doi: 10.1111/j.1742-6723.2011.01412.

x Emergency Medicine Australasia (2011) 23, 337–345

ORIGINAL RESEARCH

Chest pain in rural communities; balancing

decisions and distance emm_1412 337..345

Tim Baker,1 Scott McCoombe,2 Cate Mercer-Grant2 and Susan Brumby2

1
Centre for Rural Emergency Medicine, Deakin University School of Medicine, Warrnambool, and
2
National Centre for Farmer Health, Deakin University School of Medicine and Western District Health
Service, Hamilton, Victoria, Australia

Abstract

Objective: This pilot study examines the prevalence of cardiac risk factors in a cohort of agricultural
workers, assesses their knowledge of local emergency health services and investigates their
decision-making abilities with regard to when and how they would seek help when
experiencing chest pain.
Methods: Farm men and women were recruited from 20 rural Victorian sites and underwent health
assessments for total cholesterol, blood glucose, weight, height and blood pressure. Par-
ticipants completed a survey to determine their knowledge of chest pain treatment, local
emergency services and likely response to chest pain.
Results: Cardiac risk factors within this cohort of 186 adult farming men and women were common,
with 61% of men (58/95, 95% confidence interval [CI] 51–70) and 74% of women (68/91,
95% CI 65–83) either overweight or obese. When asked to name their nearest ED, 10% of
participants (19/184, 95% CI 7–16) nominated health services or towns where no ED exists.
Furthermore, 67% of respondents (123/185, 95% CI 59–73) believed it was safe to travel to
hospital by car while potentially having a myocardial infarction.
Conclusions: This cohort of agricultural workers were at considerable risk of experiencing acute coro-
nary events, but many would make decisions about when and how to seek medical help for
chest pain that are at odds with published community guidelines. These results highlight
the need for education to improve knowledge of local emergency services and address
behavioural barriers to accessing care.
Key words: agricultural worker, chest pain, emergency medicine, health literacy, rural health service.

dial infarction accounting for approximately half of these

Introduction deaths. Nine hundred of these lives would be saved if
mortality rates in regional areas were the same as those
Each year in regional Australia approximately 9000 in metropolitan areas.1 Heightened regional mortality is
people die of coronary artery disease, with acute myocar- partly explained by a higher incidence of cardiac risk

Correspondence: Clinical Associate Professor Tim Baker, Centre for Rural Emergency Medicine, Deakin University School of Medicine,
Ryot Street, Warrnambool, Vic. 3280, Australia. Email: [email protected]
Tim Baker, MB BS, Emergency Physician; Scott McCoombe, PhD, Lecturer; Cate Mercer-Grant, BBus, Program manager; Susan Brumby, RN,
MHM, Clinical Associate Professor.

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EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 T Baker et al.

factors.2 Delays in initiating treatment for acute cardiac for more than a generation, of a general practice clinic
events in rural areas might also contribute. and a small local hospital that dealt with every emer-
Treatment in the first 2 h following a myocardial gency situation occurring within its district.
infarction can decrease mortality by half.3 Also, one in The objectives of this pilot study were:
four people who experience a myocardial infarction die 1. To determine the prevalence of cardiac risk factors in
from cardiac arrest within 1 h of their first chest pain.4 a population of agricultural workers.
If the person has already reached hospital when they 2. To assess their knowledge of local emergency health
have a cardiac arrest, treatment success rates of services, and
between 20% and 40% are described.5 If the arrest 3. To examine decision-making processes among agri-
occurs outside of hospital care, the survival rate is cultural workers about when and how they would
much lower. In rural Victoria, Australia, where this seek help for chest pain.
survey was conducted, survival rates for witnessed
cardiac arrests occurring outside of medical care are
less than 2%.6 Methods
Studies around the world have found many reasons
why people with chest pain procrastinate before seeking This cross-sectional study, of exploratory design, was
treatment.7 Two common explanations are the failure to conducted in Victoria, Australia between July 2009
recognize a heart attack when the symptoms are atypi- and August 2010, in conjunction with the Sustainable
cal, and delay due to fear and embarrassment, even Farm Families (SFF) programme (developed by the
when symptoms indicate a heart attack is almost cer- National Centre for Farmer Health, Hamilton, Victoria,
tain.8 Living in a rural or remote location has been Australia). SFF is an evidence-based service delivery
described as an additional cause for delay.8 Even allow- programme that focuses on the health, well-being
ing for travel time, rural men and women with chest and safety of farm men, women and their families Aus-
pain have been found to wait 30 min longer than their tralia wide.13 Participants are primarily recruited to SFF
urban counterparts before seeking treatment.9 This programmes through an industry group, although pro-
delayed decision-making behaviour is not restricted to grammes are open to all farming men and women who
chest pain, with rural men and women presenting later meet eligibility criteria. The industry group can be any
for a wide range of emergency conditions.10 group within a local community that involves farmers;
Farmers and non-town dwellers are often thought to these groups have included sporting groups, progress
be the slowest rural Australians to seek emergency associations and livestock groups among many others.
medical treatment. Reasons given include the poorly Farmers are self-selecting to participate in the pro-
defined and stereotypical concept of stoicism and an gramme, although extensive media campaigns are
apparent fatalistic acceptance of supposed outcomes.11 undertaken across rural areas to encourage a broad
We postulate that a lack of health literacy might also range of the local agricultural community to participate.
play a role in delaying medical help seeking behav- The SFF programme is well-documented elsewhere14,15
iours in emergencies. Health literacy has been defined with participants undertaking health education work-
as the knowledge and skills to understand and use shops and having individual physical assessments over
health resources, including in medical emergencies.12 a period of 2–3 years.
In rural areas, the understanding of emergency To be eligible for this chest pain pilot study, partici-
medical service roles and capabilities appears to be pants were required to be aged between 18 and 80 years,
adversely affected by a period of change where local speak and understand English. Each person undertak-
district hospitals, emergency or after hours services ing the present study self-identified as being involved in
have been closed with people advised to ring central- active farming over the last 5 years as required by SFF
ized after hours triage or attend alternative larger selection criteria. As the present study reflected the
services. demographics of farm men and women, both husband
Over this period, rural and remote Australians might and wife were classified as farmers. If other family
not have received appropriate information explaining members such as parents and adult children met the
how to access and use these new emergency services above criteria and were actively employed within the
effectively. It seems conceivable that there is a discon- farming enterprise they too were eligible to participate.
nect between modern emergency services and people Farmers were recruited from 20 rural locales across
more familiar with the old system, which was in place Victoria to undertake the present study. Using Victorian

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 Farmers with chest pain: A pilot study

Government Department of Human Services bound- knowledgeable about, or respond more rapidly to, chest
aries, participants were recruited from four SFF pro- pain. However, this is based on assumptions that people
grammes conducted in the Hume region, six within who have poor health do not want to receive free health
Loddon Mallee, four within Grampians, four within assessment and advice. SFF programmes are free to
Barwon South Western and two within Gippsland. A attend and the availability of medical bulk billing is
plain language statement approved by South-West mul- lower in rural communities. It is possible that people
tidisciplinary ethics committee and signed consent was who were unwell might have been motivated to attend
obtained from each participant. and have their health checked. It is not within the scope
Each consenting agricultural worker completed a of this pilot study to determine whether the selection
short chest pain questionnaire on the first morning of criteria resulted in a positive or negative skew, but
the 2 day SFF workshop. The questionnaire asked how rather to provide an important insight into the cardiac
long it would take to drive, at legal speed, to local health and emergency knowledge of farmers in Victoria.
health-care facilities, and the name of the nearest ED. A With an unknown estimated prevalence (assumed to
scenario question required participants to estimate how be 50% for study size calculations), the chosen sample
long they would delay seeking medical advice with size has sufficient statistical power to measure param-
chest pain depending on whether they were in town or eters with a 95% confidence interval (CI) range of 7.5%.
on farm. Participants responded to a further 12 state- CIs were calculated using the Adjusted Wald method.
ments about chest pain behaviour using a 5-point Likert Spearman’s rho was used to determine the correlation
scale. Questions were constructed so they could be later between time to seek medical advice and distance from
grouped into pairs to determine response consistency. the nearest ED.
Questions were written to either strongly agree or dis-
agree with published community chest pain guidelines,
such as from the National Heart Foundation of Austra- Results
lia’s Every Minute Counts campaign.16
In addition to the questionnaire, fasting total choles- Participants
terol and blood glucose levels were tested using finger
prick capillary samples following a 10 h fast. Weight was One hundred and eighty-six farmers (91 female and 95
measured using calibrated scales and height determined. male) from 20 rural locales in Victoria were enrolled in
From this, the body mass index could be calculated. the study. All completed the survey with questions
Blood pressure was measured using paired readings achieving between 98% and 100% usable response rate.
from an automated blood pressure machine. People were The one exception to this response rate was in the
considered to be at risk of acute coronary events if they scenario asking how long a participant would wait at
had a systolic blood pressure ⱖ140 mmHg and/or dias- home with chest pain. Fifteen per cent of respondents
tolic blood pressure ⱖ90 mmHg.17 Other risk factors gave a non-numerical answer, such as ‘minutes’, ‘hours’
include having a body mass index ⱖ25, fasting blood or ‘days’, or left the question blank.
glucose level ⱖ5.5 mmol/L18 or a total fasting cholesterol
measurement ⱖ5.5 mmol/L.18 Cardiac risk factors
Data were collated using Microsoft Excel 2007 and
analysed using the statistical software package PASW- The average age was 53.4 (SD 13.0) years for men and
Statistics 18.0 (SPSS Inc. (Statistical Package for the 51.8 (SD 11.2) years for women. Cardiac risk factors are
Social Sciences Inc.) Chicago, Illinois, United States of listed in Table 1. In this cohort, 61% of men (58/95, 95%
America). Non-numerical or blank answers to questions CI 51–70) and 74% of women (68/91, 95% CI 65–83) were
were not included in the dataset. Questionnaires with either overweight or obese. Over half of the participants
less than 90% of questions answered were to be were hypertensive (52%, 95/186, 95% CI 44–58) and a
removed from this analysis, but no participant had less similar number (53%, 99/186, 95% CI 46–60) had fasting
than a 90% response. blood glucose levels that required referral for further
As participants in this chest pain pilot study were testing. Twenty-six per cent of participants (49/186, 95%
recruited through their attendance at SFF programmes, CI 21–33) had raised cholesterol during testing or had
there was the possibility of selection bias. Participant previously been identified as having raised cholesterol.
self-selection could influence the data presented, as Ten per cent (18/186, 95% CI 6–15) returned positive
healthy and motivated individuals might be more results for hypercholesterolaemia during the SFF

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 T Baker et al.

Table 1. Cardiac risk factors

Female % (n, 95% CI) Male % (n, 95% CI)
Body mass index ⱖ25 74.7 (68/91, 64.9–82.6) 61.1 (58/95, 51.0–70.3)
Fasting blood glucose ⱖ5.5 mmol/L 59.3 (54/91, 49.1–68.9) 47.4 (45/95, 37.6–57.3)
Total cholesterol ⱖ5.5 mmol/L 5.5 (5/91, 2.1–12.5) 13.7 (13/95, 8.0–22.2)
Already taking lipid lowering agents 12.1 (11/91, 6.7–20.5) 21.1 (20/95, 14.0–30.4)
Hypertension (BP ⱖ140/90 mmHg) 49.5 (45/91, 39.4–59.5) 52.6 (50/95, 42.7–62.4)
Current smoker 2.2 (2/91, 0.1–8.1) 3.2 (3/95, 0.7–9.3)
Previous smoker 29.7 (27/91, 21.2–39.8) 22.1 (21/95, 14.9–31.5)

Table 2. Characteristics of departments named staffed or non-staffed) was 24 min (range 2–60 min). In
% (n, 95% CI) this cohort, 39% of respondents (73/184, 95% CI 33–47)
reported that they were closer to their local general
Time to drive to nearest ED at legal speed
practitioner service than the nearest emergency service.
Under 10 min 31.9 (59/185, 25.6–38.9)
10–20 min 40.0 (74/185, 33.2–47.2)
20–30 min 17.8 (33/185, 12.9–24.0)
Understanding the role of general practice clinics
30–40 min 7.0 (13/185, 4.0–11.7)
40 min and over 3.2 (6/185, 1.3–7.0)
The majority of participants (70%, 129/185, 95% CI
General practice clinic or ED closer
63–76) thought they should attend the ED directly if
General practice clinic closer 39.2 (73/184, 32.9–46.9)
ED closer 7.5 (14/184, 4.5–12.5)
suffering chest pain. Upon further questioning, 22%
Same time to ED and general 52.2 (97/184, 45.5–59.8) (41/185, 95% CI 17–29) thought it was necessary to ring
practice clinic their local doctor first, and 18% (34/185, 95% CI 13–25)
Type of nearest ED named were unsure. In this farming cohort, 55% of participants
ED with 24 h doctor present 38.2 (71/184, 31.9–45.8) (102/186, 95% CI 48–62) believed that a local doctor
ED with doctor on call from home 49.5 (94/184, 43.9–58.2) could exclude an acute myocardial infarction with an
Non-ED 10.2 (19/184, 6.6–15.6) electrocardiogram (Table 3). Thirty-seven per cent (68/
186, 95% CI 30–44) thought that exclusion of acute
myocardial infarction required several hours, at least, in
programme, with a further 17% of participants (31/186, hospital.
95% CI 12–23) using oral hypolipidaemic medication at
the time of testing to maintain normal cholesterol levels.
Impact of distance and delay
Three per cent of participants were current smokers
(3/186, 95% CI 0–5) and 26% (48/186, 95% CI 20–33) When questioned about appropriate emergency deci-
indicated they had previously smoked. sion making, 57% of respondents (105/185, 95% CI
50–64) agreed with the National Heart Foundation of
Understanding EDs and local health services Australia’s major community message, that people with
10 min of chest pain should seek medical advice. Most
When asked to nominate the nearest ED (Table 2), 38% participants recognized that time of day should not
(71/184, 95% CI 32–46) named hospitals with a doctor in influence medical seeking behaviours. In fact, 82% (151/
attendance 24 h each day. A further 50% (94/184, 95% CI 184, 95% CI 76–87) disagreed with the statement that
44–58) nominated EDs where doctors had to be called in people with chest pain should wait until morning to
from home, whereas 10% of participants (19/184, 95% CI seek medical help. The cohort appeared less certain with
7–16) named health services or towns where no ED the delays caused by distance with 84% (157/186, 95%
exists. Some of these towns had a general practice clinic CI 79–89) indicating they thought it unwise for people
whereas others had health services where the ED had who have a long way to go to hospital to wait for hours
been closed. Furthermore, 14 of these 19 (74%, 95% CI to see if pain would go away by itself, yet only 64%
51–89)) stated that it would be appropriate to travel by (119/185, 95% CI 57–71) responding that more remote
car with chest pain to these non-emergency facilities. The patients should move earlier (Table 3). When the time
average time to drive to the nearest ED named (either participants would wait with chest pain at home before

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 Farmers with chest pain: A pilot study

Table 3. Questionnaire responses

Question Agree % (n, 95% CI) Disagree % (n, 95% CI) Unsure % (n, 95% CI)
1 Many people having a heart attack 69.2 (128/185, 62.2–75.4) 6.5 (12/185, 3.6–11.1) 24.3 (45/185, 18.7–31.0)
mistakenly think that their chest
pain is due to a non-serious cause,
such as indigestion.
2 It is usually easy for a person to tell 12.9 (24/186, 8.8–18.5) 49.5 (92/186, 42.4–56.6) 37.6 (70/186, 31.0–44.8)
if their chest pain is due to a heart
attack, rather than indigestion.
3 Most people with chest pain at 75.3 (140/186, 68.6–80.9) 5.9 (11/186, 3.2–10.4) 18.8 (35/186, 13.8–25.1)
02.00 hours should seek medical
attention immediately.
4 Most people with chest pain at 9.2 (17/184, 5.8–14.4) 82.1 (151/184, 75.9–87.0) 8.7 (16/184, 5.3–13.7)
02.00 hours should wait until the
morning to seek medical attention.
5 It is recommended that a person 56.8 (105/185, 49.6–63.7) 14.1 (26/185, 9.7–19.9) 29.2 (54/185, 9.7–19.9)
should seek immediate medical
help if they have 10 min of chest
pain, even if it is mild.
6 It is recommended that people should 31.9 (59/185, 25.6–38.9) 56.2 (104/185, 49.0–63.2) 11.9 (22/185, 7.9–17.4)
seek immediate medical help only
if they think their chest pain is due
to a heart attack.
7 It is difficult to be sure that chest 36.6 (68/186, 30.0–43.7) (28.0 52/186, 22.0–34.8) 35.5 (66/186, 29.0–42.6
pain is not due to a heart attack
without at least several hours in
hospital.
8 A doctor in their rooms can safely 54.8 (102/186, 47.7–61.8) 14.5 (27/186, 10.1–20.4) 30.7 (57/186, 24.5–37.6)
rule out a nasty cause of chest
pain in most people by examining
the person and taking an
electrocardiograph of the heart.
9 If an ambulance can attend quickly, 78.4 (145/185, 71.9–83.7) 8.1 (15/185, 4.9–13.0) 13.4 (25/185, 9.3–19.2)
someone worried about chest pain
should go to hospital by
ambulance.
10 It is safe to go to the ED by car with 66.5 (123/185, 59.4–72.9) 18.4 (34/185, 13.4–24.6) 15.1 (28/185, 10.6–21.0)
chest pain, as long as the person
with chest pain does not drive.
11 Most doctors recommend that people 69.7 (129/185, 62.8–75.9) 4.9 (9/185, 2.5–9.1) 25.3 (47/185, 19.7–32.2)
with chest pain should go straight
to the ED.
12 Most doctors recommend that people 22.2 (41/185, 16.8–28.7) 59.5 (110/185, 52.3–66.3) 18.4 (34/185, 13.4–24.6)
with chest pain should ring their
general practitioner first, before
going to the ED.
13 People who live a long way from 64.3 (119/185, 57.2–70.9) 28.5 (53/185, 22.6–35.6) 7.0 (13/185, 4.1–11.8)
hospital should decide to go to
hospital when they have chest
pain earlier than patients who
live near the hospital.
14 It is sensible that people who have to 5.4 (10/186, 2.8–9.7) 84.4 (157/186, 78.5–89.0) 10.2 (19/186, 6.6–15.5)
go a long way to hospital wait at
home, for an hour or two, to see if
the chest pain will go away.
Agree = Agree + Strongly agree, Disagree = Disagree + Strongly disagree.
Answers consistent with Australian Heart Foundation guidelines are written in bold.

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 T Baker et al.

Time possible heart attack pain tolerated before seeking medical advice Minutes
50

40
(To see if pain will go away)

30

20

10

0
Under 10 10−20 20−30 30−40 40 and over Minutes

Figure 1. Median time that chest pain will be tolerated plotted against distance from the nearest ED. Spearman’s rho = 0.112, P = 0.157.

seeking emergency assistance was plotted against how of farm men and women in rural Victoria. Of concern is
far the person with chest pain lived from hospital, the a pervading uncertainty of what to do if experiencing
opposite was found. The further away a person lived, chest pain. This farming cohort were unsure of how
the longer they would wait on the farm before seeking long they should wait if experiencing chest pain and
emergency medical assistance. The median waiting hesitant on whether they should first contact their
times have been graphed and show a striking trend general practitioner or go directly to the nearest ED.
towards more remote individuals waiting longer with Farmers were sometimes unaware that their local hos-
chest pain before seeking help (Fig. 1). However, it pital no longer (or never) had an ED, and were sceptical
should be noted that there was a wide range of on whether they should call an ambulance in emergency
responses to this question (from 1 min to 1 day), result- scenarios.
ing in a large degree of overlap between groups, and a The potential for poor emergency outcomes is further
small, but not statistically significant association compounded by this farming cohort being at heightened
(Spearman’s rho = 0.112, P = 0.157). risk of experiencing acute coronary events according to
clinical cardiac risk factors collected during the present
Ambulance services study. For example, 68% of our representative farming
sample was either overweight or obese (on body mass
The majority (78%, 145/185, 95% CI 72–84) of partici- index criteria) compared with the national average of
pants thought travelling by ambulance was the 60%.17 We also revealed in this cohort high rates of
appropriate means to seek emergency treatment. elevated blood glucose 54% and hypertension (52%
However, 67% (123/185, 95% CI 59–73) also indicated compared with 29% nationally17,19) although these com-
that travelling by car while potentially having a myo- parisons are not age, race or sex standardized. The low
cardial infarction was safe. Many thought that it was rates of current smokers within our cohort (3%) was a
safe to go by either ambulance or car. health positive and reflects previous studies showing
lower than average smoking rates in farmers.20 This
Discussion very low rate compares favourably with the 20% of
Victorians who currently smoke.21
This pilot study provides an interesting and disturbing Although our cohort size and non-randomized selec-
insight into emergency medical care seeking behaviours tion criteria prohibit conclusions to be drawn about

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 Farmers with chest pain: A pilot study

cardiac risk factors in the wider population of farmers, In the present study, it appears that many farmers
they do correlate well with other studies showing saw being driven to hospital as an acceptable alterna-
increased rates of cardiac risk factors in rural and tive to calling the ambulance. Many reasons have been
remote communities.2 More importantly, these results suggested for the reluctance of rural people to use
depict a population of farmers that are at risk of ambulance services.26 Most rural people can recall an
cardiac events, and could be adversely affected if anecdote, from word of mouth or the media, where the
they make the wrong decisions. The findings of this use of an ambulance service was said to result in a
pilot study also highlight the need for further inv- poor health outcome.26 There is a widespread belief
estigation into cardiac risk factors in agricultural that travelling by car is quicker and thus safer. One
communities. participant wrote on their questionnaire that it was
Although participants had a theoretical understand- ‘sometimes quicker to drive to hospital rather than get
ing that waiting at home to see if the chest pain an ambulance’. Although the wait at home might be
would recede was not a good idea, there was little evi- shorter in this scenario, the time to care, which is the
dence to suggest that they understood that people most important factor, has been shown to be longer on
living further away from treatment should start to average.24,27,28 Calling the ambulance also provides
move earlier to overcome the unavoidable delay of immediate telephone advice and activates the emer-
longer travel time. In fact, there is a suggestion that gency medical system. Paramedics also have the
they might even wait longer when more distant. ability to defibrillate once on the scene. From our
This finding is in agreement with the often described cohort, it is not difficult to foresee a tragedy when
‘distance-decay effect’,22 which is summarized by the someone travels by car for 30 min to an ED where the
longer the trip, the greater the disincentive to travel. doctor is unavailable or, even worse, to a town without
As commented by one participant ‘Many times, we an ED.
tend to avoid it (seeking assistance) if possible Because of the limited size of our cohort and rela-
because of the distance. If we lived closer to facilities, tively small number of questions, definitive statements
we would be asking advice from experts a lot more on emergency medical care seeking behaviours in rural
often.’ communities cannot yet be made. However, the need for
In the present study, many participants felt they further investigation using a randomized sample is
should contact their doctor first, or were unsure on apparent to determine whether these concerning trends
what course of action to take, when experiencing chest hold true across the remainder of Australia’s farming
pain. As outlined by Farmer et al., rural people base and remote communities.
their attitudes of appropriate health-care behaviour on Improving health literacy among farm men and
their experience with local general practitioners.23 women is of the utmost importance as they have higher
Rural men and women are also reluctant to seek help rates of clinical risk factors and appear to be lagging in
unless it is a ‘genuine’ emergency. Factors influencing emergency knowledge and services when compared
this behaviour include fear of medical treatment, an with their urban and regional counterparts. Further-
ongoing relationship with the doctor and reluctance to more, farmers are generally the most remotely located
be thought of as a ‘time-waster’.23 Among the cohort of within a population and would achieve greater benefit
farmers in the present study, about one-third thought from acting rapidly in response to acute myocardial
that they should not seek help unless they thought the events and other medical emergencies. Programmes
pain was caused by a heart attack. Furthermore, if addressing behavioural barriers to accessing care8
chest pain was experienced during the night, approxi- and improving emergency decision making within the
mately one in ten would wait until the morning before farming cohort might be readily translatable into rural
seeking treatment. lives saved.
A close relationship with a general practitioner
remains the cornerstone of good rural health care, but
contacting or visiting a local doctor at their clinic is not Acknowledgements
recommended when a patient has chest pain.8 Despite
this cohort’s beliefs to the contrary, acute coronary syn- The authors are appreciative of the statistical help pro-
drome can seldom be excluded in a clinic setting, and it vided by Benjamin Philpot from Flinders University
has been shown to delay hospital presentation by at and also to acknowledge the continued support of
least 1 h.24,25 farming communities Australia-wide.

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 T Baker et al.

Author contributions 10. Veitch PC. Anticipated response to three common injuries
by rural and remote area residents. Soc. Sci. Med. 1995; 41:
739–45.
TB and SM developed the questionnaire, analysed
results and co-wrote the paper. CM-G recruited 11. Howat A, Veitch C, Cairns W. A descriptive study comparing
health attitudes of urban and rural oncology patients. Rural
programme participants, ensured completion of ques- Remote Health 2006; 6: 563.
tionnaires and provided feedback on the paper. SB 12. Australian Bureau of Statistics. Health Literacy, Australia. 2008
secured funding for the study, developed the SFF Catalogue No. 4233.0. [Cited 22 May 2008.] Available from URL:
model, oversaw data collection, questionnaire dev- http://www.abs.gov.au
elopment, data analysis and compilation of the 13. Brumby SA, Willder SJ, Martin J. The Sustainable Farm Families
manuscript. Project: changing attitudes to health. Rural Remote Health
2009; 9: 1012 (online). [Cited 1 November 2010.] Availa-
ble from URL: http://www.rrh.org.au/publishedarticles/article_
print_1012.pdf
Competing interests 14. Brumby SA, Wilson B, Willde S. Living Longer on the Land –
Sustainable Farm Families in Broadacre Agriculture. RIRDC
None declared. Publication No 08/048. Canberra: Rural Industries Research and
Development Corporation, 2008.
Accepted 11 January 2011 15. Blackburn J, Brumby S, Willder S McKnight R. Intervening to
improve health indicators among Australian farm families.
J. Agromedicine 2009; 14: 345–56.
16. National Heart Foundation of Australia. Will you recognise your
heart attack? 2009. [Cited 4 Aug 2010.] Available from URL:
http://www.heartfoundation.org.au
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