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Flinterman LE, González-González AI, Seils L, Bes J, Ballester M, Bañeres J, Dan S, Domagala A, Dubas-Jakóbczyk K, Likic R, Kroezen M, Batenburg R. Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries. Int J Health Policy Manag 2023; 12:7454. [PMID: 38618823 PMCID: PMC10590222 DOI: 10.34172/ijhpm.2023.7454] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 05/30/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies). METHODS We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes. RESULTS Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%). CONCLUSION Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.
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Affiliation(s)
- Linda E. Flinterman
- Health Workforce and Organization Studies, Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | | | - Laura Seils
- Avedis Donabedian Research Institute – UAB, Madrid, Spain
| | - Julia Bes
- Health Workforce and Organization Studies, Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | | | | | - Sorin Dan
- Innovation and Entrepreneurship InnoLab, University of Vaasa, Vaasa, Finland
| | - Alicja Domagala
- Department of Health Policy and Management, Institute of Public Health, Jagiellonian University, Krakow, Poland
| | - Katarzyna Dubas-Jakóbczyk
- Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University, Krakow, Poland
| | - Robert Likic
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marieke Kroezen
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Ronald Batenburg
- Health Workforce and Organization Studies, Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of Sociology, Radboud University, Nijmegen, The Netherlands
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Shiikha Y, Ledingham R, Playford D. The ties that bind: Social network analysis describes the social element of medical workforce recruitment to rural/remote Australia. Soc Sci Med 2023; 322:115806. [PMID: 36871335 DOI: 10.1016/j.socscimed.2023.115806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 12/06/2022] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
We present the argument that medical recruitment to a previously under-recruited remote town was effected through what Social Network Analysis (SNA) measures as "brokerage" which operates amidst "structural holes". We proposed that medical graduates being generated by the national Rural Health School movement in Australia were particularly affected by the combined effect of workforce lacks (structural holes) and strong social commitments (brokerage) - all key SNA concepts. We therefore chose SNA to assess whether the characteristics of RCS-related rural recruitment had feature that SNA might be able to identify, as operantly measured using the industry-standard UCINET's suite of statistical and graphical tools. The result was clear. Graphical output from the UCINET editor showed one individual as being central to all recently recruited doctors to one rural town with recruitment issues like all the others. The statistical outputs from UCINET characterised this person as the single point of most connections. The real-world engagements of this central doctor were in accord with the description of brokerage, a core SNA construct, relationship with reported the reason for these new graduates both coming and staying in town. SNA thus proved fruitful in this first quantification of the role of social networks in drawing new medical recruits to particular rural towns. It allowed description at the level of individual actors with a potent influence on recruitment to rural Australia. We propose these measures could be helpful as key performance indicators for the national Rural Clinical School programme that is generating and distributing a large workforce in Australia, which appears from this work to have a strong social basis. This redistribution of medical workforce from urban to rural is needed internationally.
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Affiliation(s)
- Yulia Shiikha
- The Rural Clinical School of WA, UWA School of Medicine, Western Australia, WA, 6009, Australia.
| | - Rebekah Ledingham
- The Rural Clinical School of WA, UWA School of Medicine, Western Australia, WA, 6009, Australia
| | - Denese Playford
- The Rural Clinical School of WA, UWA School of Medicine, Western Australia, WA, 6009, Australia
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Noya F, Carr S, Freeman K, Thompson S, Clifford R, Playford D. Strategies to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review. Int J Health Policy Manag 2022; 11:2022-2037. [PMID: 34973053 PMCID: PMC9808272 DOI: 10.34172/ijhpm.2021.160] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 11/14/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Medical workforce shortages in rural and remote areas are a global issue. High-income countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs. METHODS The Arksey and O'Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates. RESULTS Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in HICs, with only eight studies from LMICs. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce. CONCLUSION This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country's commitment to act to improve the rural medical workforce shortage is most critical.
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Affiliation(s)
- Farah Noya
- Division of Health Professions Education, School of Allied Health, University of Western Australia, Perth, WA, Australia
| | - Sandra Carr
- Division of Health Professions Education, School of Allied Health, University of Western Australia, Perth, WA, Australia
| | - Kirsty Freeman
- Division of Health Professions Education, School of Allied Health, University of Western Australia, Perth, WA, Australia
- Duke National University Singapore Medical School, Singapore, Singapore
| | - Sandra Thompson
- Western Australian Centre for Rural Health, The University of Western Australia, Perth, WA, Australia
| | - Rhonda Clifford
- School of Allied Health, University of Western Australia, Perth, WA, Australia
| | - Denese Playford
- The Rural Clinical School of WA, School of Medicine, The University of Western Australia, Perth, WA, Australia
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Russell DJ, Wilkinson E, Petterson S, Chen C, Bazemore A. Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice. J Grad Med Educ 2022; 14:441-450. [PMID: 35991106 PMCID: PMC9380633 DOI: 10.4300/jgme-d-21-01143.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/16/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Rural US populations face a chronic shortage of physicians and an increasing gap in life expectancy compared to urban US populations, creating a need to understand how to increase residency graduates' desire to practice in such areas. OBJECTIVE This study quantifies associations between the amount of rural training during family medicine (FM) residencies and subsequent rural work. METHODS American Medical Association (AMA) Masterfile, AMA graduate medical education (GME) supplement, American Board of Family Medicine certification, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services hospital costs data were merged and analyzed. Multiple logistic regression measured associations between rural training and rural or urban practice in 2018 by all 12 162 clinically active physicians who completed a US FM residency accredited by the ACGME between 2008 and 2012. Analyses adjusted for key potential confounders (age, sex, program size, region, and medical school location and type) and clustering by resident program. RESULTS Most (91%, 11 011 of 12 162) residents had no rural training. A minority (14%, 1721 of 12 162) practiced in a rural location in 2018. Residents with no rural training comprised 80% (1373 of 1721) of those in rural practice in 2018. Spending more than half of residency training months in rural areas was associated with substantially increased odds of rural practice (OR 5.3-6.3). Only 4% (424 of 12 162) of residents spent more than half their training in rural locations, and only 5% (26 of 436) of FM training programs had residents training mostly in rural settings or community-based clinics. CONCLUSIONS There is a linear gradient between increasing levels of rural exposure in FM GME and subsequent rural work.
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Affiliation(s)
- Deborah J. Russell
- Deborah J. Russell, MBBS, MClinEpid, PhD, is Senior Research Fellow, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| | - Elizabeth Wilkinson
- Elizabeth Wilkinson, BA, is former Junior Analyst, Robert Graham Center for Policy Studies in Family Medicine and Primary Care
| | - Stephen Petterson
- Stephen Petterson, PhD, is Affiliate Faculty, The George Washington University Milken Institute School of Public Health
| | - Candice Chen
- Candice Chen, MD, MPH, is Associate Professor, The George Washington University Milken Institute School of Public Health
| | - Andrew Bazemore
- Andrew Bazemore, MD, MPH, is Senior Vice President of Research and Policy, American Board of Family Medicine, and Co-Director, Center for Professionalism and Value in Health Care
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Beks H, Walsh S, Alston L, Jones M, Smith T, Maybery D, Sutton K, Versace VL. Approaches Used to Describe, Measure, and Analyze Place of Practice in Dentistry, Medical, Nursing, and Allied Health Rural Graduate Workforce Research in Australia: A Systematic Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:1438. [PMID: 35162455 PMCID: PMC8834932 DOI: 10.3390/ijerph19031438] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 01/06/2023]
Abstract
Redressing the maldistribution of the health workforce in regional, rural, and remote geographical areas is a global issue and crucial to improving the accessibility of primary health care and specialist services. Geographical classification systems are important as they provide an objective and quantifiable measure of access and can have direct policy relevance, yet they are not always consistently applied in rural health research. It is unclear how research focusing on the graduate health workforce in Australia has described, measured, and analyzed place of practice. To examine approaches used, this review systematically scopes Australian rural studies focusing on dentistry, medicine, nursing, and allied health graduates that have included place of practice as an outcome measure. The Joanna Brigg's Institute Scoping Review Methodology was used to guide the review. Database searches retrieved 1130 unique citations, which were screened, resulting in 62 studies for inclusion. Included studies were observational, with most focusing on the practice locations of medical graduates and predicators of rural practice. Variations in the use of geographical classification approaches to define rurality were identified and included the use of systems that no longer have policy relevance, as well as adaptations of existing systems that make future comparisons between studies challenging. It is recommended that research examining the geographical distribution of the rural health workforce use uniform definitions of rurality that are aligned with current government policy.
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Affiliation(s)
- Hannah Beks
- School of Medicine, Deakin University, Geelong 3220, Australia; (H.B.); (L.A.)
| | - Sandra Walsh
- Department of Rural Health, University of South Australia, Whyalla 5608, Australia; (S.W.); (M.J.)
| | - Laura Alston
- School of Medicine, Deakin University, Geelong 3220, Australia; (H.B.); (L.A.)
| | - Martin Jones
- Department of Rural Health, University of South Australia, Whyalla 5608, Australia; (S.W.); (M.J.)
| | - Tony Smith
- Department of Rural Health, University of Newcastle, Taree 2430, Australia;
| | - Darryl Maybery
- Department of Rural Health & Indigenous Health, Monash University, Warragul 3820, Australia; (D.M.); (K.S.)
| | - Keith Sutton
- Department of Rural Health & Indigenous Health, Monash University, Warragul 3820, Australia; (D.M.); (K.S.)
| | - Vincent L Versace
- School of Medicine, Deakin University, Geelong 3220, Australia; (H.B.); (L.A.)
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Noya F, Carr S, Thompson S, Clifford R, Playford D. Factors associated with the rural and remote practice of medical workforce in Maluku Islands of Indonesia: a cross-sectional study. HUMAN RESOURCES FOR HEALTH 2021; 19:126. [PMID: 34627282 PMCID: PMC8502290 DOI: 10.1186/s12960-021-00667-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Many factors contribute to engagement in rural and remote (RR) medical practice, but little is known about the factors associated with rural and remote medical practice in such remote locations as the Maluku Province of Indonesia. This study describes factors associated with actual RR practice, preferred RR practice, and intention to remain practice in Maluku Province. METHODS An online survey of work-related experience and intentions for future rural work was administered to 410 doctors working in the Maluku province of Indonesia. Participant characteristics were described using descriptive statistics, associations between the independent variables with the location of the workforce, intention to remain practice in Maluku, preference for future RR practice in Maluku were analysed using Chi-square tests and logistic regression. RESULTS A total of 324 responses (79% response rate) were recorded, comprising 70% females and 30% Pattimura University graduates of doctors employed in Maluku. Doctors working in RR areas were more likely to be a GP (OR 3.49, CI 1.03-11.8), have a monthly salary of more than IDR 6 million (OR 11.5, CI 4.24-31.1), and have no additional practice (OR 2.78, CI 1.34-5.78). Doctors intended to stay practice in Maluku were more likely to be born in Maluku (OR 7.77, CI 3.42-17.7) and have graduated from Pattimura University (OR 3.06, CI 1.09-8.54), and less likely to be a temporary employee (OR 0.24, CI 0.10-0.57). Doctors who prefer future RR practice in Maluku were more likely to experience rural living (OR 2.05 CI 1.05-3.99), have a positive indication of the impact of community exposure during medical schools on their current practice (OR 2.08, CI 1.06-4.09), currently practising in RR Maluku (OR 8.23, CI 3.27-20.8); and less likely to have bigger take-home pay (OR 0.30, CI 0.13-0.70). CONCLUSION This study indicates that special attention should be given to recruiting doctors with a rural background and ongoing support through attractive opportunities to build a sustainable RR workforce. Since a regional medical school helps supply doctors to the RR areas in its region, a sustained collaboration between medical schools and local government implementing relevant strategies are needed to widen participation and improve the recruitment and retention of RR doctors.
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Affiliation(s)
- Farah Noya
- Division of Health Professions Education, School of Allied Health, University of Western Australia, Perth, Australia
- Medical Education Unit, Faculty of Medicine, Pattimura University, Ambon, Indonesia
- Health Professions Education Building, The University of Western Australia, Crawley Avenue (off Mounts Bay Road-next to CAR PARK 25), Nedlands, WA 6009 Australia
| | - Sandra Carr
- Division of Health Professions Education, School of Allied Health, University of Western Australia, Perth, Australia
| | - Sandra Thompson
- Western Australian Centre for Rural Health, The University of Western Australia, Perth, Australia
| | - Rhonda Clifford
- School of Allied Health, University of Western Australia, Perth, Australia
| | - Denese Playford
- The Rural Clinical School of WA, School of Medicine, The University of Western Australia, Perth, Australia
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Ostini R, McGrail MR, Kondalsamy-Chennakesavan S, Hill P, O'Sullivan B, Selvey LA, Eley DS, Adegbija O, Boyle FM, Dettrick Z, Jennaway M, Strasser S. Building a sustainable rural physician workforce. Med J Aust 2021; 215 Suppl 1:S5-S33. [PMID: 34218436 DOI: 10.5694/mja2.51122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/17/2022]
Abstract
CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. DESIGN, SETTING AND PARTICIPANTS Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants. MAIN OUTCOME MEASURES Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. RESULTS Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8). CONCLUSION Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas. DESIGN, SETTING AND PARTICIPANTS In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19. MAIN OUTCOME MEASURES Individual and collective descriptors of professional identity. RESULTS We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation. CONCLUSION Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality. DESIGN, SETTING AND PARTICIPANTS A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters. MAIN OUTCOME MEASURES Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location. RESULTS Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors. CONCLUSION Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action. DESIGN We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles. RESULTS Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles. CONCLUSION These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.
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Poole P, Van Lier D, Verstappen A, Bagg W, Connell CJW, Nixon G, Wilkinson TJ. How rural is rural? The relationship between rural background of medical students and their career location intentions. Aust J Rural Health 2021; 29:363-372. [PMID: 34080758 DOI: 10.1111/ajr.12743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/18/2021] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Rural background is associated with greater interest in rural practice. However, there is no universally agreed definition of 'rural' background used in medical school selection. This study explored the association between definitions of 'rural' background and students' intended career locations. DESIGN Prospective cohort study using survey data on career intention, hometown size, rurality of background, home address, high school and intended career location. SETTING University of Auckland, New Zealand (NZ). PARTICIPANTS Commencing medical students 2009-2017, inclusive. MAIN OUTCOME MEASURES Univariate associations between student background according to 7 definitions of 'rural', and 3 definitions of intended practice location based on population size: urban intention (>100 000); regional intention (25 000-100 000); rural intention (<25 000). RESULTS The sample size was 1592 students. 27.4% had a rural background by at least one definition. All definitions of rural background were associated with a greater rural intention. Applying a restrictive definition of rural (population<25 000) was associated with a higher likelihood of rural intention, but captured a smaller number of students. There was strong agreement between the population size of a student's background and intended practice location (chi-square P < .0001). CONCLUSION Rural intention varies by definition, but the number of students captured by each definition is important. Applying a binary or overly restrictive definition may limit interested students. Medical schools should adopt a definition of 'rural' that optimises the number of eligible students and their propensity to work rurally. Further, alternative ways of identifying students with rural intentions without a rural background should be explored.
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Affiliation(s)
- Phillippa Poole
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Dylan Van Lier
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Antonia Verstappen
- Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
| | - Warwick Bagg
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | | | - Garry Nixon
- Division of Health Sciences, University of Otago, Dunedin, New Zealand
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Holloway P, Bain-Donohue S, Moore M. Why do doctors work in rural areas in high-income countries? A qualitative systematic review of recruitment and retention. Aust J Rural Health 2020; 28:543-554. [PMID: 33197109 DOI: 10.1111/ajr.12675] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To identify and assess the drivers and barriers to recruiting and retaining doctors in rural communities of high-income countries. DESIGN A systematic review and thematic analysis. SETTING Publications were sourced from medical and scientific databases online. PARTICIPANTS Qualitative, mixed-methods and review studies from peer-reviewed journals published since 2000 that discussed recruitment or retention of doctors to rural areas in high-income countries. MAIN OUTCOME MEASURES Identification and assessment of themes in the literature pertaining to recruitment and retention of rural doctors. Recurrent themes were assessed for relevance and applicability to current rural shortages. RESULTS A thematic analysis was completed on 41 papers assessed as in scope of the review. Papers were scrutinised for relevance to established rural recruitment and retention strategies. Key themes were rural background, education and training, personal and professional circumstances, and integration with the community. CONCLUSION While rural origin has long been promoted as the key factor for recruiting rural doctors, initiatives targeting only these individuals ignore a potentially larger cohort of future rural doctors. Rurally focused medical education and training need to encompass students and doctors from all backgrounds. The major barriers to rural recruitment are family-unit considerations for partners and children, concerns over isolation and a poor perception of rural practice. Attracting doctors to practise rurally is only half the challenge however, and strategies to retain rural doctors need a greater focus on personal and professional support networks and community integration. Additional strategies are needed to retain international and bonded doctors restricted to rural areas.
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Affiliation(s)
- Patrick Holloway
- Medical School - Australian National University (ANU) Medical School, ANU College of Health and Medicine, Canberra, ACT, Australia.,Rural Clinical School, Australian National University (ANU) Medical School, ANU College of Health and Medicine, Canberra, ACT, Australia
| | - Suzanne Bain-Donohue
- Rural Clinical School, Australian National University (ANU) Medical School, ANU College of Health and Medicine, Canberra, ACT, Australia
| | - Malcolm Moore
- Rural Clinical School, Australian National University (ANU) Medical School, ANU College of Health and Medicine, Canberra, ACT, Australia
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Kim C, Ngo H, Playford D. Gender equity at last: a national study of medical students considering a career in rural medicine. BMC MEDICAL EDUCATION 2020; 20:432. [PMID: 33198731 PMCID: PMC7667784 DOI: 10.1186/s12909-020-02355-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/02/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The rural medical workforce internationally suffers from a significant imbalance between male- and female- identifying practitioners. Not only do male doctors outnumber female doctors, but additionally female doctors work fewer hours than their male counterparts. This has health implications for rural communities. In response, In Australia, Rural Clinical Schools (RCSs) are a national training strategy to increase the number of graduates entering the rural medical workforce. It has been observed that RCSs attract a greater number of female students than male students. However, the future work intentions of male versus female RCS students is not known. This paper therefore asked whether male and female RCS students have equivalent intent for future rural practice. METHODS Participants were all students who attended RCSs from 2015 to 2017, who completed an exit survey that gathered data on demographic, experiential and intentional variables. Univariate analyses examined differences between the sexes. A multivariate model was constructed to determine the independent predictors for rural intention. RESULTS There were 2017 respondents across the 3 years, of whom 937 identified as male, and 1138 identified as female. In univariate analysis, female-identifying students had significantly higher rural intention than male-identifying students. There were no other sex-based differences in age, rural background, overall perception of support, and overall excellence of clinical education whilst in RCS. However, in multivariate analysis, sex was not a significant predictor for rural work intention, whereas older age, rural background, and first preference for RCS were all predictive of increased rural intent, as expected from the literature. There were no differences between male and female students in their perceptions of the overall support and the clinical education provided by RCS. CONCLUSION We conclude from this national study that sex is not an independent predictor for future rural work intention among RCS students. Considering the disproportionate number of female students entering RCS, this is reassuring for ultimately achieving rural workforce gender equity.
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Affiliation(s)
- Caleb Kim
- Rural Clinical School of WA, School of Medicine, UWA, 35 Stirling Highway, Crawley, WA 6009 Australia
| | - Hanh Ngo
- Rural Clinical School of WA, School of Medicine, UWA, 35 Stirling Highway, Crawley, WA 6009 Australia
| | - Denese Playford
- Rural Clinical School of WA, School of Medicine, UWA, 35 Stirling Highway, Crawley, WA 6009 Australia
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Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, Zhao Y, Ramjan M, Murakami-Gold L, Jones MP. Remote health workforce turnover and retention: what are the policy and practice priorities? HUMAN RESOURCES FOR HEALTH 2019; 17:99. [PMID: 31842946 PMCID: PMC6915930 DOI: 10.1186/s12960-019-0432-y] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 11/01/2019] [Indexed: 05/08/2023]
Abstract
BACKGROUND Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention. MAIN TEXT Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'. CONCLUSION Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.
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Affiliation(s)
- John Wakerman
- Menzies School of Health Research, Centre for Remote Health, CNR Simpson and Skinner Streets, Postal: PO Box 4066, Alice Springs, NT 0871 Australia
| | - John Humphreys
- Monash University School of Rural Health, PO Box 91, Strathdale, VIC 3550 Australia
| | - Deborah Russell
- Menzies School of Health Research, Centre for Remote Health, CNR Simpson and Skinner Streets, Postal: PO Box 4066, Alice Springs, NT 0871 Australia
| | - Steven Guthridge
- Centre for Child Development and Education, Menzies School of Health Research, Building Red 9, Charles Darwin University, Casuarina campus, Ellengowan Drive, Postal: PO Box 41096, Casuarina, NT 0811 Australia
| | - Lisa Bourke
- University Department of Rural Health, The University of Melbourne, PO Box 6500, Shepparton, VIC 3632 Australia
| | - Terry Dunbar
- Indigenous Social and Wellbeing Centre, School of Population Health Research, Australian National University, Canberra, Australia
| | - Yuejen Zhao
- Northern Territory Department of Health, 87 Mitchell Street, Darwin, NT 0800 Australia
| | - Mark Ramjan
- Top End Health Service, Northern Territory Government, GPO Box 40596, Area 2C Casuarina Plaza, Casuarina, NT 0810 Australia
| | - Lorna Murakami-Gold
- Poche Centre for Indigenous Health & Well-Being, Flinders NT, Rubuntja Building – Alice Springs Hospital, PO Box 2234, Alice Springs, NT 0871 Australia
| | - Michael P. Jones
- Psychology Department, Macquarie University, North Ryde, NSW 2109 Australia
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Playford DE, Mercer A, Carr SE, Puddey IB. Likelihood of rural practice in medical school entrants with prior tertiary experience. MEDICAL TEACHER 2019; 41:765-772. [PMID: 30961405 DOI: 10.1080/0142159x.2019.1570099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Background: Workforce decisions of medical students with prior tertiary education, relative to those without, are not known. Methods: Rural workforce outcomes for three separate streams of medical students were compared: school leaver entry (SLE) entered medical school direct (N = 682), non-standard entry (NSE) had some prior tertiary education (N = 123), and graduate entry (GE) (N = 317), had a prior completed degree. All students were at least in postgraduate year 3 in 2018, when current urban or rural medical workforce participation was ascertained. Results: Multivariate logistic regression allowing for the influences of rural background, rural clinical school participation, gender, being born overseas, socioeconomic status, and being a bonded rural scholar, showed that NSE students and GE students had increased odds of being in rural practice relative to SLE students. This increase was more than three-fold for NSE students (OR = 3.41, 95% CI 1.94, 5.99, p < 0.001) and greater than two-fold for GE students (OR = 2.54, 95% CI 1.57, 4.10, p < 0.001). Conclusion: Graduates with prior tertiary education were more likely to enter the rural medical workforce than direct school entrants. This suggests that increasing graduate entry programs may augment the rural medical workforce and that undergraduate programs allowing non-standard entry may have the same benefit.
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Affiliation(s)
- Denese E Playford
- a The Rural Clinical School of Western Australia, School of Medicine , University of Western Australia , Crawley , WA , Australia
| | - Annette Mercer
- b Division of Health Professions Education, School of Allied Health, Faculty of Health and Medical Sciences , University of Western Australia , Crawley , WA , Australia
| | - Sandra E Carr
- b Division of Health Professions Education, School of Allied Health, Faculty of Health and Medical Sciences , University of Western Australia , Crawley , WA , Australia
| | - Ian B Puddey
- c School of Medicine, Faculty of Health and Medical Sciences , University of Western Australia , Crawley , WA , Australia
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Larkins S, Johnston K, Hogenbirk JC, Willems S, Elsanousi S, Mammen M, Van Roy K, Iputo J, Cristobal FL, Greenhill J, Labarda C, Neusy AJ. Practice intentions at entry to and exit from medical schools aspiring to social accountability: findings from the Training for Health Equity Network Graduate Outcome Study. BMC MEDICAL EDUCATION 2018; 18:261. [PMID: 30424760 PMCID: PMC6234627 DOI: 10.1186/s12909-018-1360-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 10/25/2018] [Indexed: 05/05/2023]
Abstract
BACKGROUND Understanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions. METHODS The Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet's Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent. RESULTS Findings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds. CONCLUSIONS These findings, from a diverse range of schools with social accountability mandates in different settings, provide preliminary evidence for the selection and training of a medical workforce motivated to meet the needs of underserved populations. These respondents are being followed longitudinally to determine the degree to which these intentions translate into actual practice.
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Affiliation(s)
- Sarah Larkins
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland Australia
- Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, Queensland Australia
- James Cook Drive, James Cook University, Townsville, 4810 Australia
| | - Karen Johnston
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland Australia
- Training for Health Equity Network, New York, NY USA
| | - John C. Hogenbirk
- Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ontario Canada
| | - Sara Willems
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Salwa Elsanousi
- Community Medicine, Department of Family and Community Medicine, University of Gezira, Gezira, Sudan
| | - Marykutty Mammen
- Teaching and Learning Centre, University of Fort Hare, East London, Eastern Cape South Africa
| | - Kaatje Van Roy
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Jehu Iputo
- Department of Medical Education, Walter Sisulu University, Mthatha, South Africa
| | | | | | - Charlie Labarda
- School of Health Sciences at the University of the Philippines, Manila, Philippines
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14
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Ranmuthugala G. Rural recruitment and training promotes rural practice by GPs, but is it enough to retain them? Med J Aust 2016; 205:210-1. [DOI: 10.5694/mja16.00783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/14/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Geetha Ranmuthugala
- University of New England, Armidale, NSW
- Rural Clinical School, University of Queensland, Toowoomba, QLD
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15
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McGrail MR, Russell DJ, Campbell DG. Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce. Med J Aust 2016; 205:216-21. [DOI: 10.5694/mja16.00063] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 06/27/2016] [Indexed: 11/17/2022]
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Runge CE, MacKenzie A, Loos C, Waller M, Gabbett M, Mills R, Eley D. Characteristics of Queensland physicians and the influence of rural exposure on practice location. Intern Med J 2016; 46:981-5. [DOI: 10.1111/imj.13156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 11/30/2022]
Affiliation(s)
- C. E. Runge
- Schools of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - A. MacKenzie
- Schools of Public Health; The University of Queensland; Brisbane Queensland Australia
| | - C. Loos
- Schools of Public Health; The University of Queensland; Brisbane Queensland Australia
| | - M. Waller
- Schools of Public Health; The University of Queensland; Brisbane Queensland Australia
| | - M. Gabbett
- Schools of Medicine; The University of Queensland; Brisbane Queensland Australia
- Genetic Health Queensland; Royal Brisbane & Women's Hospital; Brisbane Queensland Australia
- The Royal Australasian College of Physicians; Sydney New South Wales Australia
- School of Medicine; Griffith University; Nathan Queensland Australia
| | - R. Mills
- Office of the Principal Medical Officer; Queensland Health; Brisbane Queensland Australia
| | - D. Eley
- Schools of Medicine; The University of Queensland; Brisbane Queensland Australia
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