The sustainable provision of medical, nursing and allied health services to rural and remote communities is of significant international concern1-8. In Australia, the issue of staff recruitment to and retention in rural and remote health services is a long-standing problem2,9. While nursing and particularly medical workforce issues dominate the Australian literature, recruitment of allied health staff is similarly problematic10,11.
Podiatry, as one of the allied health professions, provides important services to clients in rural and remote communities. New South Wales (NSW) data12 show only 17.7% of the total podiatry workforce to be located in rural or remote areas, significantly less than the 27% of the total State rural population12. Similarly, the recruitment and retention of podiatrists in rural South Australia (SA) is of concern, with only 14.7% of the State's total podiatry labour force servicing a rural population that is 26.7% of State population13,14.
Rural podiatry in South Australia
The allied health professional rural labour force has been characterised by low availability and high turnover. In a 2000 study undertaken by Services for Australian Rural and Remote Allied Health (SARRAH), 42% of respondents indicated they had been employed in their current position for less than 2 years15. A similar figure (49%) was cited in a 1999 SA rural labour-force report11. Fifty-three podiatrists have worked in 16 positions in a permanent or locum capacity in the seven major rural regions within the State in the past 5 years. During this time many of the positions have remained vacant for periods in excess of 6 months, and currently, seven of the 16 positions remain vacant. Rural allied health position vacancy rates of up to 83.7% are more than double those in urban areas and in rural areas the availability of locum services to provide relief to struggling services is low16. Rural services are dependant on new graduates to fill vacant podiatry positions at the end of the academic year, but even this does not guarantee adequate staffing. It is not surprising, therefore, that in 2001 the Rural Health Subcommittee of the Australian Health Ministers Advisory Committee (AHMAC) identified podiatry as the allied health profession most in need of recruitment and retention support in the rural public sector17.
Addressing service gaps
In Australia and other countries, the issue of recruitment to rural health services has been addressed by an increase of undergraduate rural-health curricula, preferential university admission of rural students, bound scholarships, rural attachments, financial incentives, community involvement, and international recruitment3-7.
In the rural allied health arena, the Australian Federal government has established various funding initiatives that include More Allied Health Services (MAHS) and Regional Health Services (RHS) funding18. MAHS funding was provided to eligible Divisions of General Practice, to provide additional allied health services and to encourage a collaborative approach between medical and allied health services. RHS funding was designed to help small rural communities expand their local primary health-care services18. These initiatives have provided an opportunity to increase allied health services to regional Australia but this approach has neither considered nor addressed the ongoing difficulties in recruitment and retention of staff. Instead, this has become the responsibility of each individual State health region.
Traditional methods of addressing recruitment issues in local health services have met with only moderate success, and it became evident that a multi-faceted, innovative approach was needed. A current Australian study identified that recruitment to allied health professional services in rural and remote areas may be enhanced by such factors as provision of incentive package, a visiting or sessional service, appropriate accommodation, mentoring, provision of good equipment, providing aid in finding employment for spouses and partners, and accessible professional development10.
Recruitment from an undergraduate level
Rural health employers and the health industry have for some time looked to undergraduate education as an important starting point for addressing recruitment15. It has been argued that the responsibilities of university extend beyond the provision of education to students and research to 'social responsibility' within the industry19. This involves a commitment to ensuring underserved populations have access to essential health services by preparing graduates to work in areas of need. This is not only so for rural and remote areas within the country of origin, but should also be addressed to the global shortage of rural health professionals that promotes depletion of rural services in the least developed countries4,5.
In Australia, as internationally, various models have been proposed to enhance rural recruitment by intervention at an undergraduate level, including bound scholarships, rural education scholarships such as the Australian John Flynn Scholarships, reimbursement of education costs and student rural health clubs8,19,20. Sheppard and Hedges in their Australian report on rural and remote health undergraduate and post-graduate allied health education identified low numbers of rural students attending health-based university courses as a factor21. Strategies designed to combat this issue are evident at many university websites and include the provision of specific places within programs for rural-origin students, the addition of extra points to admission scores of students who experience 'educational disadvantage', and preferential selection programs. Studies by Sheppard and Hedges21, and Davies22 give conflicting opinions about the benefit of this approach. Of particular concern is that vacant rural podiatry positions still far out-weigh numbers of rural-origin students within specific rural programs. Additionally, it is not guaranteed that rural-origin students will choose to return to rural areas. Either way, it seems that relying merely on the admission of rural-origin students to universities, or indeed on any strategy alone, is not sufficient. Rabinowitz et al. identified that in addition to rural background, another factor associated with graduates entering rural practice was 'positive rural clinical and educational experiences at the undergraduate level'23. Neill and Taylor identified the need for the provision of rural placements to urban students to avoid lost 'recruitment opportunities'24 and this is supported by Dunabin and Levitt, albeit in association with the belief that the link between rural placement exposure and the choice to practice in a rural area upon graduating is tenuous8.
Many students avoid opportunities to 'go rural' simply because of a lack of rural experience, decreased confidence, pre-conceived and sometimes unfounded ideas, an emphasis in literature on rural disadvantage, or due to a stigma associated with rural living4,8,24-26. However anecdotal evidence and a number of studies8,27-29 have shown that students who undertake rural placements feel positive about their rural experiences and this increased their desire to work in rural areas on graduation.
Joint clinical-academic position model
Recent Federal Government funding has allowed the establishment of rural clinical schools at 10 sites in Australia8. Apart from minor structural differences, each of these medical schools has been established with the intent of increasing the exposure of medical students to rural practice. Each rural medical school aims to provide 25% of students with 50% of their clinical practice20. In order to address issues relating to recruitment and retention of podiatrists in rural areas, a similar approach at the level of the framework of established undergraduate courses was deemed necessary.
The alternative approach of making a joint academic-clinical podiatry position at the University of SA, in tandem with a greater commitment to rural health teaching within the course curriculum, was designed to increase student rural exposure and positively impact on recruitment of graduates to SA rural areas.
The initiative was due to the collaborative efforts of the University of SA, School of Physiotherapy and Podiatry; the SA Centre for Rural and Remote health (SACRRH); and the Northern and Far Western Regional Health Service (NFWRHS). The tripartite approach was a consequence of limited funding opportunities available within both university and public health sectors. It has also enhanced links among the funding bodies and ensured a rural clinical perspective to the role. This has enabled a more realistic, 'true to life' approach to teaching, research and committee representation. Additionally, Gadiel and Ridoutt made a recommendation for the inclusion of allied health professionals on management committees of University Departments of Rural Health30 and the collaborative involvement of the three parties may be seen as a positive move to adopting this recommendation.
Early initiatives of the joint appointment: An early initiative of the academic appointment was the implementation of a three-day rural health workshop for 20 second-year podiatry students. The aim of the workshop was to introduce students to a range of rural health issues, including primary health care, Aboriginal cultural awareness, rural clinical health issues, multidisciplinary work, and new graduate experiences. The workshop was held at a rural location, with local rural health professionals providing the tuition. The workshop received positive evaluation from participants who expressed enthusiasm about subsequent rural placements. Ninety percent of respondents scored the workshop experience as four or above on a 1-5 scale (where 1 = Very Poor, and 5 = Very Good) regarding the overall effect on their understanding of rural podiatry. Qualitative feedback was also positive.
A recent article by LaPorta et al.31 reported the relative success of in introducing US physical therapy students to rural practice using a weekend conference and subsequent 5 week rural clinical placement. With the support of the SA joint position, a mandatory five-week rural placement was introduced, in 2003, for final-year podiatry students to provide comprehensive 'hands on' experience of rural podiatry. Although not all students were expected to find the rural experience a positive one, nor would they have opportunities to work rurally at the end of their studies, it was hoped that this invaluable clinical experience would result in an increase in the number of graduates willing to consider rural employment.
Other benefits of the joint appointment: The provision of professional support, particularly to new graduates, is a commonly identified factor for successful rural employment2,10,21,27, and this joint position provides an ideal opportunity to establish a mentoring and supporting role. This aspect of the position is currently limited to students in placements within the NFWRHS and neighbouring regions but could potentially expand to placements in any SA rural area.
Gadiel and Ridoutt, in a report on rural allied health in NSW, identified providing a career path as important to laying the groundwork for recruitment30. The establishment of the joint academic position has provided an alternative career pathway for podiatrists within the NFWRHS, increasing recruitment and retention potential within the region. Finally, the joint position increases prospects for research in the areas of podiatry and rural health, something currently absent from the literature. While it is too soon to fully evaluate the impact of the academic appointment on rural recruitment, this could well be the objective of a future study.
A joint academic position was established as a collaborative effort, in part to address difficulties in the recruitment of podiatrists to rural communities. In the least it will increase the exposure of undergraduate podiatry students to rural health, a strategy linked with graduates accepting rural employment. An added benefit of the position is that it has increased links among SACRRH, the University of SA and the Northern and Far Western Regional Health Service, providing numerous opportunities for collaborative projects in both rural clinical practice and research.
The author acknowledges the assistance of Dr Sara Jones, Program Director Podiatry, School of Health Sciences, University of South Australia, and also Spencer Gulf Rural Health School (Incorporating the South Australian Centre for Rural and Remote Health and the Adelaide University Rural Clinical School).
1. Hays R. Common international themes in rural medicine. Australian Journal of Rural Health 1999; 7: 191-194.
2. Humphreys J, Jones J, Jones M, Hugo G, Bamford E, Taylor D. A critical review of rural medical workforce retention in Australia. Australian Health Review 2001; 24: 91-102.
3. Bushy A. International perspectives on rural nursing: Australia, Canada, USA. Australian Journal of Rural Health 2002; 10: 104-111.
4. Couper I. Rural hospital focus: staffing. Rural and Remote Health 3. (2003) online. Available: http://rrh.org.au (accessed 19 August 2003).
5. Couper I. Recruiting foreign doctors to South Africa: difficulties and dilemmas Rural and Remote Health 3. (2003) online. Available: http://rrh.org.au (accessed 19 August 2003).
6. Rabinowitz HK. Recruitment, Retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. New England Journal of Medicine 1993; 328: 934-939.
7. Rabinowitz HK. Evaluation of a selective medical school admissions policy to increase the number of family physicians in rural and underserved areas. New England Journal of Medicine 1988; 319: 480-486.
8. Dunabin J, Levitt L. Rural origin and rural medical exposure: their impact on the rural and remote medical workforce in Australia. Rural and Remote Health 3. (2003) online. Available: http://rrh.org.au (accessed 19 August 2003).
9. Worley P, Silagy C, Prideaux D, Newble D, Jones A. The parallel rural community curriculum: an integrated clinical curriculum based in rural general practice. Medical Education 2000; 34: 558-565.
10. Battye KM, McTaggart K. Strategies for the development of a sustainable outreach allied health service in remote north-west Queensland, Australia. Rural and Remote Health 3. (2003) online. Available: http://rrh.org.au (in production).
11. Golding S. Report on the South Australian rural allied health workforce. Adelaide, SA: Department of Human Services, South Australia, 1999.
12. Labour Force and Rural Health Unit, Australian Institute of Health and Welfare. Podiatry Labour Force 1994. National Health Labour Force Bulletin 1996. In, Services for Australian Rural and Remote Allied Health Inc. A study of allied health professionals in rural and remote Australia. Available: www.ruralhealth.org.au/sarrah (accessed 19 August 2003).
13. Labour Force and Rural Health Unit, Australian Institute of Health and Welfare. Podiatry Labour Force 1999. SARRAH. (2000) online. Available: www.ruralhealth.org.au/sarrah (accessed 16 October 2002).
14. Australian Bureau of Statistics. Census products and services. (2001) online. Available: http://www.abs.gov.au/websitedbs/D3110124.NSF/24e5997b9bf2ef35ca2567fb00299c59/ 034b261536480e03ca256c3a0000d6a8!OpenDocument (accessed 19 August 2003).
15. Fitzgerald K, Hornsby D, Hudson L. A study of Allied Health Professionals in Rural and Remote Australia. SARRAH. (2000) online. Available: www.ruralhealth.org.au/sarrah (accessed 16 August 2002).
16. Gadiel D, Ridoutt L. Towards a rural allied health strategy. NSW Health, 1993. In, K Fitzgerald, D Hornsby, L Hudson. A study of Allied Health Professionals in Rural and Remote Australia. SARRAH. (2000) online. Available: www.ruralhealth.org.au/sarrah (accessed 12 August 2003).
17. O'Kane A. Draft paper on the definition of rural and remote allied health. National Rural and Remote Allied Health Advisory Service, 2002.
18. Office of Rural Health, Department of Health and Ageing. More Allied Health Services. (2001) online. Available: www.ruralhealth.gov.au (accessed 18 October 2002).
19. Kamien M. Rural Student clubs and the responsibility for medical schools. Australian Journal of Rural Health 1996; 4: 237-241.
20. Office of Rural Health. Australian Department of Health and Ageing. Scholarships (online) 2002. Available: http://www.ruralhealth.gov.au/scholarships/index.htm (accessed 19 October 2002).
21. Sheppard L, Hedges G. A model for undergraduate and postgraduate allied Health education in rural and remote areas. Adelaide, SA: University of South Australia, Rural and Remote Areas Research Group, 1996.
22. Davies P. A comparison of rural and non-rural RACGP training program trainees. Australian Family Physician 1994; 23: 1330-1333, 1336.
23. Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. A program to increase the number of Family Physicians in rural and underserved areas: impact after 22 years. Journal of the American Medical Association 1999; 281: 255-260.
24. Neill J, Taylor K. Undergraduate nursing students' clinical experiences in rural and remote areas: recruitment implications. Australian Journal of Rural Health 2002; 10: 239-243.
25. McGrail MR. Echidna: a web-based community information database to assist students undertaking rural clinical placements. Rural and Remote Health 3. (2003) online. Available: http://rrh.org.au (accessed 19 August 2003).
26. Strasser R. Preparation for Rural Practice. In: D Wilkinson, I Blue (Eds). The New Rural Health. Melbourne: Oxford University Press, 2002; 204-220.
27. Barney T. Retention of Allied Health Professionals in Rural and Remote Areas of South Australia. Masters Thesis, University of South Australia, SA, 1998.
28. Murphy B, McEwan E, Hays RB. The University of Sydney rural career project: a nursing perspective. Australian Journal of Rural Health 1995; 3: 20-24.
29. Courtney M, Edwards H, Smith S, Finlayson K. The impact of rural clinical placement on student nurses' employment intentions. Collegian 2002; 9: 12-18.
30. Gadiel D, Ridoutt L, Towards a rural allied health strategy: A workforce and economic analysis of Allied Health in NSW. New South Wales Department of Allied Health, Sydney, 1993. In: National Rural Health Policy Sub-Committee (AHMAC), Draft Allied Health Workforce issues paper. 2002.
31. LaPorta L, McWhorter JW, Naas E. Assessment of a curricular component designed to introduce physical therapy students to Rural practice issues. Journal of Rural Health 2002; 18: 384-387.