Access and issues of equity in remote/rural areas.

This article reports on a workshop in which the major focus was a review of the barriers that prevent access to the array of community-based services available to the rural elderly. The demographics of the elderly were outlined and key components of the service system described. Attention was given to access hospital-based care, the closing of hospitals and the reasons for bypassing rural hospitals for those in large towns or cities. Special emphasis also was given to mental health services and their uneven accessibility. A review of the policy implications closed the workshop.

Community decision-making about critical access hospitals: lessons learned from Montana's Medical Assistance Facility Program.

Limited-service hospitals have been used as a means of maintaining health care services in rural communities with full-service hospitals at risk of closure. The Medical Assistance Facility (MAF) limited-service hospital model has been implemented in 12 communities in Montana and has been evaluated by the Health Care Financing Administration as a viable alternative to a full-service hospital in frontier communities. The 1997 federal Critical Access Hospital (CAH) legislation is the most recent nationwide alternative for maintaining health care in rural communities, and it incorporates many of the features of the MAF model. The purpose of this study was to examine rural community decision making regarding MAF conversion from the perspectives of key informants who were involved in the decision-making process. A descriptive multiple case study design was used. Data were obtained through interviews with community members during site visits. The research focused on identification of local issues that were influential in the decision to convert to or reopen as an MAF, features of the MAF model that made it a locally acceptable alternative, and elements that characterized the decision-making process. The issues found to be influential in the conversion decision and the features that made the MAF locally acceptable were those that made the provision of basic services more stable and sustainable. The study suggests that programs to maintain health care services in isolated communities should allow for and encourage an expanded role for nonphysician providers. The lessons learned from the communities included in this study are instructive to rural communities nationwide that are considering a CAH as well as to policy-makers, researchers, and regional and national health care decision makers.

Culturally sensitive research methods of surveying rural/frontier residents.

This article describes adaptations to conventional survey research methods based on knowledge of and respect for characteristics and qualities of rural communities and rural culture. These culturally sensitive methods may have contributed to a high response rate in a population-based study of frontier residents conducted in one western state in the United States. Through these methods, residents' interests in the study was heightened and the study's visibility was increased. Adaptations were also necessary to compensate for shortcomings in the available sample frame for the rural population of interest. References on survey research by mail provide standards for generally accepted procedures but offer few guidelines for tailoring these approaches for varying cultures. Approaches based on the local culture of the persons to be surveyed can increase response rates as well as demonstrate respect for the culture of intended study participants.

An ecological view of the rural environment: levels of influence on access to health care.

Access to health care has diminished for rural Americans due in part to a record number of rural hospital closures. Hospitals have served as the infrastructure of rural health care. When hospitals close, other health services and providers are frequently lost. Adequate access to health care is one determinant of health. An ecological perspective on environment reveals multiple levels of influence that support or do not support access to rural health care. Implications for nursing science and practice involving all levels of environment are suggested by an ecological view.