Volume 47 Number 3 
Summer 2014

Rural Issues

Edited by Susana Helm

The Rural IG column highlights the work of community psychologist and colleagues in their rural environments.  Please send submissions to me ( This is a great opportunity for students to share their preliminary thesis/dissertation work, or insights gained in rural community internships.  For this issue we have a brief report co-authored by Erika Jang, an undergraduate majoring in Family Relations, in the College of Tropical Agriculture and Human Resources at the University of Hawai`i. Erika completed her junior year internship (one semester, Spring 2014) in our department’s Rural Health Initiatives program. 

Brief Report:  Enhancing Access to Health Resources through Professional Development.

Written by Susana Helm and Erika Jang,  Department of Psychiatry, University of Hawai`i

To emphasize the limited access to health resources in rural areas of our own State, we studied proportional differences among adult patients in the emergency department with PTSD, mood disorders, and anxiety (Onoye, Helm, Koyanagi, Fukuda, Hishinuma, Takeshita, & Ona (2013).  Among the 74,787 emergency department visits during the study period, 2.7% of adult patients had been diagnosed with PTSD, mood disorder, or anxiety disorder, while 7.4% had been diagnosed with any mental health issue.  Analysis indicated that the there were more emergency department visits by patients living in rural than urban communities, suggesting that people who live in rural areas with common mental health problems (PTSD, mood disorder, or anxiety disorder) appear to use hospital emergency departments to get mental health services, and this results in higher costs and less resources for non-urgent care.  Therefore, improved professional development for screening and appropriate referral may reduce the rate of ED use and improve access to more appropriate care.

With this in mind, our Rural Health Initiative group is working with our Continuing Medical Education (CME) Committee.  CME consists of educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance that physicians use to provide services to patients, the public, or the profession (excerpted from: The CME committee reviews and coordinates a number of CME activities, such as weekly grand rounds, monthly journal clubs, and annual conferences.  The primary audience is physicians, and specifically psychiatrists.  Not surprisingly, other health professionals participate in our department’s CME activities because the mental health is an interdisciplinary field.  Furthermore, our grand rounds and other activities often are available to rural and remote health practitioners through videoteleconferencing. 

By becoming more inclusive of rural communities, where health resources tend to be limited and where the majority of Native Hawaiians tend to reside, our Rural Health Initiative group is working to enhance rural and Native Hawaiian access to health resources by expanding professional development opportunities via our CME sponsored grand rounds.  Our initiative aligns with “Rural Healthy People 2010 - Evolving Interactive Practice” which identified rural health priorities by surveying state and local rural health leaders from across the nation (Gamm & Hutchison, 2006).  Among the top 14 priority areas, access to quality health services was ranked first, and mental health was ranked fourth.  Furthermore, approximately two thirds of the respondents ranked access as the first priority.

Access to health resources is linked fundamentally to rural health professional recruitment, retention, and development.  Therefore, we have created our own survey to assess the extent to which health professionals would like to earn continuing education credits in their field by participating in our grand rounds, as well as to ascertain the extent to which these health professionals reside in and/or work in rural and/or Native Hawaiian communities.  Our grand rounds generally are held weekly for an hour, and consist of a formal presentation (40-45 minutes) and a Q&A period.  Topics have included psychopharmacology in nursing homes, drug interdiction versus treatment, bedside exams to screen for mild cognitive impairment, stigmatizing experiences during psychiatric residency, to name a few.

It is important to note that the definition of health resource access may vary by stakeholder, and with out an agreed upon definition, rural access to health resources may continue to be limited (Russel, Humphreys, Ward, Chisholm, Buykx, McGrail, and Wakerman, 2013).  Russsel, et al recommend delineating seven dimensions of access so that policy makers and others are able to recognize the complexity of health resource access and plan accordingly.  “Availability” addresses whether there are sufficient services available in rural and remote communities.  “Geography” refers to how easily consumers in rural and remote communities can get to services or services can be delivered to them.  “Affordability” concerns whether consumers can afford services and related expenses (e.g. in Hawai`i accessing services may require a flight to a different island, overnight lodging for family members in expensive hotels, rental car, etc). “Accommodation” focuses on the way in which the service is organized to suit the context from which the consumer comes.  “Timeliness” refers to whether the service can be obtained in a timely way.  “Acceptability” highlights the extent to which the service meets the sociocultural needs of consumers.  Finally, “awareness” focuses on the way in which consumers understand their health issue(s) and the services available to them.  With respect to our CME committee undertaking this professional development expansion initiative, we hope to improve our grand rounds across each of these dimensions of access.

In reviewing the literature on the topic of rural health professionals, a key to recruitment is exposure to rural health work settings during initial training, while a key to and retention is professional development through continuing education.  For example, in a focus group study of rural health clinic performance, clinical managers and administrators ranked continuing education as a top priority (Ortiz & Bushy, 2011).  Regarding recruitment, a study of the way in which career values and perceptions of rural work environment influence one’s career trajectory to work in a rural setting showed that prestige was the most important work value that predicted whether students and practitioners would choose to work in rural area (Conomos, Griffin, and Baunin, 2013).  People who valued prestige were less likely to select rural work.  They also found that rural exposure during training was related to a more positive view of the rural work environment, which may in turn reinforce work values (such as deemphasizing prestige). 

In a related study, Haq, Stearns, Brill, Crouse, et. al. (2013) focused on recruitment of health professionals to work in health professional shortage areas (HPSAs) with a focus on urban communities.  The authors pointed out that more than 20% of Americans live in HPSAs, which are defined as inner city or rural geographic areas/populations.  HPSAs are disproportionately affected by the increasing shortage of physicians and other health professionals projected through 2015.  The authors described the Training in Urban Medicine and Public Health (TRIUMPH) curriculum for medical students, which was designed to build skills in three interrelated domains: clinical, community and public health, and personal.  Participating students were surveyed on their TRIUMPH experience.  Results indicated that students showed a commitment to and increased confidence in working with underserved populations, that the experience gave them an opportunity to work in underserved practices with positive role models and enhanced their educational experiences in these settings. 

Looking ahead, we will be administering our survey via professional listserves that include both practitioners and students/trainees.  We are targeting professional fields most likely to encounter rural residents in need of mental health screening and referral, including psychology, social work, and nursing. 


Conomos, A. M., Griffin, B., & Baunin, N. B. (2013). Attracting psychologists to practice in rural Australia: The role of work values and perceptions of the rural work environment. Australian Journal of

Gamm, L., & Hutchison, L. (2004). Rural Healthy People 2010 - Evolving Interactive Practice. American Journal of Public Health, 94(10), 1711-2.

Haq, C., Stearns, M., Brill, J., Crouse, B., Foertsch, J., Knox K, et al. (2013). Training in urban medicine and public health: TRIUMPH. Journal of the Association of American Medical Colleges, 88(3), 352-63.

Onoye, J., Helm, S., Koyanagi, C,, Fukuda, M., Hishinuma, E., et al. (2013). Proportional differences in emergency room adult patients with PTSD, mood disorders, & anxiety for a large ethnically diverse geographic sample. Journal of Healthcare for the Poor and Underserved, 24(2), 928-42.

Ortiz, J., & Bushy, A. (2011). A focus group study of rural health clinic performance. Family and Community Health, 34(2), 111-8.

Russel, D.J., Humphreys, J.S., Ward, B., Chisholm, M., Buykx, P., McGrail, M., et al. (2013). Helping policy-makers address rural health access problems. Australian Journal of Rural Health, 21(2), 61-71.

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