Charting the future course of rural health and remote health in Australia: Why we need theory

The Ethics of Overlapping Relationships in Rural and Remote Healthcare. A Narrative Review

It is presently unclear whether a distinct "rural ethics" of navigating professional boundaries exists, and if so, what theoretical approaches may assist practitioners to manage overlapping relationships. To be effective clinicians while concurrently partaking in community life, practitioners must develop and maintain safe, ethical, and sustainable therapeutic relationships in rural and remote healthcare. A narrative review was conducted identifying a significant body of qualitative and theoretical literature which explores the pervasiveness of dual relationships for practitioners working in rural and remote healthcare. Rather than viewing dual relationships as ethically unacceptable, much contemporary work focusses on the lived experiences of healthcare workers and explores what approaches may be available that both protect the therapeutic relationship while recognizing the unique nature of rural and remote healthcare practice. We conclude that practitioners must have a means of operating within a contextually informed ethics of professional boundaries. Drawing on pre-existing work, one schema is proposed that could form the basis for further engagement through interactive teaching sessions, professional development, mentoring, or guidelines.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

What Is Rural Adversity, How Does It Affect Wellbeing and What Are the Implications for Action?

A growing body of literature recognises the profound impact of adversity on mental health outcomes for people living in rural and remote areas. With the cumulative effects of persistent drought, record-breaking bushfires, limited access to quality health services, the COVID-19 pandemic and ongoing economic and social challenges, there is much to understand about the impact of adversity on mental health and wellbeing in rural populations. In this conceptual paper, we aim to review and adapt our existing understanding of rural adversity. We undertook a wide-ranging review of the literature, sought insights from multiple disciplines and critically developed our findings with an expert disciplinary group from across Australia. We propose that rural adversity be understood using a rural ecosystem lens to develop greater clarity around the dimensions and experiences of adversity, and to help identify the opportunities for interventions. We put forward a dynamic conceptual model of the impact of rural adversity on mental health and wellbeing, and close with a discussion of the implications for policy and practice. Whilst this paper has been written from an Australian perspective, it has implications for rural communities internationally.

What Is Rural Adversity, How Does It Affect Wellbeing and What Are the Implications for Action?

A growing body of literature recognises the profound impact of adversity on mental health outcomes for people living in rural and remote areas. With the cumulative effects of persistent drought, record-breaking bushfires, limited access to quality health services, the COVID-19 pandemic and ongoing economic and social challenges, there is much to understand about the impact of adversity on mental health and wellbeing in rural populations. In this conceptual paper, we aim to review and adapt our existing understanding of rural adversity. We undertook a wide-ranging review of the literature, sought insights from multiple disciplines and critically developed our findings with an expert disciplinary group from across Australia. We propose that rural adversity be understood using a rural ecosystem lens to develop greater clarity around the dimensions and experiences of adversity, and to help identify the opportunities for interventions. We put forward a dynamic conceptual model of the impact of rural adversity on mental health and wellbeing, and close with a discussion of the implications for policy and practice. Whilst this paper has been written from an Australian perspective, it has implications for rural communities internationally.

Western organizational change capacity theory and its application to public health organizations in China: A multiple case analysis

As health reform becomes a crucial task for both Chinese and United States government, public health organizations are required to adopt changes based on reform policy. Organizational Change Capacity theory is a Western theory that indicates the capacities that organizations should possess when pursuing successful organizational change. This study seeks to understand the applicability of this theory to Chinese public health organizations by contrasting organizations that have achieved success or remained challenged in implementing organizational change to optimize health reform. The research questions are: Is the Organizational Change Capacity theory applicable in Chinese public health organizations? How should it be modified to best fit Chinese public health organizations? Seventy-two participants from 12 public health organizations in Beijing and Xi'an were recruited for interviews and follow-up questionnaires that asked for experiences during their organizational changes. During the analysis, a new Chinese Organizational Change Capacity theory with nine main themes emerged. This new framework provides a guideline for Chinese public health organizations to evaluate their change capacity, and offers a theoretical foundation for researchers to design interventions that increase these organizations' capacity in achieving successful change.

How health professionals conceive and construct interprofessional practice in rural settings: a qualitative study

BACKGROUND

Although interprofessional practice (IPP) offers the potential to enhance rural health services and provide support to rural clinicians, IPP may itself be problematic due to workforce limitations and service fragmentation. Differing socioeconomic and geographic characteristics of rural communities means that the way that IPP occurs in rural contexts will necessarily differ from that occurring in metropolitan contexts. The aim of this study was to investigate the factors contributing to effective IPP in rural contexts, to examine how IPP happens and to identify barriers and enablers.

METHODS

Using Realistic Evaluation as a framework, semi-structured interviews were conducted with health professionals in a range of rural healthcare contexts in NSW, Australia. Independent thematic analysis was undertaken by individual research team members, which was then integrated through consensus to achieve a qualitative description of rural IPP practice.

RESULTS

There was clear evidence of diversity and complexity associated with IPP in the rural settings that was supported by descriptions of collaborative integrated practice. There were instances where IPP doesn't and could happen. There were a number of characteristics identified that significantly impacted on IPP including the presence of a shared philosophical position and valuing of IPP and recognition of the benefits, funding to support IPP, pivotal roles, proximity and workforce resources.

CONCLUSIONS

The nature of IPP in rural contexts is diverse and determined by a number of critical factors. This study goes some of the way towards unravelling the complexity of IPP in rural contexts, highlighting the strong motivating factors that drive IPP. However, it has also identified significant structural and relational barriers related to workload, workforce, entrenched hierarchies and ways of working and service fragmentation. Further research is required to explicate the mechanisms that drive successful IPP across a range of diverse rural contexts in order to inform the implementation of robust flexible strategies that will support sustainable models of rural IPP.

Understanding drivers of rural and remote health outcomes: a conceptual framework in action

OBJECTIVE

To demonstrate the usefulness of a conceptual framework to increase the understanding of rural and remote health by applying it to specific rural and remote health scenarios.

DESIGN

A conceptual framework was applied to two case studies illustrative of key issues in rural health to reflect different contexts, issues and responses.

RESULTS

Application of the framework to both case studies highlighted that changes in rural and remote health are diverse. While power was a key element of the framework, the interaction of all framework components underpinned changes.

CONCLUSION

The framework facilitated understanding of change in these rural scenarios and demonstrated that improvement in rural health requires change at both the local and structural levels.

A theory of how rural health services contribute to community sustainability

Study and opinion suggest that health services play a significant role in supporting the social fabric of fragile rural communities. We draw on empirical evidence about the added-value contributions of health services to communities and unite it with theory of capitals to propose a theoretical model depicting how rural health services contribute to community sustainability. While providing an analytical framework, the paper also points to construction of a measurement tool for enabling planners to measure the contributions of diverse sectors to community sustainability and predict or measure the impact of changes to models of service delivery on the future of rural communities.

Understanding rural and remote health: a framework for analysis in Australia

People living in rural and remote areas face challenges in accessing appropriate health services, many of which struggle to recruit and retain staff. While researchers have documented these issues in Australia and internationally, rural health remains reactive to current problems and lacks comprehensive understanding. This paper presents a conceptual framework that can be used to better understand specific rural and remote health situations. The framework consists of six key concepts: geographic isolation, the rural locale, local health responses, broader health systems, social structures and power. Viewed through Giddens' theory of structuration, the framework suggests that rural health is understood as spatial and social relations among local residents as well as the actions of local health professionals/consumers that are both enabled and constrained by broader health systems and social structures. The framework provides a range of stakeholders with a guide to understanding rural and remote health.