Defining remote health

Preparing healthcare professional students for rural, regional and remote practice: demonstrating the effectiveness of an interprofessional simulation learning experience

Undertaking an authentic interprofessional simulation experience may be a useful and consistent strategy for healthcare professional students to build competencies required for a rural healthcare context. An observational comparative study design was adopted to evaluate a clinical simulation experience created to develop the interprofessional competencies of a sample of healthcare professional students at a regional university situated on multiple campuses in New South Wales (NSW), Australia. Over 200 students across three campuses of the university were involved in a simulation experience that included four interprofessional activities. Of these students, 189 (89%) agreed to participate in the study. The healthcare professional students who participated in the study were from second year occupational therapy, physiotherapy, and podiatry, and third year speech pathology programs. Retrospective pre and post self-assessed interprofessional collaborative competencies were compared for all students using the revised Interprofessional Collaborative Attainment Survey (ICCAS). Results demonstrated a statistically significant improvement in self-perceived scores using the validated revised ICCAS survey. The findings of this study suggest that carefully designed and authentic interprofessional simulation experiences can facilitate the development of competencies required for effective interprofessional practice, which are necessary for successful rural practice.

Expert consensus on the attributes and competencies required for rural and remote junior physicians to work effectively in isolated indonesian communities

Indonesian physicians working in rural and remote areas must be equipped not only with generic competencies but also with the attributes and skills necessary to provide health care services without compromising quality. This study sought to reach a consensus on the attributes and competencies that are viewed as essential and important for working effectively as an early career doctor in rural and remote practice in Indonesia. A two-round Delphi study was conducted by reference to 27 consenting physicians working in rural and remote Indonesia. Forty-three items covering 9 attributes and 34 competencies were sent to these physicians to be rated on a Likert scale ranging from 1 to 5 in terms of their importance for effective rural and remote practice. Nine attributes and 29 competencies progressed to Round 2. All nine attributes and 29 competencies were identified as essential or important for junior physicians' ability to be effective in their practice. The essential attributes included professional quality related to prioritising the rural community. The essential competencies included medical skills, professional behaviour, interprofessional skills, health promotion and connection to the rural community. The consensus thus reached on these essential and important attributes and competencies can inform curriculum development for the undergraduate and postgraduate training of junior rural and remote physicians.

Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models

OBJECTIVES

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

Residential LTCFs in rural areas worldwide.

METHODS

The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary.

RESULTS

A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth.

CONCLUSIONS AND IMPLICATIONS

This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

Socioeconomic Challenges in the Rural Patient Population in Need of Total Joint Arthroplasty

Many challenges exist for the rural patient in need of joint arthroplasty. Optimization for surgery is more difficult due to factors such as deprivation, education, employment, household income, and access to proper surgical institutions. Rural individuals have less access to primary care and even less access to surgical specialists, creating a distinct subset of patients who endure higher costs, poorer outcomes, and lack of care. Reducing socioeconomic disparities in rural communities will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation). Hopefully remote patient technologies can help with access and timely addressing of modifiable risk factors.

Health services for aboriginal and Torres Strait Islander children in remote Australia: A scoping review

In Australia, there is a significant gap between health outcomes in Indigenous and non-Indigenous children, which may relate to inequity in health service provision, particularly in remote areas. The aim was to conduct a scoping review to identify publications in the academic and grey literature and describe 1) Existing health services for Indigenous children in remote Australia and service use, 2) Workforce challenges in remote settings, 3) Characteristics of an effective health service, and 4) Models of care and solutions. Electronic databases of medical/health literature were searched (Jan 1990 to May 2021). Grey literature was identified through investigation of websites, including of local, state and national health departments. Identified papers (n = 1775) were screened and duplicates removed. Information was extracted and summarised from 116 papers that met review inclusion criteria (70 from electronic medical databases and 45 from the grey literature). This review identified that existing services struggle to meet demand. Barriers to effective child health service delivery in remote Australia include availability of trained staff, limited services, and difficult access. Aboriginal and Community Controlled Health Organisations are effective and should receive increased support including increased training and remuneration for Aboriginal Health Workers. Continuous quality assessment of existing and future programs will improve quality; as will measures that reflect aboriginal ways of knowing and being, that go beyond traditional Key Performance Indicators. Best practice models for service delivery have community leadership and collaboration. Increased resources with a focus on primary prevention and health promotion are essential.

Telehealth Services: Implications for Enhancing Sexually Transmitted Infection Prevention

ABSTRACT

In the United States, sexually transmitted infections (STIs) are among the most persistent threats to health equity. Increasing access to STI prevention and control services through the provision of Remote Health and Telehealth can improve sexual health outcomes. Telehealth has been shown to increase access to care and even improve health outcomes. The increased flexibility offered by Telehealth services accommodates both patient and provider. Although both Telehealth and Remote Health strategies are important for STI prevention, share common attributes, and, in some circumstances, overlap, this article will focus more specifically on considerations for Telehealth and how it can contribute to increasing health equity by offering an important complement to and, in some cases, substitute for in-person STI services for some populations. Telehealth assists a variety of different populations, including those experiencing STI disparities; however, although the Internet offers a promising resource for many American households and increasing percentages of Americans are using its many resources, not all persons have equal access to the Internet. In addition to tailoring STI programs to accommodate unique patient populations, these programs will likely be faced with adapting services to fit reimbursement and licensing regulations.

Nursing in a different world: Remote area nursing as a specialist-generalist practice area

OBJECTIVE

Remote area nurses provide primary health care services to isolated communities across Australia. They manage acute health issues, chronic illness, health promotion and emergency responses. This article discusses why their generalist scope of practice should be formally recognised as a specialist nursing practice area.

DESIGN

Constructivist grounded theory, using telephone interviews (n = 24) with registered nurses and nurse practitioners.

SETTING

Primary health care clinics, in communities of 150-1500 residents across Australia.

PARTICIPANTS

A total of 24 nurses participated in this study.

RESULTS

Nurses' perceived their clinical knowledge and skill as insufficient for the advanced, generalist, scope of practice in the remote context, especially when working alone. Experience in other settings was inadequate preparation for working in remote areas. Knowledge and skill developed on the job, with formal learning, such as nurse practitioner studies, extending the individual nurse's scope of practice to meet the expectations of the role, including health promotion.

CONCLUSION

Remote area nursing requires different knowledge and skills from those found in any other nursing practice setting. This study supports the claim that remote area nursing is a specialist-generalist role and presents a compelling case for further examination of the generalist education and support needs of these nurses. Combined with multidisciplinary collaboration, developing clinical knowledge and skill across the primary health care spectrum increased the availability of health resources and subsequently improved access to care for remote communities. Further research is required to articulate the contemporary scope of practice of remote area nurses to differentiate their role from that of nurse practitioners.

Mild Cognitive Impairment in Rural Areas: Research Advances and Implications for Clinical Practice and Healthcare Policy

Mild cognitive or neurocognitive impairment (MCI) may be more prevalent in rural areas. Differences between rural and urban MCI patients in terms of risk factors, course and prognosis are rarely reported. The present review aims to summarize the latest research on MCI in rural areas. A literature search was performed in the databases of PubMed, Scopus and ScienceDirect for articles published over the last decade. Eleven articles were included in this review, reporting on the differences between rural and urban MCI patients. Several risk factors, such as older age, lack of activities and food insecurity have been associated with MCI in both rural and urban areas, whereas others, such as obesity, adverse childhood experiences and plasma chemokine C-C motif ligand 11 (considered as a potential negative regulator of neurogenesis), differed according to the place of residence. No specific protective factor for rural women has been reported. There is some evidence that MCI may present earlier in rural residents, but that progression to dementia may be more rapid in urban residents. It seems that there may be clinically relevant differences in the onset, course and prognosis of MCI with regards to the place of residence (urban vs rural). Those differences should be taken into account for the design of health policies and service delivery across different settings.

Research on psychotic disorders in rural areas: Recent advances and ongoing challenges

BACKGROUND

Research on patients with chronic psychotic disorders in rural areas is scarce. Those patients may not receive adequate mental health care. Mental health disparities among rural and urban areas have been recognized.

AIMS

This review aims to present the most recent research on psychotic disorders in rural areas.

METHOD

We conducted a search in the PubMed and Scopus databases. The search involved articles published over the last decade (2011-2020). All types of research design were included, if studies had used a controlled group of urban patients and reported on the differences among rural/urban residents with psychotic disorders. The focus of the review was on outcome and treatment.

RESULTS

A total of 12 studies were included in this review. Most have been conducted in China or India. Reports from Western countries are rare. Outcome studies showed that employment rates are significantly higher in rural patients, as well as rates of marriage in women. It is not clear what is the impact of those outcomes on patients' lives. The finding of lower cost of psychotic disorders in some rural areas, should be viewed with scepticism. Studies on treatment aspects suggested that rural patients were less likely to receive antipsychotics, antipsychotic combination or clozapine. Those results were attributed to limited access to specialized treatment. When rural patients receive specialized community care they seem to have better outcomes than urban patients.

CONCLUSION

There is an ongoing, but still scarce research on patients with chronic psychotic disorders in rural areas. Researchers pointed out the impact of socioeconomic inequalities on outcome and treatment, and stressed the importance of minimizing mental health disparities. These findings may have potential implications for future research; for the introduction of accessible, locally based mental health services in rural areas; and for political initiatives that would address poverty and social inequalities.

The Effect of Heat Events on Prehospital and Retrieval Service Utilization in Rural and Remote Areas: A Scoping Review

INTRODUCTION

It is well-established that heatwaves increase demand for emergency transport in metropolitan areas; however, little is known about the impact of heat events on demand for prehospital retrieval services in rural and remote areas, or how heatwaves are defined in this context.

INCLUSION CRITERIA

Papers were eligible for inclusion if they reported on the impact of a heat event on the activity of a prehospital and retrieval service in a rural or remote area.

METHODS

A search of PubMed, Cochrane, Science Direct, CINAHL, and Google Scholar databases was undertaken on August 18, 2020 using search terms related to emergency medical transport, extreme heat, and rural or remote. Data relevant to the impact of heat on retrieval service activity were extracted, as well as definitions of extreme heat.

RESULTS

Two papers were identified, both from Australia. Both found that heat events increased the number of road ambulance call-outs. Both studies used the Excess Heat Factor (EHF) to define heatwave periods of interest.

CONCLUSIONS

This review found almost no primary literature on demand for prehospital retrieval services in rural and remote areas, and no data specifically related to aeromedical transport. The research did recognize the disproportionate impact of heat-related increase in service demand on Australian rural and regional health services. With the effects of climate change already being felt, there is an urgent need for more research and action in this area.

Factors associated with the rural and remote practice of medical workforce in Maluku Islands of Indonesia: a cross-sectional study

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.

Retention of General Practitioners in remote areas of Canada and Australia: A meta-aggregation of qualitative research

OBJECTIVE

Our aim was to systematically review qualitative evidence regarding the experiences and perceptions of General Practitioners and the factors influencing retention in remote areas of Canada and Australia. The objectives were to identify gaps and inform policy to improve retention of remote doctors, which should in turn reduce health inequalities for remote communities.

DESIGN

Meta-aggregation of qualitative studies of General Practitioners and general practice registrars who had worked in a remote area of Australia or Canada for a minimum of 1 year and/or were intending to stay remote long term in their current placement.

RESULTS

Six synthesised findings were identified: peer and professional support, organisational support, uniqueness of remote lifestyle and work, burnout and time off, personal family issues and cultural and gender issues.

CONCLUSIONS

Long-term retention of doctors in remote areas of Australia and Canada is influenced by a range of negative and positive perceptions, and experiences with key factors being professional, organisational and personal. All 6 synthesised findings span a spectrum of policy domains and service responsibilities, and therefore, a central coordinating body could be well placed to implement a multifactorial retention strategy.

Workplace locations of allied health and nursing graduates who undertook a placement in the Northern Territory of Australia from 2016 to 2019: An observational cohort study

OBJECTIVE

The aim of the study is to determine the current work locations of allied health professionals and nurses who undertook a student placement in the Northern Territory of Australia from 2016-2019.

DESIGN

An observational cohort study was conducted in October 2020, with students emailed a link to an on-line survey, plus two reminders.

SETTING

Primary health care in the Northern Territory of Australia.

PARTICIPANTS

All allied health and nursing students who undertook a student learning placement in the Northern Territory from 2016-2019 (n = 1936).

MAIN OUTCOME MEASURES

Practicing nurses and allied health professionals were asked about their work history and locations (coded using the Modified Monash Model of remoteness and population size).

RESULTS

The response rate was 14.2% (275/1936 students). Most respondents reported that their placement positively influenced them to consider working: in a rural or remote location (76%), in the Northern Territory (81%), and with marginalised or under-served populations (74%). Of the respondents, 224 had graduated and 203 were currently working in their health profession. A total of 31.4% of respondents reported that they had worked in a remote or rural location after graduation.

CONCLUSIONS

The student placement had a positive effect on the likelihood of students working in a rural or remote location. A focus on recruiting students with a remote upbringing/background and offering longer placements would likely be successful in helping build the health professional workforce in remote locations.

Understanding regional food environments: A qualitative exploration of food purchasing behaviour

The characteristics of regional food environments differ from those of urban food environments, however, the importance of these characteristics in shaping food purchasing behaviours is unclear. Using a qualitative descriptive approach, how regional adults use and perceive their food environment and the factors that determine their food purchasing behaviour were explored. Semi-structured in-depth interviews were undertaken with thirteen regional-dwelling Australian adults. Findings suggest regional residents consider a range of factors beyond proximity to home, in deciding where to purchase food. Knowing how people use their food environment will inform contextually-appropriate policy recommendations and interventions to improve regional food environments and healthy purchasing behaviours.

Evidence base for early intervention in psychosis services in rural areas: A critical review

AIM

Early Intervention in Psychosis teams (EITs) are a growing entity internationally, yet they remain under-researched given challenges facing their delivery. Model adaptations include stand-alone services, a hub-and-spoke model with various bases and integrating specialist staff into existing mental health teams. The present critical review focuses on reviewing the evidence base for the delivery of EITs in rural areas, first pertaining to evidence for model adherence and second to clinically outcomes.

METHOD

A systematic literature search was undertaken, finding 53 papers of interest. Nine papers met the inclusion criteria. A critical appraisal tool was used to consider the quality of the evidence and a narrative review of their findings is presented.

RESULTS

The five studies reporting clinical outcomes of rural EITs demonstrate positive outcomes of a hub-and-spoke and stand-alone EIT on reducing hospital admissions, psychotic symptoms and improving quality of life. One study directly comparing hub-and-spoke to stand-alone EIT found that hub-and-spoke EIT had more positive outcomes than a stand-alone service. Of the studies attempting to promote adherence to EIT model in rural areas, services show low overall adherence and report issues pertaining to funding and managerial support for practical barriers to implementation.

CONCLUSIONS

EIT services in rural areas may show similar positive outcomes to urban areas and adaptations to suit rural populations appear acceptable, such as using a hub-and-spoke model, though further research is required. Adherence to EIT service models in rural areas may be limited and training programmes to promote adherence benefit from managerial and financial support.

Rehabilitation of the frail older adults in primary healthcare in rural areas: a scoping review protocol

INTRODUCTION

Frail older adults are particularly vulnerable to functional decline and adverse outcomes because they lack the necessary resistance and ability to cope. Rehabilitation services for the frail older adults are thus vital and require clarification. The aim of this review is to identify and map the scope and breadth of literature regarding rehabilitation of the frail older adults to develop a holistic rehabilitation service in primary healthcare in rural areas. The concept of rehabilitation, how rehabilitation services are organised, how patients and next of kin are involved in planning and evaluating services during rehabilitation, as well as reported results will be identified and mapped.

METHODS AND ANALYSIS

This scoping review will be conducted based on the methodology developed by Arksey and O'Malley. The search strategy will aim to locate both published and unpublished studies in relevant databases. Key information sources include CINAHL, MEDLINE, Embase, ProQuest and Google Scholar. Data will be extracted from papers that all three reviewers have chosen to include in the review. All three reviewers will participate in screening, assessment and selection of studies against the inclusion criteria for the review and work in teams of two. The full text of selected citations will be assessed in detail against the inclusion criteria by the same teams. Data will be extracted from papers included in the scoping review by two of the reviewers. Modifications will be detailed in the full review report. Any disagreements that arise between two reviewers will be resolved through discussion or with the third reviewer's mediation. A narrative summary of the findings will be presented accompanied by tables that reflect the objective of the review.

ETHICS AND DISSEMINATION

Data will be obtained only from already publicly available materials. Special ethical approval is, therefore, not required.

Understanding the elements of a quality rural/remote interprofessional education activity: A rough guide

AIMS

To offer a rough guide to a quality rural/remote interprofessional educational activity.

CONTEXT

Australian remote and rural interprofessional undergraduate placements offered in Modified Monash Model 3-6 locations.

APPROACH

Biggs' triple P framework from the interprofessional educational literature and Allport's contact hypothesis are used to describe map, and explore the educational dimensions and positive elements, of a quality rural/remote interprofessional educational activity.

CONCLUSION

Delivery of a quality interprofessional educational activity requires attention to all dimensions of the activity with acknowledgement of the value of the remote or rural contexts. Interprofessional learning requires constructive alignment and positive contact conditions to ensure a quality and sustained experience.

The contribution of decentralised nursing education to social responsibility in rural Arctic Norway

This study explores and analyses decentralised nursing education in Finnmark County, Northern Norway, from 1991 to 2018. The study may have relevance for educational policy discussions and strategic planning. Our research question has been how decentralised nursing education can contribute to social responsibility by educating nurses rurally. The data collection includes documentation of 15 decentralised classes. The decentralised nursing education programme has been completed in nine rural communities in Finnmark County over 28 years and has resulted in 191 graduated nurses. Educating nurses locally influences recruitment and stability. The location of the study site determines where the recruited students come from. In future decentralised programmes, study sites should be located close to regions with a shortage of nurses. This is especially true of the eastern part of Finnmark, where recruitment to regular on-campus programmes is lowest. Limiting decentralised nursing programmes to local applicants should be considered. By prioritising local applicants, we will fulfil the university's responsibility to place qualified nurses in all parts of Finnmark.

Health Profession Education in Remote or Geographically Isolated Settings: A Scoping Review

Remote health has been differentiated from rural health in Australia and defined as isolated, with poor service access and a relatively high proportion of Indigenous residents, necessitating different models of care. Educational strategies for remote health practice are often needs driven and the characteristics of remote health may be used to categorise remote health professional education. This scoping review aims to identify the purpose of health professional education for remote settings, the type of educational strategies implemented and the reported outcomes. A broad search of published literature available in online bibliographic databases was conducted. A total of 33 articles met the review inclusion criteria. A further 7 articles were identified for inclusion in the review through citation searches and the authors' networks giving a total of 40 articles. Six primary themes were established based on the educational purpose: (1) cultural competency; (2) social accountability; (3) rural and remote skill development for the general workforce; (4) remote specialisation; (5) specialist skills required for a remote workforce; and (6) remote teaching. These themes also reflect the philosophical change over time recognising remote health as a separate discipline and its value as a distinctive and efficacious learning environment. The concept of education for remote practice is proposed to describe this unique leaning environment which encompasses critical pedagogy to develop a sense of agency and social accountability, embedding the delivery of primary health care through service learning and developing relationships in a context which is transformative.

Health Support for a Remote Industrial Site

This publication is derived from and rooted in the authors' experience in designing the Health Support of a remote industrial site. Summarizing the main steps of this design is the purpose of the approach. As a first step devoted to “Evaluation” (Chapters 1–5) are displayed the fundamentals for designing a Project Health Plan, such as a realistic and operative definition of “patient stabilization” and the principles of tactical reasoning for Medevacs, specifying how pathophysiology and logistic constraints should be correlated. A core element of the conceptual work consists in partnering these two domains, which usually each go their own way. Both should be considered in terms of delays: in life threatening situations, pathophysiology allows for a (maximum) delay before effective stabilization, while logistics dictates a (minimum) delay for reaching a stabilization facility. Ensuring that these two delays match is the desired result. Clearly, this conceptual work will unfold its full potential in low sanitary level countries, where most industrial commodities Projects take place, and where these delays are the longest. Next is detailed the audit/study preparation, i.e., the data gathering needed to get a clear picture of the Project conditions and concerns, workforce headcount and pattern, evacuation vectors and delays, and reference documents. Finally, risk assessment and a review of health facilities—in the vicinity and further away—complete the evaluation work. In a second phase devoted to “Implementation” (Chapters 6–9) is detailed how contracts with health providers, and health exhibits of industrial contracts should be conceived, and how on-site health support is designed, from the necessity of a pre-employment check to the design and organization of routine and emergency medicine facilities. Emergency preparedness and response plans, as well as medical coordination, should integrate with the HSE command chart. Overall, this document strongly advocates for joint engineering between HSE officers and medical specialists. An overview of key points for hygiene—often a separate topic covered in an offprint—is proposed. Finally, forward guidance for writing the audit/study report is proposed. This audit/study report must result in conclusive recommendations. Hence, a guide is proposed so that the report becomes a matrix of the Health Plan itself, and will be ended by a summary of findings and recommendations ready-to-use in Project management. In this way, the Health Plan will be launched, and gradually evolve and be amended as a “living document” throughout the lifetime of the Project.

Remoteness influences access to sexual partners and drives patterns of viral sexually transmitted infection prevalence among nomadic pastoralists

Sexually transmitted infections (STIs) comprise a significant portion of the infectious-disease burden among rural people in the Global South. Particular characteristics of ruralness-low-density settlements and poor infrastructure-make healthcare provision difficult, and remoteness, typically a characteristic of ruralness, often compounds the difficultly. Remoteness may also accelerate STI transmission, particularly that of viral STIs, through formation of small, highly connected sexual networks through which pathogens can spread rapidly, especially when partner concurrency is broadly accepted. Herein, we explored the effect of remoteness on herpes simplex virus type-2 (HSV-2) epidemiology among semi-nomadic pastoralists in northwestern (Kaokoveld) Namibia, where, in 2009 we collected HSV-2-specific antibody status, demographic, sexual network, and travel data from 446 subjects (women = 213, men = 233) in a cross-sectional study design. HSV-2 prevalence was high overall in Kaokoveld (>35%), but was heterogeneously distributed across locally defined residential regions: some regions had significantly higher HSV-2 prevalence (39-48%) than others (21-33%). Using log-linear models, we asked the following questions: 1) Are sexual contacts among people in high HSV-2-prevalence regions more likely to be homophilous (i.e., from the same region) than those among people from low-prevalence regions? 2) Are high-prevalence regions more "functionally" remote, in that people from those regions are more likely to travel within their own region than outside, compared to people from other regions? We found that high-prevalence regions were more sexually homophilous than low-prevalence regions and that those regions also had higher rates of within-region travel than the other regions. These findings indicate that remoteness can create contact structures for accelerated STI transmission among people who are already disproportionately vulnerable to consequences of untreated STIs.

Ruralization of students' horizons: insights into Australian health professional students' rural and remote placements

INTRODUCTION

Health workforce shortages have driven the Australian and other Western governments to invest in engaging more health professional students in rural and remote placements. The aim of this qualitative study was to provide an understanding of the lived experiences of students undertaking placements in various nonmetropolitan locations across Australia. In addition to providing their suggestions to improve rural placements, the study provides insight into factors contributing to positive and negative experiences that influence students' future rural practice intentions.

METHODS

Responses to open-ended survey questions from 3,204 students from multiple health professions and universities were analyzed using two independent methods applied concurrently: manual thematic analysis and computerized content analysis using Leximancer software.

RESULTS

The core concept identified from the thematic analysis was "ruralization of students' horizons," a construct representing the importance of preparing health professional students for practice in nonmetropolitan locations. Ruralization embodies three interrelated themes, "preparation and support," "rural or remote health experience," and "rural lifestyle and socialization," each of which includes multiple subthemes. From the content analysis, factors that promoted students' rural practice intentions were having a "positive" practice experience, interactions with "supportive staff," and interactions with the "community" in general. It was apparent that "difficulties," eg, with "accommodation," "Internet" access, "transport," and "financial" support, negatively impacted students' placement experience and rural practice intentions.

CONCLUSIONS

The study findings have policy and practice implications for continuing to support students undertaking regional, rural, and remote placements and preparing them for future practice in nonmetropolitan locations. This study may, therefore, further inform ongoing strategies for improving rural placement experiences and enhancing rural health workforce recruitment, retention, and capacity building.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland

OBJECTIVE

the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice.

DESIGN

online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis.

SETTING AND PARTICIPANTS

222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland.

FINDINGS

underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities.

KEY CONCLUSIONS

rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth.

IMPLICATIONS FOR PRACTICE

findings will inform the preparation of midwives for rural midwifery practice.

Who provides care for people dying of cancer? A comparison of a rural and metropolitan cohort in a South Australian bereaved population study

OBJECTIVE

To examine and compare urban and rural palliative care service availability and patterns of care from randomised, population-based surveys of caregivers of people at the end of life.

DESIGN, SETTING & PARTICIPANTS

Survey responses on the death of 'someone close' from 23,588 interviews of South Australians conducted between 2001 and 2007 are analysed.

INTERVENTIONS

A randomised population survey.

MAIN OUTCOME MEASURES

Explored palliative care service availability, caregiving provided, and characteristics of the deceased and their caregivers.

RESULTS

There was no difference in reported rates of accessing specialist palliative care services between rural and urban respondents (in unadjusted and adjusted analyses) nor did the proportion of people for whom cancer was their life-limiting illness. There was greater reliance on friends than first degree relatives in hands-on care provided at the end of life in rural settings. The rates of reported need for more support did not differ between urban and rural respondents for caregivers of people at the end of life.

CONCLUSION

Use of palliative care services was similar for rural and urban caregivers for someone close at the end of life with similar levels of met and unmet needs.

Open, trusting relationships underpin safety in rural maternity a hermeneutic phenomenology study

BACKGROUND

There are interwoven personal, professional and organisational relationships to be navigated in maternity in all regions. In rural regions relationships are integral to safe maternity care. Yet there is a paucity of research on how relationships influence safety and nurture satisfying experiences for rural maternity care providers and mothers and families in these regions. This paper draws attention to how these relationships matter.

METHODS

This research is informed by hermeneutic phenomenology drawing on Heidegger and Gadamer. Thirteen participants were recruited via purposeful sampling and asked to share their experiences of rural maternity care in recorded unstructured in-depth interviews. Participants were women and health care providers living and working in rural regions. Recordings were transcribed and data interpretively analysed until a plausible and trustworthy thematic pattern emerged.

RESULTS

Throughout the data the relational nature of rural living surfaced as an interweaving tapestry of connectivity. Relationships in rural maternity are revealed in myriad ways: for some optimal relationships, for others feeling isolated, living with discord and professional disharmony. Professional misunderstandings undermine relationships. Rural maternity can become unsustainable and unsettling when relationships break down leading to unsafeness.

CONCLUSIONS

This study reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care. Relationships are founded on mutual understanding and attuned to trust matter. These relationships are forged over time and keep childbirth safe and enable maternity care providers to work sustainably. Yet hidden unspoken pre-understandings of individuals and groups build tension in relationships leading to discord. Trust builds healthy rural communities of practice within which everyone can flourish, feel accepted, supported and safe. This is facilitated by collaborative learning activities and open respectful communication founded on what matters most (safe positive childbirth) whilst appreciating and acknowledging professional and personal differences.

A systematic review of published interventions for primary and secondary prevention of ischaemic heart disease (IHD) in rural populations of Australia

BACKGROUND

Rural Australians are known to experience a higher burden of ischaemic heart disease (IHD) than their metropolitan counterparts and the reasons for this appear to be highly complex and not well understood. It is not clear what interventions and prevention efforts have occurred specifically in rural Australia in terms of IHD. A summary of this evidence could have implications for future action and research in improving the health of rural communities. The aim of this study was to review all published interventions conducted in rural Australia that were aimed at the primary and/or secondary prevention of ischaemic heart disease (IHD) in adults.

METHODS

Systematic review of the peer-reviewed literature published between January 1990 and December 2015. Search terms were derived from four major topics: (1) rural; (2) ischaemic heart disease; (3) Australia and; (4) intervention/prevention. Terms were adapted for six databases and three independent researchers screened results. Studies were included if the published work described an intervention focussed on the prevention or reduction of IHD or risk factors, specifically in a rural population of Australia, with outcomes specific to participants including, but not limited to, changes in diet, exercise, cholesterol or blood pressure levels.

RESULTS

Of 791 papers identified in the search, seven studies met the inclusion criteria, and one further study was retrieved from searching reference lists of screened abstracts. Typically, excluded studies focused on cardiovascular diseases without specific reference to IHD, or presented intervention results without stratification by rurality. Larger trials that included metropolitan residents without stratification were excluded due to differences in the specific needs, characteristics and health service access challenges of rural populations. Six interventions were primary prevention studies, one was secondary prevention only and one included both primary and secondary intervention strategies. Two interventions were focussed exclusively on Aboriginal and Torres Strait Islander (Australian Indigenous) populations.

CONCLUSIONS

Few interventions were identified that exclusively focussed on IHD prevention in rural communities, despite these populations being at increased risk of IHD in Australia, and this is consistent with comparable countries, internationally. Although limited, available evidence shows that primary and secondary interventions targeted at IHD and related risk factors can be effective in a rural setting.

Falls in rural and remote community dwelling older adults: a review of the literature

OBJECTIVE

Falls in older adults represent a significant challenge in Australia; however, the focus is often on urban-dwelling older adults. The aim of this review was to explore the literature on falls epidemiology and falls prevention interventions (FPI).

DESIGN

A literature review was conducted searching Medline, Scopus, Social Sciences Citation Index, Google Scholar, Google and the Australian Institute of Health and Welfare publication catalogue.

SETTING

Rural and remote Australia.

PARTICIPANTS

Rural and remote community dwelling Australians aged 50 years and older.

INTERVENTION

Literature review.

MAIN OUTCOME MEASURES

Falls epidemiology and effective falls prevention interventions.

RESULTS

Twenty references were identified: 14 related to falls epidemiology and 7 to FPI. No significant differences were found between rural, remote and major cities residents in relation to falls hospitalisation, falls mortality or fall-related injuries sustained. There are a wide assortment of health professionals and non-health professionals who are involved in providing FPI in rural and remote Australia. However, there was limited information on the effectiveness of these interventions in influencing falls outcomes.

CONCLUSION

Few studies explored falls and their prevention in rural and remote Australia. The limited literature on the topic suggests that a change in focus to one that utilises existing services and resources will be required to create sustainable outcomes. Four areas are proposed for concentrated effort to reduce the impact of fall-related injury in rural and remote Australia: integration and collaboration among health professionals, promotion of physical activity across the lifespan, community involvement and ownership of interventions, and evaluation and publication of findings.

The 'rural pipeline' and retention of rural health professionals in Europe's northern peripheries

The major advance in informing rural workforce policy internationally over the past 25 years has been the recognition of the importance of the 'rural pipeline'. The rural pipeline suggests that people with 'rural origin' (who spent some childhood years in rural areas) and/or 'rural exposure' (who do part of their professional training in rural areas) are more likely to select rural work locations. What is not known is whether the rural pipeline also increases the length of time professionals spend in rural practice throughout their careers. This paper analyses data from a survey of rural health professionals in six countries in the northern periphery of Europe in 2013 to examine the relationship between rural origin and rural exposure and the intention to remain in the current rural job or to preference rural jobs in future. Results are compared between countries, between different types of rural areas (based on accessibility to urban centres), different occupations and workers at different stages of their careers. The research concludes that overall the pipeline does impact on retention, and that both rural origin and rural exposure make a contribution. However, the relationship is not strong in all contexts, and health workforce policy should recognise that retention may in some cases be improved by recruiting beyond the pipeline.

Defining Remoteness from Health Care: Integrated Research on Accessing Emergency Maternal Care in Indonesia

The causes of maternal death are well known, and are largely preventable if skilled health care is received promptly. Complex interactions between geographic and socio-cultural factors affect access to, and remoteness from, health care but research on this topic rarely integrates spatial and social sciences. In this study, modeling of travel time was integrated with social science research to refine our understanding of remoteness from health care. Travel time to health facilities offering emergency obstetric care (EmOC) and population distribution were modelled for a district in eastern Indonesia. As an index of remoteness, the proportion of the population more than two hours estimated travel time from EmOC was calculated. For the best case scenario (transport by ambulance in the dry season), modelling estimated more than 10,000 fertile aged women were more than two hours from EmOC. Maternal mortality ratios were positively correlated with the remoteness index, however there was considerable variation around this relationship. In a companion study, ethnographic research in a subdistrict with relatively good access to health care and high maternal mortality identified factors influencing access to EmOC, including some that had not been incorporated into the travel time model. Ethnographic research provided information about actual travel involved in requesting and reaching EmOC. Modeled travel time could be improved by incorporating time to deliver request for care. Further integration of social and spatial methods and the development of more dynamic travel time models are needed to develop programs and policies to address these multiple factors to improve maternal health outcomes.

Mentoring as a retention strategy to sustain the rural and remote health workforce

OBJECTIVE

To propose a model of mentoring suitable for rural and remote health professionals.

DESIGN

Given the rural and remote health workforce shortage, mentoring is proposed as a workforce retention strategy. Mentoring literature was reviewed; aspects of mentoring highlighted in the literature were considered to ascertain their suitability for rural and remote health professionals.

METHOD

A total of 39 mentoring papers were reviewed to outline key factors in mentoring rural and remote health professionals. Using this literature, key ways that rural and remote practice enhance or are barriers to mentoring were identified. From this, a model for mentoring rural and remote health practitioners, students and academics was developed.

RESULTS

Four models of mentoring were identified: the cloning, nurturing, friendship and apprenticeship models. The apprenticeship model was identified as suitable for students, the nurturing model as suited to new health professionals to rural and remote settings and the friendship model for senior practitioners/academics. Factors more likely to enable mentoring in rural and remote settings were identified as feelings of obligation by senior practitioners, strong relationships between staff, blurred work/social boundaries, lack of hierarchy, inter-professional practice and technology. The barriers identified included workloads, access to mentors, fee-for-service system for some practitioners, conflicts which could jeopardise working and business relationships, and feelings of being judged.

CONCLUSIONS

A model of mentoring for rural and remote health professionals was presented. Given the potential to strengthen and increase the rural and remote health workforce, trialling such a model is worthwhile and evaluation would identify its impact.

Supervisor continuity or co-location: which matters in residency education? Findings from a qualitative study of remote supervisor family physicians in Australia and Canada

PURPOSE

Changes to health care systems and working hours have fragmented residents' clinical experiences with potentially negative effects on their development as professionals. Investigation of off-site supervision, which has been implemented in isolated rural practice, could reveal important but less overt components of residency education.

METHOD

Insights from sociocultural learning theory and work-based learning provided a theoretical framework. In 2011-2012, 16 family physicians in Australia and Canada were asked in-depth how they remotely supervised residents' work and learning, and for their reflections on this experience. The verbatim interview transcripts and researchers' memos formed the data set. Template analysis produced a description and interpretation of remote supervision.

RESULTS

Thirteen Australian family physicians from five states and one territory, and three Canadians from one province, participated. The main themes were how remoteness changed the dynamics of care and supervision; the importance of ongoing, holistic, nonhierarchical, supportive supervisory relationships; and that residents learned "clinical courage" through responsibility for patients' care over time. Distance required supervisors to articulate and pass on their expertise to residents but made monitoring difficult. Supervisory continuity encouraged residents to build on past experiences and confront deficiencies.

CONCLUSIONS

Remote supervision enabled residents to develop as clinicians and professionals. This questions the supremacy of co-location as an organizing principle for residency education. Future specialists may benefit from programs that give them ongoing and increasing responsibility for a group of patients and supportive continuity of supervision as residents.

Cost of best-practice primary care management of chronic disease in a remote Aboriginal community

OBJECTIVE

To estimate the cost of completing all chronic care tasks recommended by the Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) for patients with type 2 diabetes and chronic kidney disease (CKD).

DESIGN AND SETTING

The study was conducted at a health service in a remote Central Australian Aboriginal community between July 2010 and May 2011. The chronic care tasks required were ascertained from the CARPA STM. The clinic database was reviewed for data on disease prevalence and adherence to CARPA STM guidelines. Recommended tasks were observed in a time-and-motion study of clinicians' work. Clinicians were interviewed about systematic management and its barriers. Expenditure records were analysed for salary and administrative costs.

MAIN OUTCOME MEASURES

Diabetes and CKD prevalence; time spent on chronic disease care tasks; completion of tasks recommended by the CARPA STM; barriers to systematic care identified by clinicians; and estimated costs of optimal primary care management of all residents with diabetes or CKD.

RESULTS

Projected annual costs of best-practice care for diabetes and CKD for this community of 542 people were $900 792, of which $645 313 would be met directly by the local primary care service. Estimated actual expenditure for these conditions in 2009-10 was $446 585, giving a projected funding gap of $198 728 per annum, or $1733 per patient. High staff turnover, acute care workload and low health literacy also hindered optimal chronic disease care.

CONCLUSION

Barriers to optimal care included inadequate funding and workforce issues. Reduction of avoidable hospital admissions and overall costs necessitates adequate funding of primary care of chronic disease in remote communities.

Community participation to design rural primary healthcare services

BACKGROUND

This paper explores how community participation can be used in designing rural primary healthcare services by describing a study of Scottish communities. Community participation is extolled in healthcare policy as useful in planning services and is understood as particularly relevant in rural settings, partly due to high social capital. Literature describes many community participation methods, but lacks discussion of outcomes relevant to health system reconfiguration. There is a spectrum of ideas in the literature on how to design services, from top-down standard models to contextual plans arising from population health planning that incorporates community participation. This paper addresses an evidence gap about the outcomes of using community participation in (re)designing rural community health services.

METHODS

Community-based participatory action research was applied in four Scottish case study communities in 2008-10. Data were collected from four workshops held in each community (total 16) and attended by community members. Workshops were intended to produce hypothetical designs for future service provision. Themes, rankings and selections from workshops are presented.

RESULTS

Community members identified consistent health priorities, including local practitioners, emergency triage, anticipatory care, wellbeing improvement and health volunteering. Communities designed different service models to address health priorities. One community did not design a service model and another replicated the current model despite initial enthusiasm for innovation.

CONCLUSIONS

Communities differ in their receptiveness to engaging in innovative service design, but some will create new models that fit in a given budget. Design diversity indicates that context influences local healthcare planning, suggesting community participation impacts on design outcomes, but standard service models maybe useful as part of the evidence in community participation discussions.

Workplace physical violence among hospital nurses and physicians in underserved areas in Jordan

AIMS AND OBJECTIVES

To: (1) examine the incidence, frequency and contributing factors to workplace violence among nurses and physicians in underserved areas in Jordan, and (2) identify the existing policies and the management modalities to tackle workplace violence.

BACKGROUND

Workplace violence is a major problem in healthcare organisations. An understanding of the nature of violence is essential to implementing successful management.

DESIGN

A descriptive exploratory research design.

METHODS

The questionnaire that was developed in 2003 by the International Labor Office, the International Council of Nurses, the World Health Organization, and the Public Services International was used to collect data from a convenience sample of 521 Jordanian physicians and nurses (396 nurses, 125 physicians) who worked in hospitals located in underserved areas.

RESULTS

Around 15% of the participants were exposed to physical violence. The factors that contributed to workplace violence were related to absence of policies, inadequate staffing and lack of communication skills. Only 16·9% of participants indicated that there were specific policies available for dealing with physical workplace violence. Strengthening security and providing training were some of the important factors indicated by participants for decreasing violence in the workplace.

CONCLUSIONS

Workplace violence is a problem in underserved areas that needs attention from administrators. Most participants were very dissatisfied with the way the administrators dealt with the incidents.

RELEVANCE TO CLINICAL PRACTICE

Instituting firm policies against perpetrators and developing protective violence guidelines to support healthcare staff in managing workplace violence are paramount to tackle the problem of workplace violence.

Occupational stress in remote area nursing: development of the Remote Area Nursing Stress Scale (RANSS)

BACKGROUND AND PURPOSE

The purpose of this study was to develop a measure that would adequately and sensitively measure the occupational stress experience of nurses working in very remote health care facilities. Because no existing nursing stress tool is suitable to assess the unique stressors of remote nursing practice, the aim was to address this gap in psychometric measurement capacity and develop the Remote Area Nursing Stress Scale (RANSS).

METHOD

A focus group (n = 19) of remote area nurses identified potential questionnaire items through open discussion and by later listing the stressors they experienced individually in their day-to-day functioning. Subsequently, the Delphi method was employed to further refine the questionnaire (n = 12 experts). The RANSS was successfully pilot tested and was afterward administered to nurses working in very remote Australia in 2008 (n = 349) and in 2010 (n = 433).

RESULTS

Principal components analysis and confirmatory factor analysis were performed for both waves of survey administration, demonstrating a robust 7-factor structure consistent across samples and accounting for significant variance in dependent measures.

CONCLUSION

The development and validation of the RANSS is a significant advancement in remote area nursing research. The RANSS should be administered on an ongoing basis to monitor occupational stress among nurses working in very remote Australia. The RANSS should also be administered internationally in countries that also accommodate remote health care facilities. This would determine whether the RANSS is a psychometrically valid stress measure beyond the context of very remote Australia.

Characteristics of the Frontier Extended Stay Clinic: a new facility model

Purpose

In 2004, 5 remote clinics – 4 in rural frontier communities in Alaska and 1 in Washington – were funded to pilot and examine the effectiveness and appropriateness of a new facility model. Transporting patients from these locations to higher levels of care is not always possible requiring these facilities to expand their scope of services and provide care for extended periods. The Frontier Extended Stay Clinic (FESC) model is staffed and equipped to provide the combined services usually found in the separate settings of an outpatient primary-care clinic, inpatient acute care hospital and emergency room. This is a descriptive study of the characteristics of these pilot facilities and an analysis of patient utilization and outcomes.

Methods

The 5 clinics collected outcome data for 2,226 extended-stay encounters of 4 hours or longer from 15 September 2005 to 14 September 2010. Data from these extended-stay encounters were summarized, and descriptive statistics were used to describe: number and duration of encounters, when the encounters started, chief compliant, discharge diagnoses, transfer destination, Medicare and Medicaid eligibility, and type of encounter.

Findings

From 2005 to 2010, the mean duration of an extended-stay encounter was 9.1 hours. All of the clinics experienced many extended-stay encounters that were initiated or continued after normal business hours. The 5 most frequent diagnoses at discharge for extended encounters were cardiovascular, gastrointestinal, injury, substance abuse and pneumonia/bronchitis. Almost half, 47.6%, of extended-stay encounters resulted in discharge of the patient without a need for either non-urgent follow-up referral or transport. Extended-stay encounters that ended in a patient being transported to another medical facility were 43.7% of the total. More than a quarter (26.9%) of extended-stay encounters were eligible for Medicare payment.

Conclusion

While many of communities can support a facility for primary care, there is an on-going need for facilities in remote frontier areas to also provide emergent and extended-stay care. The FESC can provide access to primary, emergent and extended-stay services in these locations.

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.

Medication supply and management in rural Queensland: views of key informants in health service provision

BACKGROUND

Rural settings challenge health care providers to provide optimal medication services in a manner that is timely and of high quality. Extending the roles of rural health care providers is often necessary to improve access to medication services; however, there appears to be a lack of pharmacy-based involvement and support within the medication system.

OBJECTIVES

This article explores medication supply and management issues in rural settings, based on the governance perspectives of key informants on regulatory aspects, policy, and professional practice. The specific objectives were to (1) identify the key issues and existing facilitators and (2) explore the potential roles of pharmacy to improve medication supply and management services.

METHODS

Semi-structured interviews were conducted with representatives within regulatory or professional organizations. The participants were key informants who held leadership and/or managerial roles within their respective organizations and were recruited to provide insights from a governance perspective before data collection in the community. An interview guide, informed by the literature, assisted the flow of interviews, exploring topics, such as key issues, existing initiatives, and potential pharmacy-based facilitators, in relation to medication supply and management in rural settings.

RESULTS

Issues identified that hindered the provision of optimal medication supply and management services in the rural areas centered on workforce, interprofessional communication, role structures, and funding opportunities. Legislative and electronic developments and support mechanisms aim to facilitate medication processes in rural areas. Potential initiatives to further enhance medication services and processes could explore extended roles for pharmacists and pharmacy support staff, as well as alternative service delivery models to enhance pharmacy workforce capacity.

CONCLUSIONS

The study provided an overview of key issues with medication supply and management and highlighted the potential for increased pharmacy involvement to improve and support medication services in rural areas. The governance views of these key informants could be used to inform policy and practice related to rural medication services.

Is a global rural and remote health research agenda desirable or is context supreme?

OBJECTIVE

This paper proposes that there is value in international comparison of rural and remote health-care service delivery models because of practical reasons - to find ideas, models and lessons to address 'local' delivery challenges; and for theoretical reasons - to derive a conceptual framework for international comparison.

METHODS

Literature review and commentary.

FINDINGS

There are significant challenges to international comparative research that have been highlighted generically; for example, equivalence of terminology, datasets and indicators. Context supremacy has been raised as a reason why models and research findings might not be transferable. This paper proposes that there is insufficient knowledge about how rural contexts in relation to health service delivery are similar or different internationally. Investigating contexts in different countries and identifying the dimensions on which service delivery might differ is an important stimulus for study. The paper suggests, for discussion, dimensions on which rural service delivery might differ between countries and regions, including physical geographical factors, social interaction with rurality, policies of service provision and the politics and operation of health care.

CONCLUSIONS

The paper asks whether, given the need to develop models suitable for rural areas and for theory on rural health to extend, international comparative research is an imperative or an indulgence.

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

OBJECTIVE

This paper argues that rural and remote health is in need of theoretical development.

DESIGN

Based on the authors' discussions, reflections and critical analyses of literature, this paper proposes key reasons why rural and remote health warrants the development of theoretical frameworks.

RESULTS

The paper cites five reasons why theory is needed: (i) theory provides an approach for how a topic is studied; (ii) theory articulates key assumptions in knowledge development; (iii) theory systematises knowledge, enabling it to be transferable; (iv) theory provides predictability; and (v) theory enables comprehensive understanding.

CONCLUSION

This paper concludes with a call for theoretical development in both rural and remote health to expand its knowledge and be more relevant to improving health care for rural Australians.

Climate change: what competencies and which medical education and training approaches?

BACKGROUND

Much research has been devoted to identifying healthcare needs in a climate-changing world. However, while there are now global and national policy statements about the importance of health workforce development for climate change, little has been published about what competencies might be demanded of practitioners in a climate-changing world. In such a context, this debate and discussion paper aims to explore the nature of key competencies and related opportunities for teaching climate change in medical education and training. Particular emphasis is made on preparation for practice in rural and remote regions likely to be greatly affected by climate change.

DISCUSSION

The paper describes what kinds of competencies for climate change might be included in medical education and training. It explores which curricula, teaching, learning and assessment approaches might be involved. Rather than arguing for major changes to medical education and training, this paper explores well established precedents to offer practical suggestions for where a particular kind of literacy--eco-medical literacy--and related competencies could be naturally integrated into existing elements of medical education and training.

SUMMARY

The health effects of climate change have, generally, not yet been integrated into medical education and training systems. However, the necessary competencies could be taught by building on existing models, best practice and innovative traditions in medicine. Even in crowded curricula, climate change offers an opportunity to reinforce and extend understandings of how interactions between people and place affect health.