Urban Practice Settings Research Articles

Integrating sexual and reproductive health into pre-travel consultations.

Casual sex during travel is a major preventable factor in the global transmission of sexually transmissible infections (STI). Pre-travel consults present an excellent opportunity for practitioners to educate travellers about sexual and reproductive health (SRH) and safety. This scoping review aims to explore and understand the extent to which SRH is included in pre-travel consultations. PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, Medline and Web of Science were systematically searched for primary research articles exploring whether health care practitioners (HCP) included SRH in pre-travel consultations. Extracted findings were synthesized and presented in narrative form. Findings across 13 articles suggest HCPs infrequently broached SRH in pre-travel consultations with HCP discomfort, and lack of time and resources presented as key barriers. Urban practice settings, HCP experience, training in travel medicine and traveller characteristics such as sexual orientation were positively associated with discussions about SRH. SRH advice reported was general in nature, primarily focusing on safer sex, condoms or unspecified STI advice. Risk assessments based solely on age or stereotypes around sexual preferences led to key aspects of SRH care being missed for some (e.g. SRH was less likely to be discussed with older travellers). HCPs frequently miss opportunities to integrate SRH into pre-travel consultations. Strategies to promote HCP confidence and awareness present a promising means to boost the frequency and quality of SRH advice disseminated. Integrating culturally safe and responsive SRH history-taking and advice into pre-travel consultations may contribute to global reductions in STI transmission and promote traveller SRH well-being.

Specialty Preferences and Influential Factors among Medical Students in Sudan2021-2022

A country's healthcare system is strongly influenced by the career choices and specializations of its physicians. This is even more important in many sub-Saharan African countries, where there are acute and chronic shortages of medical professionals. This study aims to discern the predilections of final medical students regarding career specialization and the underlying factors that contribute to these preferences. A descriptive cross-sectional study was carried out between November 2021 and May 2022. The study included 218 participants, drawn from Alzaiem Alazhari University, National Ribat University, and National University.In terms of specialty preferences, it is observed that female participants exhibit a preference for obstetrics, while their male counterparts demonstrate a higher inclination towards surgery. Specifically, 20.6% of female participants chose obstetrics and gynecology compared to 6.5% of males. Conversely, 26.1% of males and 16% of all females opted for surgery as their primary choice. In the domain of internal medicine, 15.9% of females and 21.7% of males expressed interest. Pediatrics garnered the attention of 13% of female participants, while only 2.2% of males favored this option. Statistically significant factors influencing the selection of surgery and other specialties include Appraisal of own skills and aptitude" (P-value=0.019) and "Desire to provide community service" (P-value=0.0), which also pertains to internal medicine. For those opting for obstetrics and gynecology, the reasons included "Appraisal of own skills and aptitude" (P-value=0.019) and "Acceptable hours of practice" (P-value=0.971). Pediatrics was predominantly chosen based on "Appraisal of own skills and aptitude" (P-value=0.019).Evident gender disparities are observed in specialty preferences, with males showing a pronounced inclination towards surgical and internal medicine fields. While females also express interest, the percentage is notably higher among males in comparison to the total participants of each gender. The primary reasons for selecting specific specialties are rooted in "Appraisal of own skills and aptitude" and the appeal of "Acceptable hours of practice." Furthermore, an urban practice setting is favored over a rural one.

Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care.

Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate thatprimary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. Forphysicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be providedto support them in caring for patients with early psychosis.

A77 IMPLEMENTATION OF GUT LINK-IBS; RESULTS OF A SEMI-STRUCTURED INTERVIEW OF PRIMARY CARE PROVIDERS

BackgroundThe Division of Digestive Care and Endoscopy in Halifax, Nova Scotia has had longstanding challenges with GI referral volume outstripping divisional capacity resulting in limited access to specialist care. Many referrals for functional bowel disorders (FBD) are returned to referring providers. Although this helps rationalize limited system resources, it often impairs access to appropriate and necessary GI care. The co-development and implementation of clinical care pathways across gastroenterology and primary care may help to improve access to high-quality GI care.AimsThe project aimed to engage primary healthcare providers (PHCPs) to identify environmental and behavioral barriers and facilitators for managing undifferentiated lower GI disorders in primary care. Data generated from stakeholder engagement will be used to develop, implement, and evaluate strategies for referral and management of FBD. A real-world, functional clinical care pathway that supports the implementation of evidence-based practices in the diagnosis and management of functional GI conditions within primary care will enhance care and timely access to specialist.MethodsThis is a qualitative study using semi-structured interviews of PHCPs working in Nova Scotia. Interview questions were developed and guided by the evidence-based implementation science frameworks. Physicians were recruited through existing primary care networks. Participants were offered a Zoom™virtual semi-structured interview. A brief intake questionnaire was administered to collect baseline demographics. Interviews were recorded and transcribed for data analysis. Data were categorized into coding schemes and themes were created using an inductive coding approach.ResultsAs of October 2021, 9 interviews have been conducted. Average participant age was 44 years, with the majority identifying practice in a group or collaborative care setting (n=7, 78%). Five worked in urban practice settings and the remainder in rural areas. Preliminary major themes included:1. A lack of satisfaction with access to gastrointestinal care, with most physicians noting it to be worse than access to other specialist services.2. Management of FBDs were felt to be within the scope of primary care practice3. Access to diagnostic tests like fecal calprotectin with appropriate education on its use as a diagnostic tool would be useful.4. PHCP’s suggested care pathways be easy to use, require minimal time, and ideally be implemented within their pre-existing EMR or in paper form.ConclusionsPHCPs acknowledge a significant burden of undifferentiated lower GI complaints in their practice and poor access to gastroenterology services. All participants were open to helping develop and use a clinical care pathway for the investigation and management of undifferentiated lower GI symptoms. Data collection and analysis are ongoing.Funding AgenciesNone

Exploring the Distressing Events and Perceptions of Support Experienced by Rural and Remote Nurses: A Thematic Analysis of National Survey Data.

Exposure to traumatic events is an occupational hazard with potential adverse psychological consequences. Previous research has focused mainly on urban practice settings; therefore, this study explored the distressing experiences encountered by rural/remote nurses and their perception of organizational support. Thematic analyses were conducted on open-ended data from a pan-Canadian survey of 3,822 regulated nurses, where 1,222 nurses (32%) reported experiencing an extremely distressing health care incident within the past 2 years. Among the respondents, 804 nurses (65%) reported that they did not receive psychological support from the organizations leadership following incidents. Three main themes regarding distressing events were: (a) involvement in profound events of death/dying, traumatic injury and loss, (b) experiencing or witnessing severe violence and/or aggression, and (c) failure to rescue or protect patients/clients. Three themes were identified regarding perceptions of organizational support including: (a) feeling well supported in the work setting with debriefing and reliance on informal peer support, (b) lack of acknowledgement and support from leaders on the nature and impact of distressing events, and (c) barriers influencing access to adequate mental health services in rural/remote settings. Findings suggest that rural/remote nurses rely on informal, peer supports; there is a lack of organizational understanding of the potential risks to their psychosocial health and safety. They require more accessible, structured, appropriate, and timely supports within these settings. Increased understanding of the psychological hazards will assist organizations to establish workplace policies and practices designed to protect and support rural/remote nurses.

Pediatric provider perspectives and practices regarding health policy discussions with families: a mixed methods study

BackgroundAdvocacy regarding child health policy is a core tenet of pediatrics. Previous research has demonstrated that most pediatric providers believe collective advocacy and political involvement are essential aspects of their profession, but less is known about how pediatric providers engage with families about policy issues that impact child health. The objectives of this study were to examine providers’ perceptions and practices with regards to discussing health policy issues with families and to identify provider characteristics associated with having these discussions.MethodsIn this cross-sectional mixed methods study, pediatric resident physicians, attending physcians, and nurse practitioners at primary care clinics within a large academic health system were surveyed to assess (1) perceived importance of, (2) frequency of, and (3) barriers to and facilitators of health policy discussions with families. Multivariable ordinal regression was used to determine provider characteristics (including demographics, practice location, and extent of civic engagement) associated with frequency of these discussions. A subset of providers participated in subsequent focus groups designed to help interpret quantitative findings.ResultsThe overall survey response rate was 155/394 (39%). The majority of respondents (76%) felt pediatricians should talk to families about health policy issues affecting children, but most providers (69%) reported never or rarely having these discussions. Factors associated with discussing policy issues included being an attending physician/nurse practitioner (OR 8.22, 95% CI 2.04–33.1) and urban practice setting (OR 3.85, 95% CI 1.03–14.3). Barriers included feeling uninformed about relevant issues and time constraints. In provider focus groups, four key themes emerged: (1) providers felt discussing policy issues would help inform and empower families; (2) providers frequently discussed social service programs, but rarely discussed policies governing these programs; (3) time constraints and concerns about partisan bias were a barrier to conversations; and (4) use of support staff and handouts with information about policy changes could help facilitate more frequent conversations.ConclusionsPediatric providers felt it was important to talk to families about child health policy issues, but few providers reported having such conversations in practice. Primary care practices should consider incorporating workflow changes that promote family engagement in relevant health policy discussions.

Practice Patterns of Family Physicians With and Without Sports Medicine Certification.

To update information regarding practice patterns of family physicians with a certificate of added qualifications (CAQ) in Sports Medicine (SM), because it has been over 10 years since the last comprehensive study. Cross-sectional analysis of 2017 and 2018 American Board of Family Medicine (ABFM) Family Medicine Certification and SM CAQ examination registration practice demographic questionnaire data. N/A. Family physicians with a CAQ in SM [sports medicine family physicians (SM-FPs)] and family physicians without a CAQ registering for the ABFM Family Medicine Certification or SM CAQ examinations. N/A. Self-reported time spent practicing SM, activities in SM, scope of practice, and practice setting. Sports medicine family physicians are predominately men (78.7%) and below 49 years (65.8%). Most SM-FPs spend 60% of their time or less practicing SM and the scope of practice of SM-FPs is only slightly narrower than that of their family physician counterparts without a CAQ. In addition, 92.8% of SM-FPs are practicing in an urban setting. The similarity of scope of practice for SM-FPs and family physicians without a CAQ and the time spent practicing SM by SM-FPs suggests that most SM-FPs are spending a significant amount of time continuing to practice their primary specialty. Sports medicine family physicians are largely attracted to urban practice settings, most likely because of the higher likelihood of employment opportunities. Finally, factors that may be dissuading women from entering the field of SM deserve further investigation.

OT and Interprofessional Collaborative Practice in Low-Vision Service Delivery in Rural, Micropolitan, and Urban Practice Settings

Abstract Date Presented 04/06/19 Collaboration during provision of low-vision services is paramount to comprehensive service delivery. Despite rural practitioners having decreased access to other members of the rehabilitation team, professional collaboration occurred similarly among OTs working in rural, micropolitan, and urban settings. Methods of collaboration, including online technology, should be explored as a means of increasing interprofessional collaboration to foster improved client outcomes. Primary Author and Speaker: Whitney Lucas Molitor Additional Authors and Speakers: Diana Feldhacker

Vertical characteristics of posterior teeth in untreated malocclusions

ObjectiveUnderstanding the influence of tooth eruption on skeletal growth patterns can contribute to development of timely and effective orthodontic treatment protocols. In this retrospective cross-sectional study, our objective was to use a previously published cephalometric method to measure the maxillary and mandibular molar and premolar dentoalveolar heights from an untreated sample of Class II and Class III subjects and compare them to untreated Class I normodivergent. Materials and MethodsA total of 218 subjects with full permanent dentition that met the defined inclusion, exclusion, and grouping criteria were analyzed. The sample of 13- to 56-year-old subjects was diverse in ethnic backgrounds and representative of an urban practice setting. Using cephalometric grouping criteria, subjects were assigned to one of five groups: Class I normodivergent (control), Class II or Class III hyperdivergent or hypodivergent. Cephalometric images were traced and data were analyzed using independent t-tests, one-way analysis of variance, and Bonferroni post hoc tests (P < 0.05). ResultsThe study showed strong trends of short maxillary dentoalveolar heights in Class II hypodivergent subjects and short mandibular dentoalveolar heights in Class III hyperdivergent subjects. Statistically significant differences ranged from 1.11 mm to 4.55 mm. The results of this study indicate gender dimorphism. ConclusionsThis study suggests that posterior dentoalveolar characteristics differ among the established malocclusions. There is likely an interplay between tooth eruption and vertical growth of the jaws. One factor can influence the severity of another, as the dentition and skeleton develop simultaneously. Clinical treatment approaches to minimize divergence from the normal skeletal pattern can be established for growing patients.

NEEDS AND CHALLENGES OF HOME VISITORS CONDUCTING PERINATAL DEPRESSION SCREENING.

This article describes the needs and challenges faced by home visitors, supervisors, and clients when conducting perinatal depression screening. Home visitors (n = 11), supervisors (n = 5), and clients (n = 9) representing rural and urban practice settings in Wisconsin were recruited into three separate focus groups. Themes were identified from the transcribed audio-recorded interviews using content analysis. Results indicate that a trusting relationship was leveraged to facilitate depression screening and referral. Home visitors personalized care to a client's context and to protect confidentiality. Home-visiting practice demanded flexibility and negotiation in decision-making with clients and families. Coordinating access to mental health evaluation in areas of limited access was a common challenge. Participants reported a need for further training on safety management. With adequate training and support, home visitors are well-positioned to promote access to mental health services in vulnerable families to support infant mental health.

Willingness of Psychotherapists in Private Practice to Treat Patients With Complex Post-Traumatic Stress and Dissociative Disorders

Analyses of patient care with severe mental disorders. Psychotherapists in private praxis were interviewed about their willingness to treat patients with a range of diagnoses in the context of post-traumatic disorders. Therapists were found more willing to treat "less severe" disorders, independent of years in practice, school of psychotherapy, a rural or urban practice setting. Therapists criticized the quality of their training and the health insurance review process. Therapists are generally willing to treat patients with severe mental disorders, but experience limits of competency attributed to training deficits. They further experience the bureaucratic procedures of the health insurance review process as barriers to accepting these patients into treatment.These results indicate that recently developed concepts of psychotherapy for these patient groups should be more intensively integrated into the existing training curricula. Furthermore, a simplified health insurance review process ought to be considered.

National trends in burn and inhalation injury in burn patients: results of analysis of the nationwide inpatient sample database.

The aim of this study was describe national trends in prevalence, demographics, hospital length of stay (LOS), hospital charges, and mortality for burn patients with and without inhalational injury and to compare to the National Burn Repository. Burns and inhalation injury cause considerable mortality and morbidity in the United States. There remains insufficient reporting of the demographics and outcomes surrounding such injuries. The National Inpatient Sample database, the nation's largest all-payer inpatient care data repository, was utilized to select 506,628 admissions for burns from 1988 to 2008 based on ICD-9-CM recording. The data were stratified based on the extent of injury (%TBSA) and presence or absence of inhalational injury. Inhalation injury was observed in only 2.2% of burns with <20% TBSA but 14% of burns with 80 to 99% TBSA. Burn patients with inhalation injury were more likely to expire in-hospital compared to those without (odds ratio, 3.6; 95% confidence interval, 2.7-5.0; P < .001). Other factors associated with higher mortality were African-American race, female sex, and urban practice setting. Patients treated at rural facilities and patients with hyperglycemia had lower mortality rates. Each increase in percent of TBSA of burns increased LOS by 2.5%. Patients with burns covering 50 to 59% of TBSA had the longest hospital stay at a median of 24 days (range, 17-55). The median in-hospital charge for a burn patient with inhalation injury was US$32,070, compared to US$17,600 for those without. Overall, patients who expired from burn injury accrued higher in-hospital charges (median, US$50,690 vs US$17,510). Geographically, California and New Jersey were the states with the highest charges, whereas Vermont and Maryland were states with the lowest charges. The study analysis provides a broad sampling of nationwide demographics, LOS, and in-hospital charges for patients with burns and inhalation injury.

489 USE OF PARTIAL NEPHRECTOMY IN RURAL VERSUS URBAN PRACTICE SETTINGS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II1 Apr 2010489 USE OF PARTIAL NEPHRECTOMY IN RURAL VERSUS URBAN PRACTICE SETTINGS Christopher Filson, Zaojun Ye, and David Miller Christopher FilsonChristopher Filson More articles by this author , Zaojun YeZaojun Ye More articles by this author , and David MillerDavid Miller More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.564AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) is underutilized for patients with early-stage renal cell carcinoma (RCC). For a variety of reasons, urologists working in rural settings may be particularly slow to adopt nephron-sparing surgery (NSS), potentially exacerbating unwarranted variations in the use of PN. In this context, we evaluated differences in the longitudinal utilization of PN among patients with RCC treated by surgeons working in rural versus urban practice settings. METHODS Using linked SEER-Medicare data, we identified patients who underwent surgical treatment for RCC from 1995 through 2005. We used a validated algorithm to determine whether each patient received NSS (i.e., partial nephrectomy) or radical nephrectomy. We used rural-urban commuting area codes (based on the zip code of the surgeon's primary office) to classify each surgeon's practice setting as rural (population < 10,000), micropolitan (population 10,000-50,000), or urban (population > 50,000). We then used bivariate and multivariate analyses to evaluate the relationship between surgeon practice setting and patient receipt of PN, adjusting for both tumor size and year of diagnosis. RESULTS We identified 12,899 patients treated surgically for RCC by 2,057 unique surgeons. Among the surgeons, 37 (1.8%) and 141 (6.8%) worked in rural and micropolitan practice settings, respectively. During the study interval, the proportion of patients treated with NSS by urban surgeons increased from 8.7% (1995) to 21.6% (2005), compared with an increase from 4.4% to 17.8% among patients treated by surgeons in non-urban settings (p<0.01) (Figure). After adjusting for tumor size and year of diagnosis, patients treated by rural (OR=0.32, 95% CI 0.12-0.87) and micropolitan (OR=0.62, 95% CI 0.43-0.89) surgeons remained significantly less likely than those treated by urban surgeons to receive NSS. CONCLUSIONS Patients with RCC who receive treatment from surgeons in non-urban settings are significantly less likely to undergo NSS. These data highlight the need for educational and other initiatives aimed at dismantling barriers to the adoption of NSS among urologists in more geographically-isolated practice settings. Ann Arbor, MI© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e193 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Filson More articles by this author Zaojun Ye More articles by this author David Miller More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Does Office Location Influence the Work Actions of Public Sector Human Service Managers?

Numerous studies have empirically examined the influence of situational determinants on the nature of managerial work. One important determinant that has received little attention is office location, or, more specifically, rural versus urban practice settings. The present study addresses this underexplored area of inquiry by assessing the relative influence of office location on core managerial role competencies. Eighty-one office managers responsible for three types of county-based human service agencies in New York State were surveyed. Public managers responsible for larger, more rural human service offices reported engaging in human resource management role competencies significantly more than their urban colleagues. After controlling for the effects of office size, public managers situated in more rural practice and settings were significantly more likely to engage in the role competencies of mentoring and staff development than were their urban counterparts. Possible explanations for the findings are discussed, along with implications for public management research and practice.

Services provided for preschool-aged children with suspected amblyopia

This study is based on a random survey of 542 ophthalmologists and 501 optometrists actively practicing in Michigan to evaluate variations in pediatric eye care services for preschool-aged children with abnormal vision screening tests. The response rate was 65% (optometrists, 75%; ophthalmologists, 57%). More optometrists than ophthalmologists evaluated preschool-aged children (97% vs 79%, ph 0.001). Optometrists reported that most of their preschool-aged patients were referred from community-based screening programs or by parent self-referral. Ophthalmologists reported that most of their preschool-aged patients were referred by primary care providers. Fewer optometrists than ophthalmologists dilated eyes routinely during the first evaluation of a preschool-aged child (39% vs 93%; ph 0.001). Most optometrists and ophthalmologists managed amblyopia themselves rather than referring to another specialist (80% vs 77%; p = 0.372). More ophthalmologists in nonurban setting practices managed amblyopia than did those in urban practice settings (90% vs 65%, ph 0.001), whereas no such difference was found between nonurban and urban optometrists (p = 0.289). More optometrists than ophthalmologists reported that they managed strabismus (89% vs 80%; p = 0.002), although optometrists were much less likely than ophthalmologists to treat non accommodative esotropia and exotropia (ph 0.009). As with amblyopia, more ophthalmologists in nonurban practices than in urban practices managed strabismus (89% vs 66%; ph 0.001), whereas no such differences were found between nonurban and urban optometrists (p =0.756). Michael D. Wagoner

Dimensions of retention: a national study of the locational histories of physician assistants.

This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as "all rural," "all urban," "urban to rural" or "rural to urban." The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings left for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 21 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance.

Rural practice. Preference, perception, and reality.

Numerous studies have approached the geographic maldistribution of physicians in the United States by evaluating factors associated with rural placement and retention, with "rural" being variably defined. To our knowledge, no one has qualitatively investigated physicians' perceptions of rurality or how closely those perceptions fit commonly used definitions of rurality. In addition, no one has evaluated physicians' preference for rural practice or the association between this preference and the rurality of their practice as they perceive it. This descriptive study uses a questionnaire mailed to graduates of a community hospital, university-affiliated Family Medicine residency program to evaluate physician perception and preference regarding rural practice. The participation rate was 83.1%. Agreement between the rurality of practice sites, as perceived, and definitions of rural was greatest when defined as a "nonurban population center of less than 25,000." Twenty-one (44.7%) of 47 respondents who preferred rural practice sites perceived themselves to be in urban practice sites. Respondents identified a nonurban population center of less than 25,000 as their perceived threshold between rural and urban practice settings. This threshold should be further evaluated as a potential operational standard. Nearly one half of the respondents who preferred rural practice perceived themselves to be in urban practice, indicating significant barriers to rural practice in this population. Potentially many more physicians may settle in rural practices if barriers for those who prefer rural practice can be identified and eliminated.