Two decades of building capacity in rural health education, training and research in Australia: University Departments of Rural Health and Rural Clinical Schools

International declaration on rural mental health research: 10 guiding principles and standards

Rural communities have unique mental health needs and challenges which are often related to the uniqueness of the community itself. On a per-capita basis, the investment in rural mental health research is far less than that in urban communities. Added to this, rural communities are often at risk of researchers, based in large urban universities, visiting, conducting the research with minimal engagement with local stakeholders and limited understanding of the community's social-service-environmental context. Often this research leaves no visible benefit to the community with respect to increased knowledge, resources or community capacity. This commentary is based on the insights of a panel of authors from 9 countries, each with extensive experience of rural mental health research and work. And it seeks to stimulate the discourse on responsible rural mental health practice. The aim of this commentary is to provide a reference on research practice for novice and experienced researchers on rural mental health research and practice, to assist policymakers, government and funding bodies to establish appropriate standards and guidelines for rural mental health research, and support rural communities to advocate for equity of funding and sustainable research as they engage with researchers, funders and governments. The 10 standards in this declaration will help guide researchers toward research that is beneficial to rural communities and also help develop the local community's research capability, which ultimately will serve to enhance the mental health and well-being of rural communities.

A retrospective descriptive review of community-engaged research projects addressing rural health priorities

BACKGROUND

Most rural populations experience significant health disadvantage. Community-engaged research can facilitate research activities towards addressing health issues of priority to local communities. Connecting scholars with community based frontline practices that are addressing local health and medical needs helps establish a robust pipeline for research that can inform gaps in health provision. Rural Health Projects (RHPs) are conducted as part of the Doctor of Medicine program at the University of Queensland. This study aims to describe the geographic coverage of RHPs, the health topic areas covered and the different types of RHP research activities conducted. It also provides meaningful insight of the health priorities for local rural communities in Queensland, Australia.

METHODS

This study conducted a retrospective review of RHPs conducted between 2011 and 2021 in rural and remote Australian communities. Descriptive analyses were used to describe RHP locations by their geographical classification and disease/research categorisation using the International Classification of Diseases and Related Health Problems - 10th Revision (ICD-10) codes and the Human Research Classification System (HRCS) categories.

RESULTS

There were a total of 2806 eligible RHPs conducted between 2011 and 2021, predominantly in Queensland (n = 2728, 97·2%). These were mostly conducted in small rural towns (under 5,000 population, n = 1044, 37·2%) or other rural towns up to 15,000 population (n = 842, 30·0%). Projects mostly addressed individual care needs (n = 1233, 43·9%) according to HRCS categories, or were related to factors influencing health status and contact with health services (n = 1012, 36·1%) according to ICD-10 classification.

CONCLUSIONS

Conducting community focused RHPs demonstrates a valuable method to address community-specific rural health priorities by engaging medical students in research projects while simultaneously enhancing their research skills.

Factors associated with satisfaction of the australian rural resident medical officer cadetship program: results from a cross-sectional study

BACKGROUND

Australian Rural Resident Medical Officer Cadetships are awarded to medical students interested in a rural medical career. The Rural Residential Medical Officer Cadetship Program (Cadetship Program) is administered by the Rural Doctors Network on behalf of the NSW Ministry of Health. This study aimed to assess the overall experience of medical students and key factors that contributed to their satisfaction with the Cadetship Program.

METHODS

A quantitative cross-sectional study was conducted among 107 former cadets who had completed the Cadetship Program. Data on medical students' experience with the Cadetship Program (outcome variable) and potential explanatory variables were collected using a structured self-administered questionnaire. Explanatory variables included gender, geographical location, rural health club membership, rural clinical school attendance, financial support, mentorship benefits, networking opportunities, influence on career decisions, opportunity for preferential placements, and relocation. Both bivariate (Pearson's chi-squared test) and multiple logistic regression analysis were employed to identify the factors associated with medical students' overall experience with the Cadetship Program. The non-linear analysis was weighted to represent the rural/remote health workforce, in Stata/SE 14.1.

RESULTS

Our results indicate that 91% of medical students were satisfied with the Cadetship Program. The logistic regression model identified two significant predictors of a positive experience with the Cadetship Program. Medical students who perceived financial support as beneficial were significantly more likely to report a satisfactory program experience (aOR = 6.22, 95% CI: 1.36-28.44, p = 0.019) than those who perceived financial support as not beneficial. Similarly, those who valued networking opportunities were more likely to have a positive view of their cadetship experience (aOR = 10.06, 95% CI: 1.11-91.06, p = 0.040) than their counterparts.

CONCLUSION

Our study found that students who valued financial support and networking opportunities had the most positive views of the Cadetship Program. These findings demonstrate that the Cadetship Program may be most helpful for those who need financial support and for students who seek networking opportunities. These findings increase our knowledge about the characteristics of medical students who have the most positive experiences with the Cadetship Program. They help us to understand the mechanisms of influence of such programs on individuals' decisions to be part of the future rural health workforce.

Handle with Care: Transformative Learning as Pedagogy in an Under-Resourced Health Care Context

Issue: A significant component of health professions education is focussed on students' exposure to the social determinants of health and the challenges that patients within the health care system face. An appropriate way to provide such exposure is through distributed clinical training. This usually entails students training in smaller groups along the continuum of care, away from tertiary academic hospitals. This also means students are away from their existing academic and social support systems. It is evident that knowledge and clinical skills alone are not sufficient to prepare students, they also need to be taught to critically reflect on how their own values and attitudes traverse their knowledge and skills to influence their practice as healthcare professionals. This process of critical reflection should aim to provide a transformative learning experience for students and requires active facilitation. In under-resourced health care contexts where clinicians responsible for student training are facing high patient load, lack of resources, inequitable health care services and high levels of burn-out, the facilitation of student learning may be compromised. Evidence: Clinical learning opportunities that are considered transformative, frequently challenge students' sense of self and sense of belonging. This experience can have detrimental effects if the processes of transformative learning pedagogy are not adequately facilitated. The provision of support staff, lecturers and clinical facilitators on the distributed training platform is challenged by the remote nature of some of the sites and the cost of recruiting and capacitating additional on-site staff. The potential for what has been termed "transformative trauma" and the subsequent halted transformative learning experience, has ethical implications in terms of student wellness and the educational responsibility institutions carry. Implications: The authors suggest considerations in facilitating an ethical transformative learning process. These include making the transformative learning pedagogy explicit to students and clinical facilitators and using the 'brave spaces' framework to help students with individuation and provide them with the tools to understand how emotion influences behavior. Strategies to improve relationship development and communities of support, as well as ideas for faculty development are offered.

Rural nutrition and dietetics research-Future directions

AIM

The aim of this study was to summarise key evidence from recent Australian rural nutrition research and provide recommendations for future nutrition and dietetics research with rural communities.

CONTEXT

Clear evidence demonstrates that diet plays a role in the health gap between rural and metropolitan Australia. Despite the opportunity to address the health of rural Australians through better nutrition, alarmingly low investment in nutrition and dietetics research has occurred historically, and over the past decade.

APPROACH

A review of the evidence was undertaken by rural nutrition and dietetics leaders to provide a commentary piece to inform future rural nutrition research efforts.

CONCLUSION

Establishing strong, collaborative place-based nutrition and dietetics research teams are necessary to combat the significant gaps in the scientific knowledge of solutions to improve nutrition in rural Australia. Further, dieticians and nutritionists who live in and understand the rural contexts are yet to be fully harnessed in research, and better engaging with these professionals will have the best chance of successfully addressing the nutrition-related disease disparity between rural and metropolitan Australia.

An exploration of mental health, stress and well-being concerns among health students undertaking rural placements in Australia during the early stages of the COVID-19 pandemic

INTRODUCTION

The emergence of COVID-19 in 2020 led to an increase in stressors for students on rural placements, but little is known about how this impacted their mental health and well-being.

OBJECTIVE

To explore self-reported mental health, stress and well-being concerns among allied health, nursing and medical students who completed a scheduled University Department of Rural Health (UDRH)-faciliated rural placement in Australia between February and October 2020 (n = 1066).

DESIGN

Cross-sectional design involving an online survey measuring mental health, stress and well-being concerns. The survey was distributed via email by the 16 UDRHs across Australia.

FINDINGS

A total of 42.9%, 63.8% and 41.1% of survey respondents reported concerns about their mental health, levels of stress and well-being, respectively, during the early stages of the pandemic. Multiple logistic regression models found clinical training, course progression and financial concerns were predictive of negative mental health, increased stress and reduced well-being, while feeling connected was predictive of positive mental health, reduced stress and increased well-being.

DISCUSSION

Universities, UDRHs and health placement sites all have a responsibility to support the mental health and well-being of students undertaking rural placements. This support needs to encompass strategies to reduce financial stress, protect learning opportunities and increase connectedness. Ensuring adequate resourcing and support for those providing rural placement opportunities will safeguard quality rural placements during times of pandemic disruption.

Supporting nursing and allied health student placements in rural and remote Australia: a narrative review of publications by university departments of rural health

University departments of rural health are Commonwealth-funded to improve recruitment and retention of the rural allied health and nursing (including midwifery) workforce, primarily through student placements. We examined publications by university departments of rural health that were focused on allied health and nursing students undertaking placements in rural Australia, to understand the characteristics, main findings and implications of the research conducted. Interprofessional learning was a key feature of placements and placement education, although other activities such as community engagement added to placement experiences. Factors such as quality supervision and being involved in the community contributed to a positive placement experience and increased rural practice intention. Tracking studies showed a relationship between rural placements, rural practice intention and rural practice. Rural placements occurred across a variety of settings and in locations consistent with the policy framework. Embedding university departments of rural health in rural communities enabled staff to build relationships and increase placement capacity.

Design and implementation characteristics of research training for rural health professionals: a qualitative descriptive study

BACKGROUND

Research capacity and capability of rural health professionals is essential to the delivery of evidence-based care and for informing strategies to address rural health inequities. Effective implementation of research education and training is fundamental to building rural health professional research capacity and capability. A lack of overarching guidance to inform the delivery of research education and training in rural health services can contribute to gaps in capacity-building approaches. The aim of this study was to identify characteristics of the design and implementation of current research training for rural health professionals in Victoria, Australia, to inform a future model for rural health professional research capacity and capability building.

METHODS

A qualitative descriptive study was undertaken. Key informants, with extensive knowledge of research education and training in rural health services in Victoria, were invited to participate in semi-structured telephone interviews via snowballing recruitment methods. Interview transcripts were analysed inductively, with themes and codes mapped to the domains of the Consolidated Framework for Implementation Research.

RESULTS

Of the 40 key informants approached, 20 agreed to participate including 11 regional health service managers, five rural health academics and four university managers. Participants suggested that research training varied in quality and relevance to rural health professionals. Training costs and lack of tailoring to the rural context were key barriers, whereas experiential learning and flexible modes of delivery enabled training uptake. Health service and government policies, structures, and processes both enabled or stifled implementation opportunities, with rural health professional networks from different regions offering capacity for research training development, and government departmental structures hampering training coordination. Tension between research activities and clinical practice, and health professional knowledge and beliefs, shaped the delivery of training programs. Strategically planned and evaluated research training programs and education via co-design with rural health professionals and use of research champions were strongly recommended by participants.

CONCLUSIONS

To optimise research training for rural health professionals and increase the quality and quantity of relevant rural health research, a systematically planned, implemented, and resourced region-wide research training model is required.

Tracks to Postgraduate Rural Practice: Longitudinal Qualitative Follow-Up of Nursing Students Who Undertook a Rural Placement in Western Australia

The nursing workforce is the backbone of healthcare provision in rural and remote Australia. Introducing student nurses to rural clinical placements is one strategy used to address the shortfall of healthcare workers outside of major cities, with the goal of improving the training, recruitment and retention of nurses in rural areas. The aim of this qualitative, longitudinal study was to better understand personal and professional decision-making around rural nursing practice intentions and subsequent rural employment and retention. The study methodology consisted of repeated semi-structured interviews with student nurses who had completed at least one rural placement and following them on their journey to becoming graduate nurses over a 6-year period. Thematic longitudinal analysis was undertaken, with three main themes developing, each with further subthemes: (1) participants' satisfaction with rural placements; (2) their challenges with gaining employment; and (3) considerations regarding 'going rural' for work. The participants engaged in both prospective and retrospective reflection around several professional, personal, and wider systemic barriers and enablers to rural practice, which are discussed in detail in this paper. The insights from this longitudinal study have the potential to assist the development of a sustainable rural nursing workforce through informing rural workforce programs, strategies and policies.

Job Satisfaction of Health Practitioners Providing Outreach Health Services during COVID-19 in Rural New South Wales (NSW) and the Australian Capital Territory (ACT), Australia

Background: Outreach health practitioners play a key role in enhancing access to healthcare for remote, rural, regional, and Aboriginal and Torres Strait Islander communities in Australia. Outreach health practitioners are those providing ongoing and integrated health services in communities that would otherwise have limited access. In the context of the COVID-19 pandemic, it is important to understand the job satisfaction of health workers as it correlates with long-term retention of the workforce, as well as effectiveness in the role and clinical outcomes for patients. Method: The study analysed data from 258 outreach health practitioners who responded to two cross-sectional surveys conducted by the NSW Rural Doctors Network during the COVID-19 pandemic in 2020/21 and 2021/22 in NSW and the ACT, Australia. Both bivariate and multivariate analyses were employed to assess the associations between the outcome variable (outreach health practitioners' job satisfaction) and independent variables (sociodemographic factors, motivation, self-confidence, communication, capability). Results: Overall, the study showed that 92.2% of health practitioners were satisfied in their role providing outreach health services during the COVID-19 pandemic. In the multivariable model, factors significantly associated with higher satisfaction included good communication with other local health practitioners, using telehealth along with in-person care, and having high self-rated capability compared to those health practitioners who said they had lower job satisfaction. Conclusions: Outreach health practitioners' job satisfaction is important because poor satisfaction may lead to suboptimal healthcare delivery, poor clinical outcomes, and poor retention of staff in rural settings. These findings should be taken into consideration when developing future strategies to improve job satisfaction among rural outreach health practitioners and to enhance attraction, recruitment and retention and may be applicable to the broader health workforce.

Impact assessment of the medical practice assisting (MPA) program in general practice in the hunter New England and central coast regions of Australia

BACKGROUND

A regional Australian Primary Health Network (PHN) has been subsidising administrative staff from local general practices to undertake the Medical Practice Assisting (MPA) course as part of its MPA Program. The MPA Program aimed to upskill administrative staff to undertake clinical tasks and fill in for busy or absent Practice Nurses (PNs), freeing up PNs to increase revenue-generating activity, avoiding casual replacement staff wages, and increasing patient throughput. An impact assessment was undertaken to evaluate the impact and estimate the economic costs of the MPA program to the PHN, general practices, and students to inform future uptake of the intervention.

METHODS

The Framework to Assess the Impact of Translational Health Research (FAIT) was utilised. Originally designed to assess the impact of health research, this was its first application to a health services project. FAIT combines three validated methods of impact assessment-Payback, economic analysis and narratives underpinned by a program logic model. Quantified metrics describe the impacts of the program within various "domains of benefit", the economic model costs the intervention and monetises potential consequences, and the narrative tells the story of the MPA Program and the difference it has made. Data were collected via online surveys from general practitioners (GPs), PNs, practice managers; MPA graduates and PHN staff were interviewed by phone and on Zoom.

RESULTS

FAIT was effective in evidencing the impacts and economic viability of the MPA Program. GPs and PNs reported greater work satisfaction, PNs reported less stress and reduced workloads and MPA graduates reported higher job satisfaction and greater confidence performing a range of clinical skills. MPA Program economic costs for general practices during candidature, and 12 month post-graduation was estimated at $69,756. With effective re-integration planning, this investment was recoverable within 12 months through increased revenue for practices. Graduates paid appropriately for their new skills also recouped their investment within 24 months.

CONCLUSION

Utilisation of MPA graduates varied substantially between practices and COVID-19 impacted on their utilisation. More strategic reintegration of the MPA graduate back into the practice to most effectively utilise their new skillset could optimise potential benefits realised by participating practices.

Dementia ECHO: Evaluation of a telementoring programme to increase dementia knowledge and skills in First Nations-led health services

Introduction

High rates of dementia among Australian First Nations’ peoples have resulted in an increased demand for dementia knowledge and skills among the primary health care professionals in these communities. The Dementia Extension for Community Healthcare Outcomes (ECHO) program aims to be a culturally safe way of increasing local health workforce capacity by facilitating dementia knowledge, skills and confidence among primary care professionals in First Nations community settings. Dementia ECHO is based on the international evidence-based telementoring programme, Project Extension for Community Healthcare Outcomes. Every Dementia ECHO session is delivered by videoconference and comprises a specialist-led presentation and a case discussion from a primary care health service participant. The aims of this study were to assess the uptake and reach of Dementia ECHO; examine the perceived importance of dementia care and dementia education among Aboriginal and Torres Strait Islander Community Controlled Health Service staff; and evaluate the potential impact of Dementia ECHO on health service staff pertaining to dementia knowledge, confidence to provide dementia care and professional isolation.

Method

Dementia ECHO service activity data maintained by the programme providers was reviewed to determine uptake and reach. A pre-implementation survey examined Aboriginal and Torres Strait Islander Community Controlled Health Service staff perspectives on the importance of dementia education and the priority of a range of health issues. After each Dementia ECHO session, a brief online survey gathered quantitative and qualitative data regarding the potential impact of the session.

Results

Of 30 completed pre-implementation surveys, all staff rated dementia education as either very important or important. Salient themes highlighting why it is important are presented. When asked to rank six different health priorities, dementia ( n = 10) and chronic disease ( n = 10) were placed as the top priority. The brief post-session feedback provided 44 complete survey responses demonstrating: perceived improvement in dementia knowledge and skills (88.4%); increased confidence to provide dementia care (83%); and a reduction in professional isolation (88%).

Conclusion

Dementia ECHO addresses a gap in dementia education that is much needed in health professionals with increasing numbers of First Nations people living with dementia. This current study shows that attending an evidence-based telementoring programme, such as Dementia ECHO, can increase dementia knowledge and confidence to care for someone living with dementia and their families.

What are the impacts of setting up new medical schools? A narrative review

BACKGROUND

The growth of the UK's population together with an aging society with increasingly complex health and social care needs has placed a greater demand on statutory care services. In view of this emerging landscape, the UK Government has sought to increase its medically trained workforce in order to better respond to the demands placed on the health service. Five universities were announced as homes to new medical schools offering undergraduate places to boost the numbers of doctors training in England. The aim of this narrative review was to explore how new medical schools could improve the health outcomes of the local population and evaluate the potential contribution it may make to the local economy, workforce and to research and innovation.

METHODS

A narrative review was undertaken using a systematic approach for the search literature strategy. The articles were evaluated by undertaking a critical assessment evaluating the fitness of a paper for review according to results, methods used to test the hypothesis, conclusions and impact and limitations. Thematic analysis was employed to organise and summarise the findings across a heterogeneous body of literature included in the review. The analysis was developed in an inductive manner and there were not any predefined themes to guide data extraction and analysis.

RESULTS

Thirty-six articles were selected for inclusion for this narrative review. The review identified six key themes: influence of prior rural exposure, medical school environment and rural enrichment programmes, workforce, health outcomes of local populations, social accountability, economic contribution of medical schools to communities and impact on rural research.

CONCLUSIONS

The studies included found a wealth of information on a wide-range of topics on the expansion of undergraduate education and its implications on the future medical workforce. It was shown that medical schools can have a positive effect on the health, social, economic and research activity of a region, but this literature tended to be heterogeneous in focus without consideration of the inter-connections between the wider societal and economic impacts arising from long-term sustainable change being brought to a region.

The need for a complex systems approach in rural health research

On a global scale, many major rural health issues have persisted for decades despite the introduction of new health interventions and public health policies. Although research efforts have generated valuable new knowledge about the aetiology of health, disease and health inequities in rural communities, rural health systems remain to be some of the most deprived and challenged in both the developing and developed world. While the reasons for this are many, a significant factor contributing to the current state of play is the pressing need for methodological innovation and relevant scientific approaches that have the capacity to support the translation of novel solutions into 'real world' rural contexts. Fortunately, complex systems approaches, which have seen an increase in popularity in the wider public health literature, could provide answers to some of the most resilient rural health problems in recent times. The purpose of this article is to promote the value and utility of a complex systems approach in rural health research. We explain the benefits of a complex systems approach and provide a background to the complexity sciences, including the main characteristics of complex systems. Two popular computational methods are described. The next step for rural health research involves exploring how a complex systems approach can help with the identification and evaluation of new and existing solutions to policy-resistant rural health issues. This includes generating awareness around the analytical trade-offs that occur between the use of traditional scientific methods and complex systems approaches.

Effect of Rural Clinical Placements on Intention to Practice and Employment in Rural Australia: A Systematic Review

BACKGROUND

Supporting the provision of clinical placement (CP) experiences in rural areas is a strategy used worldwide to promote the rural health workforce. While there is international evidence for this intervention in medicine, there is limited understanding of the influence of rural CP for nursing, midwifery, allied health, and dentistry health professions in Australia, which have received substantial federal investment. This review examined the relationship between rural CP and non-medicine health students' future rural practice intentions and workforce outcomes.

METHODS

Four databases were systematically searched; papers were screened using defined criteria and appraised using the mixed-methods appraisal tool (MMAT). Findings were synthesized using a critical narrative approach.

RESULTS

The methodological quality of the 29 eligible studies (13 quantitative non-randomized, 10 mixed method, 4 qualitative, 2 quantitative description) was appraised. Ten high-quality studies were identified. The review found that positive CP experiences may influence intention to practice rurally amongst undecided students and serve as a reinforcing experience for those students already interested in rural practice. There were mixed findings regarding the influence of CP length. The review also found that there is currently only evidence for the short-term effects of CP on students' future practice outcomes in rural areas with focus thus far on early practice outcomes.

CONCLUSIONS

Those looking to use rural CP to promote the rural health workforce should focus on supporting the quality of a large number of CP experiences that are undertaken in rural areas, as there are currently differing findings on the role of rural CP length. Future studies of rural CP should consider greater use of social and educational theories to guide them.

What shapes research and research capacity building in rural health services? Context matters

Objective

To determine the contextual factors influencing research and research capacity building in rural health settings.

Design

Qualitative study using semi‐structured telephone interviews to collect data regarding health professionals’ research education and capacity building. Analysis involved inductive coding using Braun and Clark’s thematic analysis; and deductive mapping to the Consolidated Framework for Implementation Research (CFIR).

Setting

Victorian rural health services and university campuses.

Participants

Twenty senior rural health managers, academics and/or research coordinators. Participants had at least three years’ experience in rural public health, health‐related research or health education settings.

Main outcome measures

Contextual factors influencing the operationalisation and prioritisation of research capacity building in rural health services.

Results

Findings reflected the CFIR domains and constructs: intervention characteristics (relative advantage); outer setting (cosmopolitanism, external policies and incentives); inner setting (implementation climate, readiness for implementation); characteristics of individuals (self‐efficacy); and process (planning, engaging). Findings illustrated the implementation context and the complex contextual tensions, which either prevent or enhance research capacity building in rural health services.

Conclusions

Realising the Australian Government’s vision for improved health service provision and health outcomes in rural areas requires a strong culture of research and research capacity building in rural health services. Low levels of rural research funding, chronic workforce shortages and the tension between undertaking research and delivering health care, all significantly impact the operationalisation and prioritisation of research capacity building in rural health services. Effective policy and investment addressing these contextual factors is crucial for the success of research capacity building in rural health services.

Starting from scratch: Developing and sustaining a rural research team lessons from a nutrition and dietetics case study

OBJECTIVE

To describe the development of and key factors for sustaining a rural-based research team focussed on nutrition and dietetics.

DESIGN

A longitudinal embedded case study approach with data sourced from publicly available records and observations. Case study sub-units were developed into 3 phases with analysis using theoretical propositions and pattern matching. Quantitative data were descriptively analysed.

SETTING

University of Newcastle Department of Rural Health across 4 rural sites.

PARTICIPANTS

Publicly available data sources from existing team members.

MAIN OUTCOME MEASURES

Staffing levels, research supervision, internal and external grant outcomes and peer-reviewed journal publications.

RESULT

Academic staffing has increased by 4 full-time equivalent positions over 18 years, with 6 current higher-degree research students. Key factors identified in the development of a discipline-specific research workforce included staff higher degree by research completions, longevity of staff in research-active roles, immersive rural placements with a research component and collaborations with nationally competitive researchers. Rural pilot research projects, community connections, understanding of the local context and research networks were fundamental to establishing a viable team.

CONCLUSION

Systematically investing in research that is embedded in local communities will ensure sustainability and relevance, capacity building of existing staff and an ability to problem solve at the local level. Sustained and focussed investment is needed if the current rural research workforce is to develop towards a capacity that meets current demand.

Supporting health students on rural placements: A scoping review

OBJECTIVE

To review Australian literature on initiatives used to provide support for pre-registration health students undertaking a rural placement.

DESIGN

A scoping literature review.

SETTING

Rural, regional and remote areas of Australia.

PARTICIPANTS

Publications were sourced from scientific databases including Ebscohost and CINAHL. Grey literature and journal citations were searched to identify other relevant articles.

MAIN OUTCOME MEASURE

Identification of the various initiatives used to support students, evaluation of the success of these initiatives, and the feasibility and sustainability of implementing these initiatives.

RESULTS

There were 36 articles included in the final analysis. The findings identified support initiatives specific to individual professions, not on supporting health students as a whole cohort. The key findings were grouped into identification of support initiatives and the alignment of these to students feeling a sense satisfaction, belonging and connectedness. Constraints to support health students undertaking rural placements identified disparity and inequity of support initiatives available for health students with medical students provided more support than other health students.

CONCLUSION

This review highlights the importance of students developing a sense of belonging and building connections to community, which are strongly aligned with rural placements and student satisfaction. The need for socio-cultural, organisational and institutional support is linked to higher student satisfaction and intention to practice rurally. A centralised collation of support initiatives would benefit students, higher education institutions and stakeholders in their efforts to attract students to undertake rural placements and be immersed in these unique learning experiences.

How might access to postgraduate medical education in regional and rural locations be best improved? A scoping review

Rural medical education is known as one of the most effective strategies in improving rural recruitment and retention. The aim was to identify modes of delivery to improve access to rural postgraduate medical education. Arksey and O'Malley's methodological framework was used for conducting scoping reviews. CINAHL, Google Scholar, ERIC, PsycINFO, Medline and PubMed were searched to identify peer-reviewed English-language literature published between 2000 and 2019 focusing on postgraduate rural and regional medical education. A total of 102 articles were identified, with 51 included in the final analysis after applying inclusion and exclusion criteria. Outcome measures included: article type; research methodology; date of publication; country of origin; and study population. Through iterative reading, common themes were identified. A typology of 6 content themes emerged as follows: rural curriculum; procedural skills; rurally based learning; service delivery; workforce; and distance learning. The majority of articles focused on rural curriculum, and rurally based learning, with half originating from Australia or New Zealand. Although results strongly emphasised context and curriculum in rural environments, lack of specific and pragmatic approaches was noted. Surprisingly, few articles focused on rural distance learning utilising information and communication technology. Pathways to improve rural education access include recognition of the unique rural context in curriculums; development of rural educational faculty; and creation of opportunities for rural specialist training. Emphasis should be given for education provided through rural centres rather than urban facilities. Use of information technology could be increased, for example in remote trainee supervision programs.

Five years on: Influences on early career health professionals from a rural interprofessional pre-registration immersion program

OBJECTIVE

To ascertain former students' perceptions of and influences from a final-year pre-registration, rurally located, clinically based, 5 week interprofessional program on their subsequent work and career in the health professions.

DESIGN

Online survey delivered 5 years post-program (4 years post-graduation).

SETTING

The Tairāwhiti interprofessional education program was first undertaken in 2012/2013 by students from six health professional degree programs (dentistry, dietetics, medicine, nursing, pharmacy and physiotherapy) in the Tairāwhiti region, New Zealand.

PARTICIPANTS

Health professionals who attended the Tairāwhiti interprofessional education program in 2012/2013 as students were invited to participate; 70 of 86 (81%) responded in 2017/2018.

RESULTS

Five years on, most respondents (91%;64/70) were working as health professionals, with a fifth (23%;15/64) working overseas. Of those currently practising in New Zealand, 51% (24/47) were working in hospital practice and 49% (23/47) in the community, with 56% (27/48) working in metropolitan areas and 44% (21/48) in regional/rural locations. Of the 51 respondents who provided free-text comments about perceived influences of program participation, the majority described positive influences on their clinical practice as health professionals or their subsequent career choices. Five themes emerged from the free-text data: 'made me a better clinician'; 'made me consider rural/regional work'; 'collaborating for care'; 'choosing an area of practice to work in,' and 'little or no impact.'

CONCLUSION

This work reports positive influences on subsequent careers among respondents who had previously participated as final-year students in a rurally located IPE program, particularly with respect to interprofessional working, rural health, and contextual and cultural influences.

An audit of health student immunisation at a University Department of Rural Health reveals the imperative for a coordinated approach

OBJECTIVE

Student healthcare worker immunisation ensures the protection of students, their patients and the wider community. This audit assessed allied health students' records of immunisation against national standards.

METHODS

This audit examined clinical students' immunisation records at a University Department of Rural Health and assessed their compliance with the national Australian Immunisation Handbook recommendations. Gaps in processes were assessed through a review of forms, guidelines and stakeholder feedback.

RESULTS

Around one-quarter (26%) of healthcare students provided evidence that they were immunised in line with national standards. Inconsistency of immunisation recommendations across universities, states and disciplines were identified.

CONCLUSIONS

This audit highlighted gaps in healthcare student immunisation assurance processes at both local and national levels, and we recommend key elements that would be required for a more consistent, streamlined and coordinated approach. Implications for public health: As a pillar of communicable disease control, immunisation compliance continues to pose important public health challenges. Without further work towards coordination of healthcare students' immunisation assurances, there is a risk of preventable morbidity and mortality in vulnerable communities, as well as suboptimal student and worker safety in an environment that poses high risks.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia.

STUDY DESIGN

Rapid review of articles published between January 2000 and May 2020.

DATA SOURCES

We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries.

DATA SYNTHESIS

Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding.

CONCLUSION

Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries.

STUDY DESIGN

We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references.

DATA SOURCES

We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence.

DATA SYNTHESIS

Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle.

CONCLUSION

There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia.

STUDY DESIGN

Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews.

DATA SOURCES

We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria.

DATA SYNTHESIS

Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma.

CONCLUSION

We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities.

STUDY DESIGN

Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km² .

DATA SOURCES

We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway.

DATA SYNTHESIS

We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3).

CONCLUSION

Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce.

STUDY DESIGN

We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool.

DATA SOURCES

We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites.

DATA SYNTHESIS

During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool.

CONCLUSION

We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings.

STUDY DESIGN

Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards.

DATA SOURCES

English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar.

DATA SYNTHESIS

Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation.

CONCLUSION

Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Exploring preference for, and uptake of, rural medical internships, a key issue for supporting rural training pathways

Background

Improved medical care access for rural populations continues to be a major concern. There remains little published evidence about postgraduate rural pathways of junior doctors, which may have strong implications for a long-term skilled rural workforce. This exploratory study describes and compares preferences for, and uptake of, rural internships by new domestic and international graduates of Victorian medical schools during a period of rural internship position expansion.

Methods

We used administrative data of all new Victorian medical graduates’ location preference and accepted location of internship positions for 2013–16. Associations between preferred internship location and accepted internship position were explored including by rurality and year. Moreover, data were stratified between ‘domestic graduates’ (Australian and New Zealand citizens or permanent residents) and ‘international graduates’ (temporary residents who graduated from an Australian university).

Results

Across 2013–16, there were 4562 applicants who filled 3130 internship positions (46% oversubscribed). Domestic graduates filled most (69.7%, 457/656) rural internship positions, but significantly less than metropolitan positions (92.2%, p < 0.001). Only 20.1% (551/2737) included a rural location in their top five preferences, less than for international graduates (34.4%, p < 0.001). A greater proportion of rural compared with metropolitan interns accepted a position not in their top five preferences (36.1% versus 7.4%, p < 0.001). The proportion nominating a rural location in their preference list increased across 2013–2016.

Conclusions

The preferences for, and uptake of, rural internship positions by domestic graduates is sub-optimal for growing a rural workforce from local graduates. Current actions that have increased the number of rural positions are unlikely to be sufficient as a stand-alone intervention, thus regional areas must rely on international graduates. Strategies are needed to increase the attractiveness of rural internships for domestic students so that more graduates from rural undergraduate medical training are retained rurally. Further research could explore whether the uptake of rural internships is facilitated by aligning these positions with protected opportunities to continue vocational training in regionally-based or metropolitan fellowships. Increased understanding is needed of the factors impacting work location decisions of junior doctors, particularly those with some rural career intent.

Time to revisit the skills and competencies required to work in rural general hospitals

OBJECTIVES

To determine the structure and demographic of medical teams working in Rural General Hospitals (RGHs) in Scotland, and to gain insight into their experiences and determine their opinions on a remote and rural medical training pathway.

DESIGN

Structured face-to-face interviews. Interviews were partially anonymised, and underwent thematic analysis.

SETTING

Medical departments of the six RGHs in Scotland 2018-2019.

PARTICIPANTS

14 medical consultants and 23 junior doctors working in RGHs in Scotland. Inclusion criteria: Present at time of site visit, medical consultant in an RGH or junior doctor working in an RGH who provides care for medical patients. Exclusion criteria: Doctors on leave or off shift. Medical consultants with less than one month of experience in post. Non-medical specialty consultants e.g. surgical or anaesthetic consultants.

RESULTS

Of 21 consultant posts in the RGHs, only eight are filled with resident consultants, the remainder rely on locums. Consultants found working as generalists rewarding and challenging, and juniors found it to be a good training experience. Consultants feel little professional isolation due to modern connectivity. The majority of consultants (12/14) and all junior doctors favour a remote and rural medicine training pathway encompassing a mandatory paediatrics component, and feel this would help with consultant recruitment and retention.

CONCLUSION

RGHs medical departments are reliant on locum consultants. The development of a remote and rural training medical training pathway is endorsed by the current medical teams of RGHs and has the potential to improve medical consultant staffing in RGHs.

What works, why and how? A scoping review and logic model of rural clinical placements for allied health students

Background

Allied health services are core to the improvement in health outcomes for remote and rural residents. Substantial infrastructure has been put into place to facilitate rural work-ready allied health practitioners, yet it is difficult to understand or measure how successful this is and how it is facilitated.

Methods

A scoping review and thematic synthesis of the literature using program logic was undertaken to identify and describe the contexts, mechanisms and outcomes of successful models of rural clinical placements for allied health students. This involved all empirical literature examining models of regional, rural and remote clinical placements for allied health students between 1995 and 2019.

Results

A total of 292 articles were identified; however, after removal of duplicates and article screening, 18 were included in the final synthesis. Australian papers dominated the evidence base (n = 11). Drivers for rural allied health clinical placements include: attracting allied health students to the rural workforce; increasing the number of allied health clinical placements available; exposing students to and providing skills in rural and interprofessional practice; and improving access to allied health services in rural areas. Depending on the placement model, a number of key mechanisms were identified that facilitated realisation of these drivers and therefore the success of the model. These included: support for students; engagement, consultation and partnership with key stakeholders and organisations; and regional coordination, infrastructure and support. Placement success was measured in terms of student, rural, community and/or program outcomes. Although the strength and quality of the evidence was found to be low, there is a trend for placements to be more successful when the driver for the placement is specifically reflected in the structure of the placement model and outcomes measured. This was seen most effectively in placement models that were driven by the need to meet rural community needs and upskill students in interprofessional rural practice.

Conclusion

This study identifies the factors that can be manipulated to ensure more successful models of allied health rural clinical placements and provides an evidence based framework for improved planning and evaluation.

Faculties to Support General Practitioners Working Rurally at Broader Scope: A National Cross-Sectional Study of Their Value

Strategies are urgently needed to foster rural general practitioners (GPs) with the skills and professional support required to adequately address healthcare needs in smaller, often isolated communities. Australia has uniquely developed two national-scale faculties that target rural practice: the Fellowship in Advanced Rural General Practice (FARGP) and the Fellowship of the Australian College of Rural and Remote Medicine (FACRRM). This study evaluates the benefit of rural faculties for supporting GPs practicing rurally and at a broader scope. Data came from an annual national survey of Australian doctors from 2008 and 2017, providing a cross-sectional design. Work location (rurality) and scope of practice were compared between FACRRM and FARGP members, as well as standard non-members. FACRRMs mostly worked rurally (75-84%, odds ratio (OR) 8.7, 5.8-13.1), including in smaller rural communities (<15,000 population) (41-54%, OR 3.5, 2.3-5.3). FARGPs also mostly worked in rural communities (56-67%, OR 4.2, 2.2-7.8), but fewer in smaller communities (25-41%, OR 1.1, 0.5-2.5). Both FACRRMs and FARGPs were more likely to use advanced skills, especially procedural skills. GPs with fellowship of a rural faculty were associated with significantly improved geographic distribution and expanded scope, compared with standard GPs. Given their strong outcomes, expanding rural faculties is likely to be a critical strategy to building and sustaining a general practice workforce that meets the needs of rural communities.

Building research experience: Impact of a novice researcher development program for rural health workers

OBJECTIVE

The objective of this study was to determine the effect of the Rural Research Capacity Building Program on self-reported research experience of rural health workers.

DESIGN

A repeat cross-sectional study design was used to assess self-reported research experience at the commencement and completion of a novice researcher development program.

SETTING

Candidates in the Rural Research Capacity Building Program are health workers employed in the rural NSW public health service who have not completed research higher degrees.

PARTICIPANTS

One hundred and thirty candidates of the Rural Research Capacity Building Program from the 2006 to 2013 cohorts were participated.

INTERVENTIONS

The Rural Research Capacity Building Program is an experiential learning program in which candidates gain research experience by undertaking a new, self-selected, local health service endorsed research project over a 2-year period, supported by 10 days face-to-face teaching, weekly teleconferencing and mentoring.

MAIN OUTCOME MEASURES

Change in self-assessed research experience using a validated 10-item measurement tool known as the Research Spider which measures 10 domains of research experience.

RESULTS

Reported research experience demonstrated statistically significant increases across all 10 domains of research experience. The largest change was 'writing and presenting a research report' and 'writing a research protocol'.

CONCLUSIONS

Significant increases in Research Spider results across all 10 domains demonstrated that completing the Rural Research Capacity Building Program significantly improves self-assessed research experience. Rural health workers who are experienced and confident to undertake research are more capable of studying health problems and finding solutions unique to the rural setting.

Importance of publishing research varies by doctors’ career stage, specialty and location of work

Purpose

To investigate whether publishing research is an important aspect of medical careers, and how it varies by specialty and rural or metropolitan location.

Methods

Annual national panel survey (postal or online) of Australian doctors between 2008 and 2016, with aggregated participants including 11 263 junior doctors not enrolled in a specialty (‘pre-registrars’), 9745 junior doctors enrolled as specialist trainees, non-general practitioner (GP) (‘registrars’) and 35 983 qualified as specialist consultants, non-GP (‘consultants’). Main outcome was in agreement that ‘research publications are important to progress my training’ (junior doctors) or ‘research publications are important to my career’ (consultants).

Results

Overall, the highest proportion agreeing were registrars (65%) and pre-registrars (60%), compared with consultants (36%). After accounting for key covariates, rural location was significantly associated with lower importance of publishing research for pre-registrars (OR 0.69, 95% CI 0.61 to 0.78) and consultants (OR 0.69, 95% CI 0.63 to 0.76), but not for registrars. Compared with anaesthetics, research importance was significantly higher for pre-registrars pursuing surgery (OR 4.46, 95% CI 3.57 to 5.57) and obstetrics/gynaecology careers, for registrars enrolled in surgery (OR 2.97, 95% CI 2.34 to 3.75) and internal medicine training, and consultants of internal medicine (OR 1.84, 95% CI 1.63 to 2.08), pathology, radiology and paediatrics.

Conclusions

This study provides new quantitative evidence showing that the importance of publishing research is related to medical career stages, and is most important to junior doctors seeking and undertaking different specialty training options. Embedding research requirements more evenly into specialty college selection criteria may stimulate uptake of research. Expansion of rural training pathways should consider capacity building to support increased access to research opportunities in these locations.