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: tim.baker@deakin.edu.au
Tim Baker, MB BS, Emergency Physician; Scott McCoombe, PhD, Lecturer; Cate Mercer-Grant, BBus, Program manager; Susan Brumby, RN,
MHM, Clinical Associate Professor.

© 2011 The Authors

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
events in rural areas might also contribute.
Treatment in the first 2 h following a myocardial
infarction can decrease mortality by half.3 Also, one in
four people who experience a myocardial infarction die
from cardiac arrest within 1 h of their first chest pain.4
If the person has already reached hospital when they
have a cardiac arrest, treatment success rates of
between 20% and 40% are described.5 If the arrest
occurs outside of hospital care, the survival rate is
much lower. In rural Victoria, Australia, where this
survey was conducted, survival rates for witnessed
cardiac arrests occurring outside of medical care are
less than 2%.6
Studies around the world have found many reasons
why people with chest pain procrastinate before seeking
treatment.7 Two common explanations are the failure to
recognize a heart attack when the symptoms are atypi-
cal, and delay due to fear and embarrassment, even
when symptoms indicate a heart attack is almost cer-
tain.8 Living in a rural or remote location has been
described as an additional cause for delay.8 Even allow-
ing for travel time, rural men and women with chest
pain have been found to wait 30 min longer than their
urban counterparts before seeking treatment.9 This
delayed decision-making behaviour is not restricted to
chest pain, with rural men and women presenting later
for a wide range of emergency conditions.10
Farmers and non-town dwellers are often thought to
be the slowest rural Australians to seek emergency
medical treatment. Reasons given include the poorly
defined and stereotypical concept of stoicism and an
apparent fatalistic acceptance of supposed outcomes.11
We postulate that a lack of health literacy might also
play a role in delaying medical help seeking behav-
iours in emergencies. Health literacy has been defined
as the knowledge and skills to understand and use
health resources, including in medical emergencies.12
In rural areas, the understanding of emergency
medical service roles and capabilities appears to be
adversely affected by a period of change where local
district hospitals, emergency or after hours services
have been closed with people advised to ring central-
ized after hours triage or attend alternative larger
services.
Over this period, rural and remote Australians might
not have received appropriate information explaining
how to access and use these new emergency services
effectively. It seems conceivable that there is a discon-
nect between modern emergency services and people
more familiar with the old system, which was in place
338
EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
for more than a generation, of a general practice clinic
and a small local hospital that dealt with every emer-
gency situation occurring within its district.
The objectives of this pilot study were:
1. To determine the prevalence of cardiac risk factors in
a population of agricultural workers.
2. To assess their knowledge of local emergency health
services, and
3. To examine decision-making processes among agri-
cultural workers about when and how they would
seek help for chest pain.
Methods
This cross-sectional study, of exploratory design, was
conducted in Victoria, Australia between July 2009
and August 2010, in conjunction with the Sustainable
Farm Families (SFF) programme (developed by the
National Centre for Farmer Health, Hamilton, Victoria,
Australia). SFF is an evidence-based service delivery
programme that focuses on the health, well-being
and safety of farm men, women and their families Aus-
tralia wide.13 Participants are primarily recruited to SFF
programmes through an industry group, although pro-
grammes are open to all farming men and women who
meet eligibility criteria. The industry group can be any
group within a local community that involves farmers;
these groups have included sporting groups, progress
associations and livestock groups among many others.
Farmers are self-selecting to participate in the pro-
gramme, although extensive media campaigns are
undertaken across rural areas to encourage a broad
range of the local agricultural community to participate.
The SFF programme is well-documented elsewhere14,15
with participants undertaking health education work-
shops and having individual physical assessments over
a period of 2–3 years.
To be eligible for this chest pain pilot study, partici-
pants were required to be aged between 18 and 80 years,
speak and understand English. Each person undertak-
ing the present study self-identified as being involved in
active farming over the last 5 years as required by SFF
selection criteria. As the present study reflected the
demographics of farm men and women, both husband
and wife were classified as farmers. If other family
members such as parents and adult children met the
above criteria and were actively employed within the
farming enterprise they too were eligible to participate.
Farmers were recruited from 20 rural locales across
Victoria to undertake the present study. Using Victorian
© 2011 The Authors

Government Department of Human Services bound-
aries, participants were recruited from four SFF pro-
grammes conducted in the Hume region, six within
Loddon Mallee, four within Grampians, four within
Barwon South Western and two within Gippsland. A
plain language statement approved by South-West mul-
tidisciplinary ethics committee and signed consent was
obtained from each participant.
Each consenting agricultural worker completed a
short chest pain questionnaire on the first morning of
the 2 day SFF workshop. The questionnaire asked how
long it would take to drive, at legal speed, to local
health-care facilities, and the name of the nearest ED. A
scenario question required participants to estimate how
long they would delay seeking medical advice with
chest pain depending on whether they were in town or
on farm. Participants responded to a further 12 state-
ments about chest pain behaviour using a 5-point Likert
scale. Questions were constructed so they could be later
grouped into pairs to determine response consistency.
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-
lia’s Every Minute Counts campaign.16
In addition to the questionnaire, fasting total choles-
terol and blood glucose levels were tested using finger
prick capillary samples following a 10 h fast. Weight was
measured using calibrated scales and height determined.
From this, the body mass index could be calculated.
Blood pressure was measured using paired readings
from an automated blood pressure machine. People were
considered to be at risk of acute coronary events if they
had a systolic blood pressure ⱖ140 mmHg and/or dias-
tolic blood pressure ⱖ90 mmHg.17 Other risk factors
include having a body mass index ⱖ25, fasting blood
glucose level ⱖ5.5 mmol/L18 or a total fasting cholesterol
measurement ⱖ5.5 mmol/L.18
Data were collated using Microsoft Excel 2007 and
analysed using the statistical software package PASW-
Statistics 18.0 (SPSS Inc. (Statistical Package for the
Social Sciences Inc.) Chicago, Illinois, United States of
America). Non-numerical or blank answers to questions
were not included in the dataset. Questionnaires with
less than 90% of questions answered were to be
removed from this analysis, but no participant had less
than a 90% response.
As participants in this chest pain pilot study were
recruited through their attendance at SFF programmes,
there was the possibility of selection bias. Participant
self-selection could influence the data presented, as
healthy and motivated individuals might be more
© 2011 The Authors
EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Farmers with chest pain: A pilot study
knowledgeable about, or respond more rapidly to, chest
pain. However, this is based on assumptions that people
who have poor health do not want to receive free health
assessment and advice. SFF programmes are free to
attend and the availability of medical bulk billing is
lower in rural communities. It is possible that people
who were unwell might have been motivated to attend
and have their health checked. It is not within the scope
of this pilot study to determine whether the selection
criteria resulted in a positive or negative skew, but
rather to provide an important insight into the cardiac
health and emergency knowledge of farmers in Victoria.
With an unknown estimated prevalence (assumed to
be 50% for study size calculations), the chosen sample
size has sufficient statistical power to measure param-
eters with a 95% confidence interval (CI) range of 7.5%.
CIs were calculated using the Adjusted Wald method.
Spearman’s rho was used to determine the correlation
between time to seek medical advice and distance from
the nearest ED.
Results
Participants
One hundred and eighty-six farmers (91 female and 95
male) from 20 rural locales in Victoria were enrolled in
the study. All completed the survey with questions
achieving between 98% and 100% usable response rate.
The one exception to this response rate was in the
scenario asking how long a participant would wait at
home with chest pain. Fifteen per cent of respondents
gave a non-numerical answer, such as ‘minutes’, ‘hours’
or ‘days’, or left the question blank.
Cardiac risk factors
The average age was 53.4 (SD 13.0) years for men and
51.8 (SD 11.2) years for women. Cardiac risk factors are
listed in Table 1. In this cohort, 61% of men (58/95, 95%
CI 51–70) and 74% of women (68/91, 95% CI 65–83) were
either overweight or obese. Over half of the participants
were hypertensive (52%, 95/186, 95% CI 44–58) and a
similar number (53%, 99/186, 95% CI 46–60) had fasting
blood glucose levels that required referral for further
testing. Twenty-six per cent of participants (49/186, 95%
CI 21–33) had raised cholesterol during testing or had
previously been identified as having raised cholesterol.
Ten per cent (18/186, 95% CI 6–15) returned positive
results for hypercholesterolaemia during the SFF
339
 T Baker et al.

Table 1. Cardiac risk factors

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

340 © 2011 The Authors

EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 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.

© 2011 The Authors 341

EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 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

342 © 2011 The Authors

EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

cardiac risk factors in the wider population of farmers,
they do correlate well with other studies showing
increased rates of cardiac risk factors in rural and
remote communities.2 More importantly, these results
depict a population of farmers that are at risk of
cardiac events, and could be adversely affected if
they make the wrong decisions. The findings of this
pilot study also highlight the need for further inv-
estigation into cardiac risk factors in agricultural
communities.
Although participants had a theoretical understand-
ing that waiting at home to see if the chest pain
would recede was not a good idea, there was little evi-
dence to suggest that they understood that people
living further away from treatment should start to
move earlier to overcome the unavoidable delay of
longer travel time. In fact, there is a suggestion that
they might even wait longer when more distant.
This finding is in agreement with the often described
‘distance-decay effect’,22 which is summarized by the
longer the trip, the greater the disincentive to travel.
As commented by one participant ‘Many times, we
tend to avoid it (seeking assistance) if possible
because of the distance. If we lived closer to facilities,
we would be asking advice from experts a lot more
often.’
In the present study, many participants felt they
should contact their doctor first, or were unsure on
what course of action to take, when experiencing chest
pain. As outlined by Farmer et al., rural people base
their attitudes of appropriate health-care behaviour on
their experience with local general practitioners.23
Rural men and women are also reluctant to seek help
unless it is a ‘genuine’ emergency. Factors influencing
this behaviour include fear of medical treatment, an
ongoing relationship with the doctor and reluctance to
be thought of as a ‘time-waster’.23 Among the cohort of
farmers in the present study, about one-third thought
that they should not seek help unless they thought the
pain was caused by a heart attack. Furthermore, if
chest pain was experienced during the night, approxi-
mately one in ten would wait until the morning before
seeking treatment.
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
recommended when a patient has chest pain.8 Despite
this cohort’s beliefs to the contrary, acute coronary syn-
drome can seldom be excluded in a clinic setting, and it
has been shown to delay hospital presentation by at
least 1 h.24,25
© 2011 The Authors
EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Farmers with chest pain: A pilot study
In the present study, it appears that many farmers
saw being driven to hospital as an acceptable alterna-
tive to calling the ambulance. Many reasons have been
suggested for the reluctance of rural people to use
ambulance services.26 Most rural people can recall an
anecdote, from word of mouth or the media, where the
use of an ambulance service was said to result in a
poor health outcome.26 There is a widespread belief
that travelling by car is quicker and thus safer. One
participant wrote on their questionnaire that it was
‘sometimes quicker to drive to hospital rather than get
an ambulance’. Although the wait at home might be
shorter in this scenario, the time to care, which is the
most important factor, has been shown to be longer on
average.24,27,28 Calling the ambulance also provides
immediate telephone advice and activates the emer-
gency medical system. Paramedics also have the
ability to defibrillate once on the scene. From our
cohort, it is not difficult to foresee a tragedy when
someone travels by car for 30 min to an ED where the
doctor is unavailable or, even worse, to a town without
an ED.
Because of the limited size of our cohort and rela-
tively small number of questions, definitive statements
on emergency medical care seeking behaviours in rural
communities cannot yet be made. However, the need for
further investigation using a randomized sample is
apparent to determine whether these concerning trends
hold true across the remainder of Australia’s farming
and remote communities.
Improving health literacy among farm men and
women is of the utmost importance as they have higher
rates of clinical risk factors and appear to be lagging in
emergency knowledge and services when compared
with their urban and regional counterparts. Further-
more, farmers are generally the most remotely located
within a population and would achieve greater benefit
from acting rapidly in response to acute myocardial
events and other medical emergencies. Programmes
addressing behavioural barriers to accessing care8
and improving emergency decision making within the
farming cohort might be readily translatable into rural
lives saved.
Acknowledgements
The authors are appreciative of the statistical help pro-
vided by Benjamin Philpot from Flinders University
and also to acknowledge the continued support of
farming communities Australia-wide.
343
 T Baker et al.
Author contributions
TB and SM developed the questionnaire, analysed
results and co-wrote the paper. CM-G recruited
programme participants, ensured completion of ques-
tionnaires and provided feedback on the paper. SB
secured funding for the study, developed the SFF
model, oversaw data collection, questionnaire dev-
elopment, data analysis and compilation of the
manuscript.
Competing interests
None declared.
Accepted 11 January 2011
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