Volume twenty-one, Issue 3

The medical literature is replete with examples of studies about groups in which researchers from the ‘outside’ present and discuss their findings without any reflection of the views of those who have been researched. RRH has taken the decision that an article about people in any country or region without authors from that country or region will not be published and a recent RRH article provides an excellent example of how communities can be meaningfully engaged in research. This Editorial is a call to the international health science community to develop and adopt research and publication policies so that there is “nothing about us without us”.

The mental strength to venture, persevere and act out of concern for one’s patient, despite lack of formally recognised expertise, is often necessary for rural doctors, who work in geographical and professional isolation. This study explores in depth how relationships with others can impact on the clinical courage of rural doctors.

Expanding community pharmacists’ scope of practice in rural and remote locations has the potential to improve access to health care and improve health outcomes. Internationally, a lack of support from other health professionals has presented a barrier to the uptake of expanded pharmacy models. Limited data on expanded practice from Australia prompted this study to explore Australian rural and remote doctor, nurse and allied health perspectives of expanded pharmacy services in non-metropolitan settings.

Working in emergency medicine in rural areas may entail challenges due to the absence of medical backup, difficulties in logistics, lack of healthcare system coordination and, potentially, feelings of loneliness. This study elucidates the experiences of physicians working in an emergency medical setting in a rural area in northern Sweden.

It is common for elderly people to experience functional decline due to a general physiological and metabolic decline and the accumulation of health threats throughout their lives. East and Southeast Asia are home to a large proportion of the world’s elderly population and 46.5% of people aged 65 and over in Indonesia have some form of disability. This study examined urban–rural differences in the functional status and disability of elderly people in Indonesia.

This case-series study describes how a small rural healthcare system managed COVID-19 patients admitted between March and May, 2020. The authors describe their "hub and spoke" approach to best utilize scarce system resources, the assembly of a multidisciplinary clinical team to manage patients admitted and the challenges faced in adapting to the rapidly changing standards of care. The authors describe how a small team of generalist physicians and others can, in a crisis, provide a level of care comparable to that found in academic centers. They conclude that the development of strong clinical and research networks will help equip rural areas to respond not only to current and future pandemics, but more broadly to emerging care delivery challenges.

Remote area nurses often work in isolated and extreme geographical locations, alongside and with Aboriginal and Torres Strait Islander people. This study investigated what remote area nurses perceived were enablers and barriers to being involved in the delivery of care to an Aboriginal person with a terminal diagnosis passing away on their traditional lands.

Sepsis, a life-threatening organ dysfunction caused by a response to infection, is a leading cause of death and hospitalisation worldwide. This study explores the demographic characteristics, disease specifics and outcomes of adult patients with suspected sepsis presenting to a remote Australian Emergency Department.

Physician shortages in rural and remote areas challenge accessibility and delivery of care to rural and remote communities, including within Scotland. Whilst there is evidence to support aspects of medical education that enhance the likelihood of practicing rurally, the mechanism by which these educational initiatives work is not clearly understood. Using a theoretical framework exploring career embeddedness, mobility and success, this study examines medical students’ perceptions of rural and remote practice. It also explores how these perceptions motivate their interest to practice rurally and what aspects of education are thought to influence these perceptions.

This study examined whether social support, problem solving and family function predicted depressive symptoms, caregiving-related life changes, self-care and caregiver burden in rural heart failure caregivers. It also compared differences in these variables between rural and urban caregivers. Findings suggest important considerations for reducing burden and improving outcomes for rural heart failure caregivers.

The management and prevention of chronic conditions is a challenge for primary care providers across Europe, and particularly in rural areas where people are less likely to be able, or willing, to have access to appropriate (well-equipped and well organised) health care. Research is needed to develop equitable chronic care models that focus on stakeholder needs, including those of individual patients, caregivers and primary care professionals. This study used a mixed-methods, online survey to determine the views of European Rural General Practitioners regarding the strengths, weaknesses, opportunities and threats of the implementation of a Chronic Care Model (CCM) in European Rural Primary Care.

The number of maternal deaths remains high in sub-Saharan Africa. Although improved antenatal care (ANC) service provision has been prioritized across the region, research is limited on the ANC experiences of Indigenous women. This study describes ANC attendance patterns at a hospital, and characterizes factors influencing attendance among Bakiga and Indigenous Batwa women in Kanungu District, Uganda.

Despite significant progress in the last decade, Greece still deals with a large number of road traffic accidents every year. This study provides an epidemiological approach to road traffic injuries presenting to a secondary hospital in a geographical area with a very low quality road network, and indicates possible preventive measures and actions.

Water is crucial for food security and health, but fewer than 40% of rural households in Brazil are connected to the water distribution network. Boardwalk Cisterns is a rainwater harvesting program that provides clean water for populations with precarious access to water in Brazil. This study reports on the perceptions of farmers about the impact of the Boardwalk Cisterns program in the northeast, semi-arid region of the country.

A água é crucial para a segurança alimentar e saúde, mas menos de 40% das famílias rurais no Brasil estão conectadas à rede de distribuição de água. O Cisternas Calçadão é um programa de captação de água da chuva que fornece água potável para populações com acesso precário à água no Brasil. Este estudo relata a percepção de produtores rurais sobre o impacto do programa Cisternas Calçadão na região semi-árida do Nordeste do país.

Rural areas in Brazil still have worse health indicators than urban areas and there are several barriers to accessing primary health care that can encourage users to seek alternative care. In a medical anthropology framework, each health system consists of three interrelated subsystems: informal, popular and professional, widely used in an overlapping and non-exclusive way, interacting according to the individual’s needs. This study analyses how informal and popular health subsystems are featured in a remote rural municipality in the Brazilian Amazon region.

Las áreas rurales en Brasil tienen peores indicadores de salud que las áreas urbanas y existen varias barreras para acceder a la atención primaria de salud que pueden alentar a los usuarios a buscar cuidados alternativos. En el marco de la antropología médica, cada sistema de salud consta de tres subsistemas interrelacionados: informal, popular y profesional, ampliamente utilizados de manera superpuesta y no exclusiva, interactuando de acuerdo con las necesidades del individuo. Este estudio analiza cómo los subsistemas de salud informal y popular se presentan en un municipio rural remoto en la región Amazonia Brasileña.

As áreas rurais no Brasil ainda apresentam piores indicadores de saúde do que as áreas urbanas e existem várias barreiras para o acesso à atenção primária à saúde que podem incentivar os usuários a buscar cuidados alternativos. Para a antropologia médica, cada sistema de saúde é composto por três subsistemas inter-relacionados: informal, popular e profissional, amplamente utilizados de forma sobreposta e não exclusiva, interagindo de acordo com as necessidades do indivíduo. Este estudo analisa como subsistemas de saúde informais e populares são apresentados em um município rural remoto da região amazônica brasileira.

Facemasks are widely recommended as a COVID-19 prevention strategy, but decisions to wear a mask depend on multiple factors. While surges in cases within rural communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. This study examined the relationship between county-level indicators of rurality and mask wearing.

Immunization is one of the most cost-effective methods for reducing the mortality and morbidity rate of children. Children being fully vaccinated helps prevent the occurrence of diseases that would have great societal costs otherwise. Incomplete vaccination poses public health risks and challenges. This study examines the issue of incomplete vaccination in Indonesia.

While cancer deaths have decreased nationally, declines have been much slower in rural areas compared with urban areas. This cross-sectional study explored the association between breast cancer service capacity, and breast cancer incidence and mortality, in Arizona’s low populous counties. Compared to urban counties, rural county status was associated with lower breast cancer incidence rates, although there were no statistically significant differences in breast cancer mortality. These findings may reflect the challenges of using county level data, particularly per capita data, in a state where counties average over 7500 square miles.

Physical therapists (PTs) play an important role in managing patient health needs in many rural areas, but are affected by healthcare provider shortages. This study examined values that differentiated PTs who accept and maintain employment in rural areas, as a means of advising health agencies within these designation areas. Findings may be useful for understanding effective recruitment and retention of PTs in rural and remote areas.

The Cooperative Extension System (a national US education network) was used to implement the Balanced Living with Diabetes (BLD) program in rural counties in Virginia. This study evaluated the implementation and effectiveness of the BLD program in 16 rural counties over two years. The program is effective at increasing lifestyle behaviors and self-efficacy that improves glycemic control in people with type 2 diabetes. The Cooperative Extension System in the US is well positioned to fill the gap in diabetes education in rural communities as part of a chronic care model.

To reduce the spread rate of COVID-19, distance education was initiated in all universities in Turkey in March, 2020. However, distance learning had never before been implemented in physical therapy and rehabilitation education. This study reports on the attitudes of Pamukkale University Physical Therapy and Rehabilitation undergraduate students towards distance learning during the COVID-19 outbreak.

This study used data from the Canadian Longitudinal Study on Aging to examine life satisfaction in rural residents, and compare this with life satisfactions of residents across the urban/rural continuum. The authors found that rural residents were generally more satisfied with life than their urban counterparts, even after accounting for the effects of sociodemographic and health-related factors. Prevention or treatment of chronic conditions and reducing income inequalities might contribute to increasing life satisfaction in rural and urban populations.

In various countries, a shortage of general practitioners (GPs) and worrying health statistics on risk factors, morbidity and mortality have been observed in rural areas. However, few comparative data are available on GPs’ activities according to their location. This study analyzed French GPs’ activity according to their rural or urban practice location.

Adolescent pregnancy remains a thorny issue in developing countries, including Indonesia. Pregnancy at an early age is a risk factor for maternal and infant mortality. A recent report indicates that adolescent pregnancy is even higher in rural areas. This study identifies factors associated with adolescent pregnancy in rural Indonesia and formulates intervention actions to reduce the teenage pregnancy rate.

It is critical that those working with Aboriginal and Torres Strait Islander communities engage in culturally safe practice by acknowledging and understanding the impacts of trauma. In this Commentary, the authors examine the origins of cultural safety as a recommended practice for working with Indigenous peoples, demonstrating its flaws and shortcomings in practice and argue that without an understanding of the impacts of trauma, ‘ticking the box’ of cultural safety training simply is not enough to achieve equity in Indigenous health outcomes.

The COVID-19 pandemic has forced a change in medical education in Israel. Clinical clerkships were suspended and lectures were delivered online, via Zoom. Tutors were able to teach from their wards and students were able to learn safely in their homes.

Point-of-care ultrasound is a rapidly evolving technology that enables rapid diagnostic imaging to be performed at the patients’ bedside, reducing time to diagnosis and minimising the need for patient transfers. This has significant applications for rural emergency and general practice, and could potentially prevent unnecessary transfers of patients from rural communities to more urban centres for the purpose of diagnostic imaging, reducing costs and preventing disruption to patients’ lives.

Grey nomads are people over the age of 55 who travel in caravans or motorhomes for extended periods of time around rural and remote areas of Australia. Although grey nomads are challenging the established view of ageing in Australia, some evidence suggests that they exert a significant burden on rural health services. This scoping literature review explored the characteristics and behaviours of grey nomads, many of whom live and travel with diabetes.

Community health workers (CHWs) connect patients in rural and remote communities to health service organizations. This diverse group of healthcare workers have aided in improving healthcare access and outcomes and enhancing the quality of life for people in hard-to-reach communities. This systematic review examines the socio-cultural challenges that CHWs experience, focusing on the unique history, geography and socio-cultural milieu of South Asia.

According to the World Health Organization, there are more than 800,000 deaths by suicide every year. Of these, 20% are from pesticide poisoning and 80% occur in low- and middle-income places, especially in rural and agricultural areas. This study investigates which countries have the most publications about suicide among agricultural workers, examines the factors that lead to either suicide or intent, identifies the methods of suicide or attempted suicide and proposes preventive measures so that rural agricultural workers are not exposed to risk factors for suicide.

De acordo com a Organização Mundial da Saúde, ocorrem mais de 800.000 mortes por suicídio a cada ano. Destes, 20% são por intoxicação por agrotóxicos e 80% ocorrem em locais de baixa e média renda, principalmente em áreas rurais e agrícolas. Este estudo investiga quais países têm mais publicações sobre suicídio entre trabalhadores agrícolas, examina os fatores que levam ao suicídio ou ideação suicida, identifica os métodos de suicídio ou tentativa de suicídio e propõe medidas preventivas para que os trabalhadores agrícolas rurais não sejam expostos a fatores de risco para suicídio.

Complicated appendicitis poses a diagnostic challenge in clinical practice, especially in rural centres with limited access to subspecialists and imaging facilities. This Clinical Case Report describes a case of a perforated appendix in a 9-year-old patient considered in the context of hyperbilirubinemia that facilitated prompt surgical management after appropriate imaging.

Regular antivitreal injections are an important treatment for diabetes-related blindness caused by macular oedema. Barriers to antivitreal treatment for rural Australian patients include travel time to appointments, especially as patients face a high volume of other medical appointments for their diabetes and related co-morbidities. This audit addresses intravitreal injection compliance by identifying patients lost to follow up in north west Western Australia.

Unpaid carers play a crucial role in supporting older people with cognitive impairment and disability, but their own health and wellbeing is often impacted in this role. There are limited data on how carer strain, depression and empowerment may be improved for carers. This study investigates the effectiveness of a carer support program developed with a community-based participatory action research approach in four remote Aboriginal communities in Western Australia.

Public health agencies around the world are concerned about the ever-increasing burden of type 2 diabetes and related disability. This study examines patterns of primary care provider use among people with and without diagnosed diabetes in a large survey of over 230,000 people in New South Wales, Australia.

A motivated, well supported rural health work force is required to provide appropriate child health services to the rural population. This study explored the views of rural health workers on the impact of a programme to improve oxygen delivery systems and provide reliable power to their health facilities in Papua New Guinea.

This Short Communication reports on the first investigation of a waterborne outbreak of Escherichia coli in Greece performed with the collaboration of a local pharmacy. The COVID-19 pandemic favored the use of alternative resources and channels of communication with the local population that can also be used in the future, especially in remote areas of the country.

Previous long-term research designed to address the inequitable distribution of health workforce has primarily focused on medical students and graduates. Few longitudinal studies have targeted nursing and allied health graduate practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is an ongoing multi-university, multi-jurisdictional investigation linking multiple data sources to better understand Australian nursing and allied health students and graduates’ choice of graduate practice location over the course of their studies and up to 10 years after graduation.

Rural residents with opioid use disorder often lack access to specialized services integrating opioid agonist therapy with counselling, social support and mental health care. This project report describes the evaluation of a Rural Opioid Outpatient Treatment (ROOT) pilot program in Ontario, Canada. The pilot project demonstrates that outpatient substance use treatment can be successfully integrated into a rural primary care setting. The authors share lessons learned, including the need for polysubstance support and the value of a harm-reduction approach in creating a safe space for program participants to engage with their healthcare providers.

Rural and remote children with burn injuries are disadvantaged if their burns require hospitalisation and specialist rehabilitation. In Queensland, Australia, most specialist burn rehabilitation is provided in regional or metropolitan cities by a multidisciplinary team, requiring rural and remote patients to travel. This project reports on the development of an Occupational Therapy-Led Paediatric Burn Telehealth Review Clinic at Townsville University Hospital to provide ongoing rehabilitation to rural and remote children closer to home.

Research within Aboriginal and Torres Strait Islander communities has not always been conducted ethically or with tangible benefits to those involved. Having a deep understanding of the ethical principles of research with Torres Strait communities is more than just ticking the boxes on ethics approvals. Genuine community involvement is paramount in conducting research with the communities and only then will research be relevant to community needs, culturally appropriate and facilitate the translation of knowledge into practice.

Safe drinking water and effective sanitation in remotely located Indigenous communities are essential services and their provision is a human right. Yet sustainable provision of these services can be challenging. This narrative review identifies five key enablers to effectively and sustainably provide essential water and sanitation services to remote Indigenous communities.

The Highlands and Islands Medical Service (HIMS) was introduced across the Scottish Highlands and Islands after the publication of the Dewar Report in 1913, which found that there was insufficient healthcare provision in the region. HIMS was the first state-funded medical service in the UK and one of the first in the world. This historical study addresses the ways in which support for new transport and telecommunication technologies contributed to the success of HIMS.

Farmers are thought to have a higher risk of skin cancers, but there is no direct evidence of this risk, and some population evidence of no greater risk to farmers of melanoma. The agricultural region of the Darling Downs in Queensland, Australia has the highest incidence of skin cancer in the State. This study defines the specific occupation risk for skin cancer among Darling Downs farmers compared with other community residents.