Volume twenty-three, Issue 4

Urban and rural areas have particular characteristics that impact the health and mortality of their inhabitants. In Mexico, the leading causes of mortality are cardiovascular diseases, diabetes mellitus, cancer, and accidents, but the differences in these trends between urban and rural populations is not clearly understood. This study describes the adjusted mortality rate in rural and urban areas and analyzes trends between 2000 and 2019.

Las zonas urbanas y rurales tienen características particulares que impactan en la salud y mortalidad de sus habitantes. En México, las principales causas de mortalidad son las enfermedades cardiovasculares, la diabetes mellitus, el cáncer y los accidentes; pero las diferencias en estas tendencias entre las poblaciones urbanas y rurales, no están completamente claras. Este estudio describe la tasa de mortalidad ajustada en áreas rurales y urbanas, y analiza las tendencias entre 2000 y 2019.

Áreas urbanas e rurais possuem características particulares que impactam a saúde e a mortalidade de seus habitantes. No México, as principais causas de mortalidade são as doenças cardiovasculares, diabetes mellitus, câncer e acidentes, entretanto, asdiferenças destas tendências entre populações urbanas e rurais não é bem compreendida. Este estudo descreve as taxas ajustadas de mortalidade em áreas urbanas e rurais, bem como analisa as tendências entre 2002 e 2019.

Rural residents have an increased risk for dementia and face significant barriers accessing information, caregiving support, and memory-related services. Physical inactivity increases the risk of Alzheimer's disease, and rural communities experience barriers to participation in physical activity. This small pilot study focused on implementing and evaluating the feasibility and safety of a synchronous, remotely delivered, aerobic exercise telerehabilitation program for persons with subjective cognitive decline living in rural northern Minnesota, USA. The exercise intervention was synchronous, remotely supervised, moderate intensity activity using a recumbent bicycle. With no drop-outs, no adverse events, and an 85% session participation rate, the study provides evidence of preliminary feasibility of synchronous audiovisual telerehabilitation programs delivered to rural residents at risk for dementia.

Colorectal cancer (CRC) remains a priority health concern within the United States and globally, with rural residents disproportionately impacted. This study used the concept mapping approach to explore cultural issues affecting the use of CRC screening and inform future education and prevention efforts among agricultural operators.

Maternal morbidity and mortality in the USA are higher than in other developed nations and continue to rise. Infant mortality, likewise, is higher in the USA than in other developed nations. Limited availability of maternal health services, particularly in rural areas, contributes to this crisis. This protocol describes the evaluation of a USA government-funded project that seeks to address the shortage of quality maternity care in rural and underserved areas by strengthening partnerships, enhancing maternal care training of Family Medicine residents and obstetrics fellows, and improving the transition from training to rural practice for residents and fellows.

Rural Generalists (RG) provide holistic and complex medical care in multiple settings (eg general practice and hospitals) across the lifespan in rural and remote areas of Australia. RGs are frequently faced with making clinical decisions about whether patients can be managed locally or need to be transferred. This Original Research study explores RG therapeutic reasoning approaches in a simulated emergency scenario in the rural and remote context.

Health workers in rural and remote areas are called on to treat a large range of diseases, provide multiple health services, and perform a wide variety of procedures. All physicians undertake lifelong learning to maintain, develop or increase the knowledge, skills, professional performance and relationships used to provide services to patients, the public or the profession. Since the mid-1960s, many government and non-government organizations, including the World Health Organization, have conducted continuing education programs for rural health workers. This systematic review and meta-analysis examines the effectiveness of continuing education for health workers in rural and remote areas.

Community-level factors, such as urban–rural status and pre-existing economic conditions, may increase risk for severe COVID-19 (defined as hospitalization, admission to the intensive care unit, intubation, mechanical ventilation, or death). Rural populations have a higher prevalence of comorbidities associated with severe COVID-19 (eg obesity, diabetes, and heart disease) and less access to adequate testing and healthcare facilities than urban populations. However, COVID-19 is more transmittable in densely populated areas.This Original Research article adds to the evidence base surrounding the incidence of severe COVID-19 outcomes in rural and urban USA. Data from over the course of 2020 are explored for medically underserviced areas (MUA) and non-MUA in Minnesota and Montana. Findings, including a shift in greater incidence from urban to rural over the year, may significantly inform future pandemic response planning.

This article reports on a study conducted in partnership with a remote First Nation in northern Canada. The study utilised concept mapping to develop a framework for identifying gaps in oral health care for Indigenous youth. Findings of the concept mapping and framework development process can provide information on strategies to improve preventive oral health services for Indigenous youth living in rural and remote communities.

The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Sexual and gender minority people who live in rural areas are less likely to have had an HIV test in the past 12 months compared with those who live in non-rural areas. Using data from 508 participants, this Original Research article assesses the independent contribution of distance and time required to travel to receive an HIV test on recent uptake of HIV testing.

Although most countries struggle to deliver adequate healthcare resources and services to rural communities, resulting in poorer health outcomes for rural-dwelling people, little attention has been paid to the need for policy to address inequities in rural and urban service delivery. Rural proofing, the systematic application of a rural lens across policies to ensure they adequately account for the needs, contexts, and opportunities of rural areas, provides a strategy to ensure rural contexts are fully considered when designing health programs and interventions. Young healthcare professionals (HCPs) will be called upon to advocate for and lead the implementation of rural proofing efforts, so their perceptions, ideas, and knowledge of rural proofing are integral to the future of rural health care. This Original Research article explores the knowledge and understanding of rural proofing among young rural HCPs from around the world.

Non-communicable chronic diseases are a major global public health concern, with impacts including premature death and disability as well as high costs for health systems and society. The burden of these diseases tends to fall disproportionately on populations with greater social vulnerability. Despite this, little is known about the prevalence of chronic diseases in rural riverside populations in the Amazon, where people live their daily lives with the dynamics of the rivers, making a living by fishing and plant extraction. People in these populations experience socioeconomic and health vulnerabilities and have limited regular access to health services. This study investigates the prevalence and risk factors of hypertension and diabetes in a rural riverside population of the Brazilian Amazon.

 As doenças crônicas não transmissíveis são uma grande preocupação global de saúde pública, com impactos que incluem morte prematura e incapacidade, bem como altos custos para os sistemas de saúde e para a sociedade. A carga dessas doenças tende a recair desproporcionalmente sobre as populações com maior vulnerabilidade social. Apesar disso, pouco se sabe sobre a prevalência de doenças crônicas em populações rurais ribeirinhas da Amazônia, onde as pessoas vivem seu cotidiano com a dinâmica dos rios, vivendo da pesca e do extrativismo vegetal. As pessoas dessas populações vivenciam vulnerabilidades socioeconômicas e de saúde e têm acesso regular limitado aos serviços de saúde. Este estudo investiga a prevalência e os fatores de risco para hipertensão e diabetes em uma população rural ribeirinha da Amazônia brasileira.

Las enfermedades crónicas no transmisibles son un importante problema de salud pública mundial, con impactos que incluyen muerte prematura y discapacidad, así como altos costos para los sistemas de salud y la sociedad. La carga de estas enfermedades tiende a ser desproporcionadamente mayor en las poblaciones con mayor vulnerabilidad social. A pesar de esto, poco se sabe sobre la prevalencia de enfermedades crónicas en las poblaciones rurales ribereñas de la Amazonía, donde las personas viven su vida cotidiana con la dinámica de los ríos, ganándose la vida con la pesca y la extracción de plantas. Las personas de estas poblaciones experimentan vulnerabilidades socioeconómicas y de salud, y tienen un acceso limitado a los servicios de salud. Este estudio investiga la prevalencia y los factores de riesgo de hipertensión y diabetes en una población rural ribereña de la Amazonía brasileña.

Rural patients with a hand injury often receive initial hand surgery and rehabilitation in metropolitan or larger regional centres. Access to follow-up treatment for rural patients after the initial phase of care can be affected by transport options, distance, staff shortages and availability of hand therapists (occupational therapists or physiotherapists who have specialised skills in optimising functional use of the hand and arm after injury). After experiencing an increase in volume and complexity of hand therapy referrals, Toowoomba Hospital, a regional hospital in the Darling Downs Health Service (DDHS) in rural Queensland, Australia, found their existing model of care did not meet the needs of rural patients or therapists, risking poorer clinical outcomes. This Project Report describes the development and success of a new shared-care model by the DDHS – The Rural Hand Therapy Project – designed to better support rural hand therapists and rural patients in accessing follow-up hand therapy services closer to home.

Rural education during all levels of medical training has been found to promote careers in rural medicine but many rural health services are limited in their ability to fulfil the supervision requirements for all levels of learners (from student to fellowship). Medical students have been successfully rurally trained via Longitudinal Integrated Clerkships (LIC), during which they’re exposed to a range of clinical settings and disciplines, facilitating continuity of supervision over the clerkship duration. Portland District Health (PDH) is among the first health services in Victoria to implement this model of training for interns. This Project Report describes the novel internship program provided at PDH and explores the experiences of participants involved during the initial year.

Translating health research knowledge into practice and policy ensures that research results in real-world improvements in health practice, quality of care and health consumer outcomes. Health-professional-led research tends to address real-world practice issues and, therefore, the findings tend to be more readily translated into practice. However, capacity-building strategies are needed to support health professionals to engage in practice-based research and translation. This is particularly critical for rural and regional health services, which often exist in communities that experience poor health outcomes compared with urban communities. The authors of this article ask: what are rural health researchers’ perspectives on capability-building requirements for emerging researchers to enable the translation of research into health practice?

Near-peer learning (NPL), where learners proactively teach and learn with their peers and discuss questions with teachers, has been found to improve participation, collaboration and learning in medical education. In Japan, NPL applied in rural contexts has been found to improve motivation and self-directed learning in family medicine and community-based medical education (CMBE). However, a lack of psychological safety among peers and medical teachers (in part because of the professional hierarchy that exists among medical professionals) may impinge on the implementation of NPL in CBME. This study investigated the effects of NPL on the psychological safety and learning of medical trainees in rural CBME.

Frozen section pathology consultations during surgery are essential for determining breast cancer stage and informing breast cancer treatment. However, pathologists are in short supply in rural areas, which may delay treatment for rural-dwelling patients. One possible solution is performing remote intraoperative frozen section consultation using telepathology: sending whole-slide images of frozen sections to pathologists at other institutions during surgery to rapidly check the condition of a resected specimen. Previous preliminary studies have reported that remote intraoperative frozen section consultation has an accuracy of 92% or better. This study evaluates the feasibility of telepathology in the post-disaster setting of Fukushima, Japan, reporting on the accuracy of remote intraoperative frozen section consultation of breast cancer sentinel lymph node biopsy and the time required to introduce telepathology at a leading breast cancer institution.

In this invited Editorial, Dr Jon Griffin discusses rural and remote access to laboratory medicine and cancer histopathology services and the potential of digital pathology to transform rural and remote cancer pathology, providing faster diagnoses and building local expertise through training, mentorship and computer-aided diagnostics.

Amazonian riverside populations are characterized by living in close connection with the ebbs, flows and floods of rivers and relying on traditional methods for producing food. People in these populations typically have little access to basic resources, including health care. Research on food consumption by traditional non-indigenous populations is scarce, but it is thought that changing environmental and social conditions is resulting in less reliance on traditional food production and more reliance on grocery stores and cheap, ultra-processed foods with low nutritional value. This article analyzes the food consumption of a rural riverside population on the Rio Negro River, Manaus County, Northern Brazil.

As populações ribeirinhas da Amazônia caracterizam-se por viver em estreita conexão com as vazantes e cheias dos rios, bem como pela utilização de métodos tradicionais na produção de alimentos. Tipicamente, os indivíduos destas populações têm pouco acesso a recursos básicos, incluindo a atenção à saúde. São raras as pesquisas sobre o consumo alimentar de comunidades tradicionais não indígenas, entretanto, acredita-se que mudanças ambientais e sociais têm resultado numa redução da produção tradicional de alimentos e no aumento da dependência por supermercados e alimentos ultraprocessados baratos e de baixo valor nutricional. Este artigo analisa o consumo alimentar de populações rurais ribeirinhas do Rio Negro, no município de Manaus, Estado do Amazonas, norte do Brasil.

Las poblaciones ribereñas amazónicas se caracterizan por vivir en estrecha conexión con los cauces, corrientes y crecidas de los ríos; y depender de métodos tradicionales para producir alimentos. Las personas de estas poblaciones suelen tener poco acceso a los recursos básicos, incluida la atención médica. La investigación sobre el consumo de alimentos por parte de las poblaciones tradicionales no indígenas es escasa, pero se cree que los cambios en las condiciones ambientales y sociales están dando como resultado una menor dependencia de la producción de alimentos tradicionales y una mayor dependencia de las tiendas de comestibles y de los alimentos ultra procesados más baratos y con bajo valor nutricional. Este artículo analiza el consumo de alimentos de una población rural ribereña de Río Negro, municipio de Manaos, en el norte de Brasil.

Participation in international academic conferences provides social, emotional and intellectual growth among attendees, but equitable access to conferences remains an issue, especially for early career professionals and delegates from low- and middle- income countries. This report describes the success of a global project of the World Organization of Family Doctors (WONCA), the 'Rural Early Career Ambassador Integration' project, which was implemented for the 2022 World Rural Health Conference held at the University of Limerick, Ireland.

As a result of lockdown measures to control COVID-19, medical schools across the world adapted teaching and training methods. In many places, this involved a shift away from face-to-face teaching and the adoption of online and virtual learning. Rather than move online, the medical school of Stellenbosch University, South Africa, instead moved substantial components of clinical training away from the traditional urban tertiary academic medical centre and into regional and district hospitals. This study examined the perspectives of final phase students regarding the quality of their restructured training at distributed health facilities during the COVID-19 pandemic and compared the perspectives of rural site students with metropolitan site students.

In Australia, voluntary assisted dying (VAD) laws have passed in each state. As is the case with many health services, inequitable access to VAD within regional communities is a pressing concern. When designing and implementing VAD laws, Western Australia implemented several initiatives to mitigate regional inequities. This Original Research article draws on the early experiences and reflections of key stakeholders to report on regional provision of VAD in Western Australia and explore the effectiveness of the initiatives introduced.

This paper describes the outcomes of a decade-long Rural Community Internship Training (RCIT) Program in Victoria, Australia. The program comprises a year of internship training delivered in smaller rural communities, including up to 20 weeks’ general practice experience working with qualified rural generalist doctors and visiting specialists, along with 8–10-week terms in emergency, general medicine and surgery in nearby larger regional hospitals. Results suggest that up to 9 years post training, 61% of interns pursue General Practice, 40% currently work in the same region and 97% work at extended scope.

This Letter to the Editor reports on the success of an educational support system specifically designed for remote novice writers engaged in case-report writing. A remote writer was provided with lectures, available on demand, and tailored and personal workshopping and feedback using Google Docs. With this support, the writer was able to successfully focus, deepen and accelerate the writing process, despite their remote location.

The COVID-19 pandemic, one of the greatest challenges to societies and global health systems in the last hundred years, has necessitated an examination of the role and initiatives of primary health care. This scoping review identifies and synthesizes the individual and collective primary health care initiatives and innovations developed to face the COVID-19 pandemic in rural and remote areas around the world.

A pandemia de COVID-19, um dos maiores desafios no último século às sociedades e aos sistemas de saúde em todo o mundo, necessita de um exame sobre a contribuição de iniciativas da Atenção Primária em Saúde. Esta revisão de escopo identifica e sintetiza iniciativas individuais e coletivas desenvolvidas pela Atenção Primária à Saúde para enfrentar a pandemia de COVID-19 em localidades rurais/remotas pelo mundo.

La pandemia de COVID-19, uno de los mayores desafíos para las sociedades y los sistemas de salud mundiales en los últimos cien años, ha requerido un examen del papel y las iniciativas de la atención primaria de salud. Esta revisión sistemática exploratoria identifica y sintetiza las iniciativas e innovaciones individuales y colectivas de atención primaria de salud desarrolladas para enfrentar la pandemia de COVID-19 en áreas rurales y remotas de todo el mundo.\\\\\

Acute appendicitis is the most common general surgical emergency worldwide. Antibiotic treatment is considered safe and effective for uncomplicated appendicitis and appendectomy remains the preferred option for acute appendicitis in most cases; however, differentiation between these diagnoses can be difficult, particularly in rural or remote areas such as rural Tibet, which has a unique social and cultural landscape that might influence the clinical characteristics of appendicitis. This study investigated the clinical characteristics and applicability of the routine risk prediction models of acute appendicitis for rural Tibetan populations.

People living in rural areas often face health inequities as a result of limited access to healthcare resources and healthcare professionals. This Letter to the Editor describes how, while ChatGPT (a generative pre-trained transformer with a large language model foundation) cannot replace the expertise and personalized care provided by healthcare professionals during remote consultations, the AI tool might serve as a valuable virtual ally for health in remote communities in areas including healthcare information, health education and promotion, symptom triage and telemedicine, mental health support, health monitoring and reminders, language and cultural sensitivity, and data collection and public health surveillance.

Decreased function of musculoskeletal, cardiorespiratory and nervous systems as a result of aging can prevent elderly people from performing their daily activities. Assessment of physical performance can therefore help determine health interventions for this population, providing crucial information for the risk of future dependence, worsening or diagnosis of chronic diseases, risk of falls and other aspects of morbidity and mortality. However, people living in rural areas generally face greater difficulties in accessing health services and have poorer health conditions than people living in urban areas. This Original Research study tests the association of sarcopenia and physical performance with the use of primary health care services by elderly people living in rural riverside areas in the Amazon, Brazil.

A redução das funções dos sistemas musculoesquelético, cardiorrespiratório e nervoso como consequência do envelhecimento pode impedir indivíduos idosos de executar suas atividades de vida diária. A avaliação do desempenho físico pode fornecer informações relevantes sobre o risco de dependência, quedas, piora ou diagnóstico de doenças crônicas, dentre outros aspectos relacionados à morbimortalidade, podendo auxiliar na escolha de intervenções adequadas. Entretanto, moradores de áreas rurais têm maior dificuldade de acesso a serviços de saúde e piores condições de saúde em comparação aos moradores de áreas urbanas. Este estudo original avalia a associação de sarcopenia e desempenho físico com o uso dos serviços de atenção primária à saúde entre idosos moradores de áreas rurais ribeirinhas na Amazônia brasileira.

La disminución de la función de los sistemas musculoesquelético, cardiorrespiratorio y nervioso como resultado del envejecimiento puede impedir que las personas mayores realicen sus actividades diarias. Por lo tanto, la evaluación del rendimiento físico puede ayudar a determinar intervenciones de salud para esta población, proporcionando información crucial para el riesgo de dependencia futura, empeoramiento o diagnóstico de enfermedades crónicas, riesgo de caídas y otros aspectos de morbilidad y mortalidad. Sin embargo, las personas que viven en zonas rurales generalmente enfrentan mayores dificultades para acceder a los servicios de salud y tienen peores condiciones de salud que las personas que viven en áreas urbanas. Este estudio de investigación original describe la asociación entre sarcopenia y rendimiento físico con el uso de servicios de atención primaria de salud, por parte de personas mayores que viven en zonas rurales ribereñas del Amazonas, Brasil.

Supporting student clinical placements in rural and remote locations is a strategy to address health workforce shortages in rural and remote areas of the Northern Territory (NT), Australia. A commonly used method for determining post-graduation workplace location is an online survey, but response rates are typically very low. Another method is to use the publicly available postcode of residence of health professionals registered with the Australian Health Practitioner Regulation Agency (AHPRA). However, not all health disciplines that have clinical placements in the NT require professional registration. This Research Letter compares previously published workplace location outcomes derived from an online survey of a student cohort who completed a clinical placement in the NT with workplace locations based on recent AHPRA registration.

Sarcopenia, the gradual loss of muscle mass, strength and function with age, and back pain both directly impede the daily activities of older people, increasing their time spent in bed and shortening their healthy lifespan. Prevention and treatment are therefore crucial in reducing medical expenses and enhancing quality of life. Older individuals living in rural areas can experience different daily activity levels, occupations, and environmental factors from those living in urban areas. In some countries, older women in rural areas have been reported to have greater handgrip strength and walking speed, but a higher prevalence of back pain, than older women in urban areas. This Original Research article investigates the correlation between sarcopenia and spinal function in older women living in a rural area (Sunchang County, Korea).

Self-measured blood pressure monitoring (SMBP) has been used successfully to manage hypertension amongst rural patients in multiple nations. This work provides a mid-point assessment of a SMBP program in West Virginia, USA, a highly rural Appalachian state where population rates of hypertension exceed the national average. Results suggest that when integrated into clinician workflows, SMBP significantly reduces the number of patients with uncontrolled hypertension; these findings were consistent across patient sex, zip code, and clinic location.

The Galapagos Islands were a model of successful COVID-19 management from the developing world. The Galapagos experience can teach important lessons to the local, regional and international public health community: even in communities where resources may be limited, the intersection of academia, local governance, and proactive strategies can dramatically uplift health outcomes and safeguard populations. The unwavering commitment to protecting both inhabitants and visitors has solidified the islands' stance as a paragon for public health management in the face of global adversity.

As Ilhas Galápagos foram um modelo de sucesso na gestão da COVID-19 entre países em desenvolvimento. A experiência de Galápagos pode trazer importantes contribuições à Saúde Pública nos níveis local, regional e internacional: mesmo em comunidades onde os recursos podem ser limitados, a intersecção entre academia, governança local e estratégias proativas podem melhorar drasticamente os resultados em saúde e proteger as populações. O inabalável comprometimento para a proteção de moradores e visitantes consolidou as Ilhas Galápagos como um modelo de gestão em Saúde Pública diante de uma adversidade global.

En las Islas Galápagos se aplicó un modelo de gestión exitosa de la COVID-19 en el contexto de países en vías en desarrollo. La experiencia de Galápagos deja lecciones importantes a la comunidad de salud pública local, regional e internacional: incluso en comunidades donde los recursos pueden ser limitados, la intersección de la academia, la gobernanza local y las estrategias proactivas pueden mejorar drásticamente los resultados de salud y salvaguardar a las poblaciones. El compromiso inquebrantable de proteger tanto a los habitantes como a los visitantes, ha consolidado la postura de las islas como modelo de gestión de salud pública frente a la adversidad globalque significo la Pandemia.

Many countries have national infectious disease surveillance systems but these can be hampered by limited timeliness, representativeness and sensitivity and therefore might miss local outbreaks that occur in small communities. This study reports on the development and implementation of a voluntary, local community-based ophthalmology sentinel surveillance system in Isa city, a rural area in Japan.