 0.001) and had a longer median length of stay (LOS; 6 vs 0 days, p = 0.001); these findings remained statistically significant when controlling for other factors (OR 3.76 [95% CI: 1.20-12.65]; p = 0.026). Conclusions: We found that reactive G-tubes were associated with increased hospitalization and LOS, suggesting that select patients may benefit from earlier G-tube placement.

Chronic hepatitis B care in regional Australia: implications for clinical practice and public health policy.

Australia is struggling to meet its National Hepatitis B Strategy care targets, particularly in nonmetropolitan settings. It is vital to engage priority populations and improve their access to recommended care to reach these targets. This retrospective study examined people living with chronic hepatitis B (CHB) in regional North Queensland, Australia, and determined whether their care adhered to current national CHB management guidelines. The analysis aimed to identify gaps in care that might be addressed to improve future outcomes. All individuals referred to the gastroenterology clinic at the Townsville University Hospital in regional North Queensland, Australia, for CHB care between January 2015 and December 2020 were identified. Their linkage to care, engagement in care and receipt of guideline-recommended CHB care were determined. Of 255 individuals, 245 (96%) were linked to care; 108 (42%) remained engaged in care and 86 (38%) were receiving guideline-recommended care in 2021. There were 91/255 (36%) who identified as Indigenous Australians. Indigenous status was the only independent predictor of not being linked to care (odds ratio (OR): 0.13 (95% confidence interval (CI): 0.03-0.60), P = 0.01), not being engaged in care (OR: 0.19 (95% CI: 0.10-0.36), P < 0.0001), not receiving guideline-recommended CHB care (OR: 0.16 (95% CI: 0.08-0.31), P < 0.0001) or not being engaged in a hepatocellular carcinoma surveillance programme (OR: 0.08 (95% CI: 0.02-0.27), P < 0.0001). Current approaches are failing to deliver optimal CHB care to Indigenous Australians in regional North Queensland. Targeted strategies to ensure that Indigenous Australians in the region receive equitable care are urgently needed.

A qualitative study of refugee men's mental health in non-metropolitan Manitoba

In bringing together literature on masculinity, refugee mental health experiences, and rural and non-metropolitan settings, we identify a gap surrounding the mental health experiences of refugee men in non-metropolitan places, and in non-metropolitan Canada specifically. In this article, we explore how refugee men in non-metropolitan Canada understood mental health; what they perceive to be the most significant barriers to good mental health; and the perceived access to and quality of support services. This collaborative qualitative study of refugee men's mental health was based in Brandon, Manitoba, and involved focus groups with a total of 29 participants, conducted in three different languages. Participants were from various countries in East Africa and the Middle East and ranged in age from 18 to 61 years old. Participants revealed diverse understandings of mental health related to cultural and religious/spiritual teachings as well as stressors that were embedded in their non-metropolitan community and their transnational journeys and relationships. Participants also indicated that both local stressors (e.g., employment/unemployment problems, challenges making a life/future) and distant stressors (e.g., concern for the safety of family in the participants’ home countries, the separation of family participants due to migration, logistical difficulties in communicating with loved ones outside of Canada, and grief over war and conflict in participants’ countries of origin) significantly impacted their mental health. We conclude that a holistic approach to health supports, including mental, physical, and spiritual wellness is important for refugee men in rural/non-metropolitan areas. These findings can inform policies, programs and funding of initiatives supporting newcomers and refugees to rural and non-metropolitan areas and contributes meaningfully to the refugee dispersion debate in Canada.

A Survey of Behavioral Health Care Providers on Use and Barriers to Use of Measurement-Based Care.

Despite robust evidence for efficacy of measurement-based care (MBC) in behavioral health care, studies suggest that adoption of MBC is limited in practice. A survey from Blue Cross-Blue Shield of North Carolina was sent to behavioral health care providers (BHCPs) about their use of MBC, beliefs about MBC, and perceived barriers to its adoption. The authors distributed the survey by using professional networks and snowball sampling. Provider and clinical practice characteristics were collected. Numerical indices of barriers to MBC use were created. Ordered logistic regression models were used to identify associations among practice and provider characteristics, barriers to MBC use, and level of MBC use. Of the 922 eligible BHCPs who completed the survey, 426 (46%) reported using MBC with at least half of their patients. Providers were more likely to report MBC use if they were part of a large group practice, had MBC training, had more weekly care hours, or practiced in nonmetropolitan settings. Physicians, self-reported generalists, more experienced providers, and those who did not accept insurance were less likely to report MBC use. Low perceived clinical utility was the barrier most strongly associated with less frequent use of MBC. Although evidence exists for efficacy of MBC in behavioral health care, less than half of BHCPs reported using MBC with at least half of their patients, and low perceived clinical utility of MBC was strongly associated with lower MBC use. Implementation strategies that attempt to change negative attitudes toward MBC may effectively target this barrier to use.

Examining audience perspectives on local newspaper futures

When it comes to examining innovation and small-town newspapers, audience expectations and perspectives have received less focus than newsroom practices and processes. This article presents the findings of Australia’s most comprehensive national survey of local newspaper audiences ( n = 4116), which engaged with readers of more than 170 independently owned, small-town newspapers across the nation. The survey was underpinned by a ‘geo-social’ methodology, which provides a multidimensional framework for understanding the ‘place’ of newspapers in the digital age within their specific geographic context, in this case rural Australia. It used ordinal, nominal and qualitative questions to explore respondents’ experiences, histories, expectations and perspectives related to their local newspaper. Respondents were asked about their preferences for reading and receiving local news, what their newspaper can do better, and the policy debates and interventions shaping the sector. Results indicate a continued desire for the printed product, a passion for localness in terms of both production and content, and a greater say for local news audiences on the policies shaping the future of news in non-metropolitan settings.

Evaluation of research capacity and culture of hospital pharmacists and pharmacy technicians in a state-wide Australian public health service: A cross-sectional survey.

Integrating research with clinical practice is essential for evidence-based practice and continuous improvement in health care. Little is known about the research capacity and culture of the Australian hospital pharmacy workforce, particularly in rural areas and for pharmacy assistants/technicians. This paper aims to characterise the research capacity and culture of a state-wide public-hospital pharmacy service at organisation, team and individual levels, and to explore variables which influence research confidence and success. An online, anonymous, cross-sectional survey using the validated Research Capacity in Context tool was emailed to all pharmacists, pharmacy assistants/technicians and non-clinical staff employed by a statewide pharmacy service in South Australia. Respondent characteristics and organisation, team and individual scores of research skill/success were summarised using descriptive statistics. T-tests compared results for pharmacists and pharmacy assistants/technicians and metropolitan-based and non-metropolitan-based staff. Regression analyses explored predictors of pharmacists individual research skill/success scores. A response rate of 43.4% (n=278/641, 19 sites) was obtained. Respondents were primarily pharmacists (68%) and pharmacy assistants/technicians (28%); 91% were practicing in a metropolitan setting. 47% reported no research experience. Highest scores for research skill/success were observed at the organisational level (mean score 6.0/10) vs. team (mean score 5.6/10) and individual levels (mean score 5.1/10). Within each level specific items that scored poorly were identified. Individual research skills/success scores were higher in pharmacists vs. pharmacy assistants/technicians (mean score 5.2/10 vs. 4.2/10, p<0.01), and were not different between staff in metropolitan vs. non-metropolitan settings (mean scores 5.2 vs. 5.0, p=0.77). For pharmacists, undertaking undergraduate or internship research projects or postgraduate research training were associated with higher individual scores of research skills and success. This research extends understanding of hospital pharmacy research capacity and culture, describes research skills and success in hospital pharmacy technicians/assistants for the first time and highlights low-scoring areas; these could be targeted to improve research capacity and culture at an individual, team and organisational levels.

Refugees, race and the limits of rural cosmopolitanism: Perspectives from Ireland and Wales

In many parts of the Global North, the imagined (and often illusionary) “whiteness” of rural societies has been both exposed and contested by the transnational movements of racialised migrant workers, refugees, asylum seekers and other immigrants. Such dynamics have prompted a renegotiation of ideas of race and rurality, with both reactionary responses of white populism and more progressive responses that assert a “rural cosmopolitanism” that evokes associations with hospitality, solidarity and community in rural culture. To explore these themes, this paper discusses evidence from three rural towns in Ireland and Wales with recent settlement of refugees or asylum seekers. The paper examines the articulation of a discourse of cosmopolitanism in the towns, the roles that are scripted within these discourses, both for migrants and for established residents, and the performance of these expectations. It reveals gaps between discourse and practice, with “actually existing cosmopolitanism” in the towns being characterized by ambivalence and precarity. The paper argues that both the discursive construction and the partial practice of cosmopolitanism are embedded in the rural, non-metropolitan settings of the towns and informed by place-specific palimpsests of migration and colonialism.

Experiences with a pilot electronic skin multidisciplinary clinic for complex skin cancer

Introduction: Complex skin cancers (CSCs) may benefit from review by a specialist skin multidisciplinary team (MDT). Accessing an MDT may be difficult for practitioners in non-metropolitan settings. Technology has been promoted as a solution. We decided to pilot an electronic or virtual skin MDT (eMDT). Methods: To gauge the level of need for a skin cancer MDT, a survey was circulated at a rural general practitioners (GPs) conference. Previous non-metropolitan referrers of skin cancer patients to our centres were also contacted to acertain the level of need, and a search was conducted for other non-metropolitan doctors who may be interested. For the skin cancer cases that were discussed at the eMDT, patient characteristics’ data was collected and included sex, age, distance from the patient’s home to our hospital, referral information, whether the patient was immuno-suppressed, whether the diagnosis involved a true CSC, what the referrer’s question was for the MDT, and whether a decision was made to advise the referring clinician of the MDT specialist team’s recommendations. Results: Five rural general practitioners (GPs) who responded to a survey, 10 previous referrers and 5 other rural GPs unanimously supported the need for a skin eMDT service. The surveys revealed that on average patients waited five months and travelled approximately 140 kilometres (km) to access specialist treatment. Four out of five (80%) of the survey respondents did not have an established referral pathway for CSC cases. Seven eMDT meetings were held fortnightly over 13 weeks. A total of 19 patients were presented. Of these, two patients were presented twice. Eighteen of the 19 patients were referred directly from members of the eMDT specialist team with radiation oncologists (ROs) accounting for most of the referrals (11/19). Only one referral came from a rurally based GP. The average age of the 19 patients was 69 years (range: 33-62 years), and 12 patients were males. The average distance from the patients’ home to our hospital was 75 kilometres. Six patients had an ECOG performance status of one or more. Five were immunocompromised, and all were reasonable cases to present. Eighteen patients had clear documented treatment decisions made by the eMDT with most decisions being for either adjuvant or definitive radiotherapy. Discussion: The structure and function of the eMDT is detailed along with the involvement of regional GPs. There could have been some bias observed because the number of ROs who participated outweighed that of other specialists. The eMDT was phased out for several reasons. It failed to serve the target referrer and patient population; process and documentation were poor; and there were issues with perceived competition from within and outside our health area. The arrival of the Covid-19 pandemic meant that our hospital’s main skin MDT became a virtual meeting, and the eMDT was therefore amalgamated into this service.

National trends in surgical subspecialisation in ophthalmology in the USA

Background/aimsTo assess surgical patterns in ophthalmology by subspecialty in the USA.MethodsOphthalmic surgeons were categorised as comprehensive/subspecialist based on billed procedures in the 2017–2018 Medicare Provider Utilization and Payment Data. Poisson...

Perceptions of research capacity in public health organisations: comparison of NSW metropolitan and non-metropolitan Local Health Districts.

Objective The aims of this study were to explore and compare the perceptions of research capacity and culture (RCC) in metropolitan and non-metropolitan New South Wales (NSW) Local Health Districts (LHDs). Methods The Research Capacity and Culture Tool was delivered online to clinicians and health managers. A 10-point Likert scale of success or skill at organisational, team and individual level of research capacity was used. An independent t -test assessed differences in domain means between non-metropolitan and metropolitan LHDs. Results A total of 1243 participants responded. Responses to the survey indicated the perception of individual's research skills were greater than the perception of RCC at both the team and organisational levels. Participants from metropolitan locations had significantly higher mean scores across all three domains compared with non-metropolitan locations (P Conclusion Results indicated the perception of individual's research skills were greater than the team and organisational levels. Participants from metropolitan locations had significantly higher perceptions of RCC across all three domains compared with non-metropolitan locations. This was the largest study to date in Australia investigating RCC in NSW LHDs, and the first study to explore multiple professions across multiple organisations while comparing metropolitan and non-metropolitan settings. This research may inform targeted strategies for building research capacity in NSW LHDs.

Listening to Transgender Patients and Their Providers in Non-Metropolitan Spaces: Needs, Gaps, and Patient-Provider Discrepancies.

Trans and gender non-conforming (TGNC) patients need better care; providers need TGNC focused medical trainings. TGNC health conferences can help, yet these events occur mostly in urban centers. Meanwhile, patients in non-metropolitan areas often face significant discrimination and notably poor access to TGNC care. This study explores the ongoing needs of TGNC patients and their providers following a one-day TGNC health conference in a small town in the American Midwest. Exploratory semi-structured interviews were used to gather in-depth information from TGNC conference attendees (N = 25). Theme analysis methods were used to identify areas of need for future trainings. Providers reported that they needed more exposure to TGNC patients, judgement-free opportunities to learn the basics about TGNC care, and ongoing trainings integrated into their medical school and ongoing education credits. Patients needed better access to care, more informed providers, and safer clinics. They cited lack of specialty care (e.g., mental health, surgery) as particularly problematic in a non-metropolitan setting. TGNC patients, and their providers in non-metropolitan areas, urgently need support. Patients lack specialized care and often possess greater knowledge than their health care teams; providers, in these areas, lack opportunities to work with patients and stay up to date on treatments.

The Experiences of Young People Living With Cancer in Regional and Remote Australia: A Qualitative Study

ABSTRACT There is limited qualitative research specifically exploring the experiences of young people living with cancer in nonmetropolitan Australia. This article reports on an in-depth qualitative study exploring young people’s experiences of diagnosis, treatment, and postcancer care and support, focusing on the impact of living in regional and remote Queensland, Australia. Thematically coded data from in-depth interviews were managed using NVivo 12 qualitative software. Connections with place, knowledge, people, support, lifestyle, and peers were key themes. Travelling for treatment interrupted these connections, with participants desiring treatment closer to home. Preventive social work in metropolitan and nonmetropolitan areas that supports maintaining connections for young patients from regional and remote areas is recommended. Further research, including the impact on young Aboriginal and Torres Strait Islander people with cancer and on the role of social workers, will inform improvements in social work practice. IMPLICATIONS Recognising the importance of connections for young people living with cancer from regional and remote areas can inform social work psychosocial assessments in metropolitan and nonmetropolitan settings, assisting social workers to respond appropriately to information young people share and supporting these valued connections. Enhancing preventive social work care with young people living with cancer from regional and remote areas will involve direct, regular communication at diagnosis and during and after cancer treatment using appropriate age-specific interventions.

Expanded practice in rural community pharmacy: a macro-, meso and micro-level perspective.

Expanding community pharmacists' scope of practice, in rural and remote locations has the potential to improve access to health care and health outcomes. Internationally, a lack of support from other health professionals (HPs) has presented a barrier to the uptake of expanded pharmacy models. Rural allied health workers, including pharmacists, however, already work across an extended scope using generalist and specialist skills to meet unique community needs with limited infrastructure for support. Limited data on expanded practice from Australia prompted this study to explore Australian rural and remote doctor, nurse and allied health perspectives of expanded pharmacy services in non-metropolitan settings. An ethnographic lens of rural culture was applied to this descriptive qualitative study. Semi-structured, in-depth interviews were conducted with HPs working in rural and remote locations in Australia. Inductive and deductive thematic analysis was guided by a multi-level lens of macro- (policy level), meso- (HP level) and micro- (consumer and community level) perspectives. The World Health Organization (WHO) framework for integrated people-centred health services provided strategies to align to the theoretical framework for the analysis. Twenty-three rural and remote HPs (doctors (8), nurses (4), allied HPs (11)) participated. Key themes identified included supportive government and funding provisions (macro); collaboration with other health providers (meso); ensuring pharmacists have the required knowledge, skills, quality assurance and safety measures in place (meso); pharmacists' capacity, including time and space (meso); and opportunity to empower and engage consumers through rural community pharmacies (micro). As pharmacists internationally continue to develop their expanded scope of practice, these results provide the first evidence for Australian rural pharmacists to consider when planning for and developing expanded practice models. Recognition of challenges and motivators for pharmacists' expanded practice are highlighted. Engagement of both government and rural health providers is seen as crucial for expanded models of pharmacy practice to evolve to deliver improved health outcomes for rural and remote communities.

Factors Associated With Quality of Life Among People Living With a Stoma in Nonmetropolitan Areas.

BackgroundInterruption of gastrointestinal continuity through surgical formation of a stoma can be lifesaving. However, it is also typically associated with reduced quality of life (QoL). Although past research has investigated QoL among people living with a stoma, no known studies have investigated stoma-related QoL, specifically among nonmetropolitan residents who may experience distinct health issues compared with their metropolitan counterparts.ObjectivesThe aim of the study was to investigate the level of and factors associated with QoL among people living with a stoma in nonmetropolitan Australia.MethodsIn a cross-sectional survey, 678 adults with colostomy, ileostomy, and/or urostomy and with membership in a regional Victorian stoma association were given the City of Hope Quality of Life Questionnaire for a Patient With an Ostomy (QOL-O). Total QoL score was calculated and described before categorization into quintiles. Patient factors associated with quintiles of QoL were assessed using univariable and multivariable proportional odds ordinal logistic regression, with a 95% confidence interval excluding 1.00 denoting statistical significance.ResultsOverall, 311 regional ostomy association members (46%) responded to any QOL-O questions; 285 members responded to >80% of QOL-O questions and contributed data to the study. Their median age was 73 years, and 60% were male. The median total QoL score was 6.9 on a scale of 0–10, where a higher number indicates better QoL. Factors independently associated with better QoL in the multivariable model were working full/part time, no poststoma clothing change, poststoma sexual activity, and older age. Factors independently associated with worse QoL were poststoma depression and a stoma location issue.DiscussionPeople living with a stoma in nonmetropolitan Australia reported moderate-to-high QoL. Better QoL was identified in those who worked, had no poststoma clothing change, were sexually active poststoma, and were older. Worse QoL was seen in those who had poststoma depression and stoma location issues. Healthcare providers could influence stoma-related QoL by identifying risk factors and tailoring interventions toward individuals in nonmetropolitan settings.

International normalised ratio control in a non-metropolitan setting in Western Cape Province, South Africa.

The quality of international normalised ratio (INR) control determines the effectiveness and safety of warfarin therapy. Data on INR control in non-metropolitan settings of South Africa (SA) are sparse. To examine the time in therapeutic range (TTR) and its potential predictors in a sample of Garden Route District Municipality primary healthcare clinics (PHCs). INR records from eight PHCs were reviewed. The TTR and percentage of patients with a TTR &gt;65% were determined. A host of variables were analysed for association with TTR. The median (interquartile range (IQR)) age of the cohort (N=191) was 56 (44 - 69) years. The median (IQR) TTR was 37.2% (20.2- 58.8); only 17.8% of patients had a TTR ≥65%. Compared with patients aged &gt;50 years, those aged &lt;50 had worse INR control (median (IQR) TTR 26.6% (16.1 - 53.0) v. 43.5% (23.5 - 60.1); p=0.01). Patients hospitalised for any reason during the study period had worse INR control than patients not hospitalised (median (IQR) TTR 26.2% (16.2 - 50.2) v. 42.9% (23.5 - 62.0); p=0.02). On multivariable regression analysis, participants on warfarin for atrial fibrillation/flutter had better INR control than those with other indications for warfarin (odds ratio 2.21; 95% confidence interval 1.02 - 4.77; p=0.04), but the control was still very poor. INR control, as determined by TTR and proportion of TTR ≥65%, in these non-metropolitan clinics was poor. Age and hospitalisation as a marker of illness predicted poor control. There was a difference in control between groups, depending on the indication for warfarin. Evidence-based measures to improve the quality of INR control in patients on warfarin therapy need to be instituted as a matter of urgency.

Geographic differences in the unpaid caregiver experience from the National Study of Caregiving (NSOC).

The objective of this cross-sectional, descriptive study was to identify unpaid caregiver differences in demographics, competing work responsibilities, support, health, caregiver burden, and interaction with healthcare professionals in US metropolitan and non-metropolitan settings. This study leveraged the nationally representative survey of older adults and their unpaid caregivers residing in the USA: the 2017 National Health and Aging Trends Study and National Study of Caregiving. Participants were unpaid caregivers for community-dwelling older adults. A total of 2278 unique unpaid caregivers corresponding to 1431 care recipients were investigated for this study. Non-metropolitan caregivers had significantly lower income than their metropolitan counterparts, were more likely to be married or have a partner, missed less work, and, when traveling to provide care, traveled on average fewer minutes than metropolitan caregivers. However, there were no significant differences in relationship to caregiver, impact on primary work responsibilities, financial assistance, resource utilization or access, caregiver burden, relationship with primary care providers, or self-rated caregiver health. Non-metropolitan caregivers experience lower income with possible greater familial support, but despite the financial disparities do not have higher caregiver burden, poorer self-rated health, or differences in other important measures. Additional studies that further divide the non-metropolitan cohort into more refined categories by population and with larger sample sizes are essential for designing policy and programs to learn from rural caregivers and build resilience among all care providers.

More than a View: School Landscape Features Are Associated with Improved Student Adjustment.

Research indicates that natural features surrounding schools are associated with better academic achievement, enhanced focus, and reduced stress in students. However, few studies have examined the associations between school landscape elements and anxiety, depression, and behavioral concerns in students. The purpose of this study was to determine whether greenery and impervious surfaces surrounding schools are associated with student internalizing and externalizing problems. Fifth-grade students (n = 21,378) reported internalizing and externalizing behaviors on the 2016 Minnesota Student Survey, an anonymous school-based survey administered statewide. Geographic information system landscape data were available for 268 schools in metropolitan areas. We calculated the percentages of tree canopy, grass and shrub cover, and impervious surfaces within 300- and 500-m radius areas around each school building. Multilevel regression models evaluated the associations between student-level internalizing and externalizing behaviors and school-level landscape percentages, controlling for sex, race, and free/reduced-price lunch. Students attending metropolitan schools with a higher percentage of impervious surfaces were more likely to report externalizing behaviors and marginally more internalizing symptoms than students in schools with a lower percentage of impervious surfaces. Higher percentages of tree canopy and grass and shrub cover surrounding schools were not associated with internalizing or externalizing behaviors. Increased impervious surfaces around schools in metropolitan areas were related to increased student externalizing behaviors. Further studies are necessary to understand the significance of the built environment, types of greenery, impact of greenery on student adjustment in nonmetropolitan settings, and varying areas surrounding schools. These results could inform initiatives to improve school landscapes.

A Real-World Perspective on Interfacility Transfers of Acute Ischemic Stroke from a Semi-Rural Center

Introduction: Interfacility transfers (IFT) of acute ischemic stroke (AIS) may not always lead to a better prognosis. Methods: Retrospective cohort study included AIS patients at an emergency department (ED) with telestroke. Multiple linear regression for departure time from ED (DT), quantile regression for length of in-hospital stay (LOS), and Kaplan-Meier estimator with Cox proportional hazards model for one-year survival (SV) were performed. Results: 192 patients included were categorised according to IFT. Mechanical thrombectomy was performed in 50% who had been transferred. Differences were found in DT, discharge disposition and LOS. An inverse relationship existed between DT and NIHSS. The strongest predictor of LOS was TACS (β = 3.14 [0.03 - 8.49]; p = 0.005). SV was related to IFT (HR 4.68 [1.37 - 16.07]; p = 0.014), age (HR 1.1 [1.04 - 1.17]), BI < 60 (HR 2.7 [1.02 - 7.1]), TACS (HR 9.82 [1.08 - 88.95]) and NIHSS ≥ 6 (HR 2.85 [1.05 - 7.74]). Conclusions: Shared decision-making with a stroke unit through telemedicine enabled a standardised clinical management in a non-metropolitan setting. Several improvement opportunities were identified: multimodal computed tomography availability before transfer, as well as optimization of response time and training in neurosonology of emergency physicians.

Perceived need for neuropsychological assessment according to geographic location: A survey of Australian youth mental health clinicians

Recent studies have shown that neuropsychological assessment is a scarce resource in youth mental health settings. The need for neuropsychological assessment might differ in metropolitan and nonmetropolitan areas due to characteristics inherent to these different regions. However, no formal studies have investigated this question. The aim of this research was to investigate whether need for neuropsychological assessment in youth mental health settings varies by geographic location. A cross-sectional online survey was completed by clinicians (N = 532) treating or assessing adolescents and young adults attending Australian primary care mental health (headspace) centers. Results indicated a similar need for neuropsychological assessment across the geographic areas. However, neuropsychological assessment was significantly less available to clients in outer regional, remote and very remote areas compared to major cities. Exploratory analyses further revealed that there were significantly fewer clinicians with a postgraduate degree and more clinicians with a bachelor degree in outer regional, remote and very remote areas than in major cities. Given the negative impact of cognitive impairments in youth with a mental illness, these findings reveal a necessity to enhance the availability and access to neuropsychological assessment in rural settings. Several plausible avenues to achieving increased access include increasing the funding available for this resource; providing nonmetropolitan clinicians with sufficient neuropsychological consultation, including rural training and rotations in neuropsychologists’ postgraduate training; and exploring the use of tele-health in the provision of neuropsychological assessments in nonmetropolitan settings.

Health care professionals talking: Are services for young adults with type 1 diabetes fit for purpose?

The challenges of becoming a mature adult may distract young adults with type 1 diabetes from disease self-management, increasing risks for premature morbidity and mortality. Despite the importance of young adults with type 1 diabetes engaging with preventative diabetes-related health care services, few studies report health care professionals' experiences and perceptions of the support that is available, including during the period of transition. This study sought to determine these factors across diverse contexts in one health jurisdiction. This qualitative study was undertaken in New South Wales, Australia. Recruitment was based on a snowball sampling technique, which began with members of an established diabetes service group. Data were collected by individual semistructured interviews with 16 health care professionals, most of whom were registered nurses (75%), working at differing levels of expertise and responsibility across metropolitan and regional/rural areas. Data were analysed using thematic analyses. Participants overwhelmingly recognized the time and care needed to support young adults with type 1 diabetes to prepare them for adult self-management and to work with adult diabetes services, and the importance of youth-friendly services. They reported shortfalls and inequitous distribution in services for these young adults. Two themes, addressing the present and future possibilities, expressed their perceptions of services for this population: working with what is available and mapping a route to better services. Findings identify opportunities for development in the planning and provision of specialist multidisciplinary health care support for this population. New ideas are needed for policy and practice innovation and for the infrastructure to facilitate this, to ensure that young adults with type 1 diabetes have access to consistent and coordinated diabetes health care services, particularly in nonmetropolitan settings.