Volume twenty-four, Issue 3

To lower Indonesia's maternal and infant mortality rates, the Indonesian government encourages women to give birth in medical buildings (eg. hospitals and health centers). However, in several remote and underdeveloped provinces, use of these services remains low due to unequal access to transportation and communication across the Indonesian archipelago. Maternity waiting homes, places or rooms located near a health center or hospital that can be used by pregnant women and their families for several days pre-labor and post birth, have been introduced to help address these challenges. This Original Research article investigates the use of maternity waiting homes and their impact on increasing institutional deliveries in remote island regions of Indonesia.

Pregnancy increases the requirement for iodine by at least 50%. Severe iodine deficiency during pregnancy can result in maternal and fetal hypothyroidism and serious adverse health effects. Birth weight can be affected by slight variations in normal maternal thyroid hormone levels and excess iodine in the diet of pregnant women can induce factitious hyperthyroidism. The few studies available in Latin America have been limited to children in metropolitan areas and did not consider pregnant women in non-metropolitan areas. This Original Research article reports on the prevalence of goiter, iodine deficiency and intrauterine growth restrictionin Indigenous and Afro-descendant pregnant women in six non-metropolitan areas of Colombia.

A gestação aumenta a necessidade de iodo em pelo menos 50%. A deficiência severa de iodo durante a gestação pode resultar em hipotireoidismo materno  e fetal com sérios efeitos adversos à saúde. O peso ao nascer pode ser afetado por pequenas variações nos níveis do hormônio da tireoide e o excesso de iodo na dieta pode induzir ao hipertireoidismo fictício. Os poucos estudos disponíveis na América Latina são limitados a crianças de áreas metropolitanas e não consideram gestantes de áreas não metropolitanas. Este estudo original apresenta a prevalência de bócio, deficiência de iodo e restrição do crescimento intrauterino em gestantes indígenas e afrodescendentes de seis áreas não metropolitanas da Colômbia.

El embarazo aumenta el requerimiento de yodo al menos un 50%. La deficiencia grave de yodo durante el embarazo puede provocar hipotiroidismo materno y fetal, y graves efectos adversos para la salud del binomio. El peso al nacer puede verse afectado por ligeras variaciones en los niveles normales de hormona tiroidea materna y el exceso de yodo en la dieta de las embarazadas, puede inducir hipertiroidismo ficticio. Los pocos estudios disponibles en América Latina se han limitado a niños en áreas metropolitanas y no consideraron a las embarazadas en áreas no metropolitanas. Este artículo de investigación original informa sobre la prevalencia de bocio, deficiencia de yodo y restricción del crecimiento intrauterino en embarazadas indígenas y afrodescendientes en seis áreas no metropolitanas de Colombia.

Inequitable access to primary health care accounts for much of the health gap between Aboriginal and Torres Strait Islander Peoples and the broader Australian population. Innovative, culturally safe strategies to improve access to high-quality chronic-disease care and prevention are needed to address these disparities. Medicare-rebated Indigenous-specific health assessments, or the Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule Item 715), known as ‘715 health checks’, have been introduced to improve preventative health opportunities and reduce rates of undetected risk factors among Aboriginal and Torres Strait Islander Peoples. Uptake of 715 health checks and follow-up services has been poor to date, prompting the trial of programs that deliver 715 health checks in community events, or ‘Health Check Days’. This Scoping Review explores how community events have been used to increase uptake of Indigenous-specific health assessments.

Maternal morbidity and mortality rates in the USA have increased over the past several decades. The closures of many rural hospital obstetric services across the country between 2004 and 2014 has resulted in greater traveling distances for rural women to access obstetric care, and approximately 25% of rural women give birth at non-local (often urban) hospitals. For rural patients, it is unclear whether delivering at an urban facility is protective against maternal morbidity. This Original Research article compares obstetric outcomes for rural people giving birth in urban and rural hospitals.

This Original Research article presents findings on the long-term impacts of Community Water Fluoridation (CWF) on dental caries in children living in remote and very remote Northern Territory (NT), Australia. Dental caries is one of the most prevalent and preventable diseases among Australian children. Untreated dental caries causes pain, distress, illness and is a leading cause of preventable hospitalisation. Children in the NT experience a higher prevalence and severity of dental caries than children who live in other parts of Australia.  Aboriginal children residing in remote and very remote areas of NT are disproportionately impacted by dental caries compared with non-Aboriginal children. Although CWF is a widely recommended public health intervention to reduce dental caries, the NT has a higher proportion of the population without access to fluoridated drinking water (22%) than the national average (11%).This study yields important findings to underpin government policymaking and public health investment using a life course approach to the prevention of dental caries at a population level.

Men located in rural areas experience a disproportionate level of burden from alcohol and other drug (AOD) use. This is exacerbated by limited access to AOD services in rural areas. One positive development from COVID-19 has been the increased uptake of virtual care, which has expanded the reach of AOD and other services. Self-Management and Recovery Training (SMART Recovery) mutual-help groups, which incorporate principles and strategies from cognitive behavioural therapy and motivational interviewing, are readily available in a virtual format and free to access. This Short Communication reports on the similarities and differences between the experiences of rural and urban men attending online SMART Recovery groups.

Nurses represent almost half of the worldwide health workforce and play a critical role in providing health care, from tertiary through to primary and community-based settings. The inadequate size of the nursing workforce has fundamental consequences for the accessibility and quality of health care provided to communities. It also detrimentally affects the health and wellbeing of the existing nursing workforce and damages community perceptions of health services, further exacerbating attrition and the acceptability and utilisation of health services. This article reviews existing literature that reports rural and remote nurses’ views on what informs the attraction, retention and resignation of the rural and remote nurse workforce.

The emergence of COVID-19, caused by SARS-CoV-2, caused an unprecedented worldwide public health crisis leading to high fatality rates and healthcare system collapse. Less than a year after the first confirmed case of COVID-19 in Ecuador in February 2020, a rate of more than 166 additional deaths per 100 000 people was reported, one of highest rates of COVID-19-related deaths during the first wave in the world. Some communities, particularly those in the Amazon Basin, are highly endangered and vulnerable to public health threats like COVID-19 due to their extreme isolation and inadequate health infrastructure. In Ecuador, Indigenous Peoples make up about 7% of the total population and are primarily located in underserved rural communities. This Original Research article presents the results of a retrospective cross-sectional study of the demographics and SARS-CoV-2 detection rate and viral loads during the first wave of the COVID-19 pandemic in 21 Indigenous communities from Ecuadorian Amazonia, including isolated and endangered Waorani, Siona, Kichwa, Kofan and Shuar communities.

La aparición de COVID-19, causada por el SARS-CoV-2, provocó una crisis de salud pública mundial sin precedentes que condujo a altas tasas de mortalidad y al colapso del sistema de atención de salud. Menos de un año después del primer caso confirmado de COVID-19 en Ecuador en febrero de 2020, se informó una tasa de más de 166 muertes adicionales por cada 100,000 personas, una de las tasas más altas de muertes relacionadas con COVID-19 durante la primera ola en el mundo. Algunas comunidades, en particular las de la cuenca amazónica, están en gran peligro y son vulnerables a amenazas de salud pública como COVID-19 debido a su aislamiento extremo y a una infraestructura sanitaria inadecuada. En Ecuador, los pueblos indígenas representan alrededor del 7% de la población total y se encuentran principalmente en comunidades rurales desatendidas. Este artículo de investigación original presenta los resultados de un estudio transversal retrospectivo con las características demográficas, la tasa de detección del SARS-CoV-2 y las cargas virales durante la primera ola de la pandemia de COVID-19 en 21 comunidades indígenas de la Amazonía ecuatoriana, incluidas aquellas aisladas y en peligro de extinción: Waorani, Siona, Kichwa, Kofan y Shuar.

A emergência da COVID-19, causada pelo SARS-CoV-2, causou uma crise sem precedentes na saúde pública mundial que levou a altas taxas de mortalidade e colapso dos sistemas de saúde. No Equador, menos de um ano após o primeiro caso confirmado de COVID-19, em fevereiro de 2020, foi relatado um excesso de mortalidade de mais de 166 mortes por 100.000 habitantes, uma das mais altas taxas de mortalidade por COVID-19 do mundo na primeira onda. Devido ao seu isolamento extremo e inadequada infraestrutura de saúde, algumas comunidades, particularmente as da bacia Amazônica, são altamente vulneráveis a ameaças à saúde pública como a COVID-19. No Equador, os povos indígenas correspondem a 7% da população, e estão basicamente localizados em comunidades rurais carentes. Este artigo original apresenta os resultados de um estudo transversal retrospectivo sobre a demografia e a taxa de detecção e carga viral do SARS-CoV-2 na primeira onda da pandemia de COVID-19 em 21 comunidades indígenas da Amazônia Equatoriana, incluindo as comunidades ameaçadas e isoladas de Waorani, Siona, Kichwa, Kofan e Shuar.

Colonization and assimilation policies have disrupted the intergenerational transfer of knowledge, which has deeply affected the health and well-being of Indigenous peoples, particularly in areas such as food security and environmental stewardship. The practice of harvesting Niska (goose) is integral to Omushkego Cree cultural traditions, reflecting a holistic approach to health that connects Indigenous knowledge, community well-being, and resilience. In Fort Albany First Nation, women play an important role in preserving the tradition, which provides a nutritious, cost-effective food source, supports the management of overabundant geese populations, and sustains the transmission of linguistic and cultural knowledge. Despite the importance of land-based activities in supporting Indigenous health, there is a need for more studies that center the perspectives of Cree women. This study aims to fill that gap by presenting the insights of Omushkego Cree women who have participated in the Niska program.

Shortages and maldistribution of the general practitioner (GP) workforce, and the subsequent impact on healthcare access and delivery, are long-standing concerns in Australian primary health care, particularly in rural and remote GP practices, where these issues are compounded by professional isolation, uncompetitive remuneration, and viability challenges. Although remuneration, workload and location-related issues of lifestyle, spousal employment and child education are factors in GP retention, characteristics of practice work-tasks may also have a role. This Original Research article analyses the prevalence and associated practice factors involved in the retention of GP registrars in their training practices.

A severe economic crisis and recent global conditions, including the global COVID-19 pandemic, have highlighted the importance of the role of primary health care (PHC), especially in low and middle-income countries. Patient perception of quality of care is an essential component in evaluating health-care delivery. This Original Research article reports on data from PHC Centers in Greece before the last PHC reform, undertaken to offer baseline information about patient experience, support the decision-making processes taking place, and provide valuable input for future policy-making comparisons in Greece.

Remote health services in Australia struggle to recruit and retain enough skilled, dedicated staff to provide a stable service. In very remote primary health clinics, small teams of Remote Area Nurses (RANs), Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers provide or facilitate all health care for their local community. Poor personal safety has been identified as a contributing factor to burnout and high turnover of staff and is linked to reduced quality of patient care. Many Work Health and Safety (WHS) recommendations and strategies have been developed for the remote health sector in Australia but there is very little evidence of their implementation. This Original Research study investigates which WHS recommendations have been implemented in very remote primary health clinics in Australia, from the perspectives of RANs.

The increasing proportion of older adults in the world demands greater attention to healthy aging. Sarcopenia, an age-related decline in musculoskeletal system function, can lead to adverse health outcomes and higher health system costs, but inconsistencies in assessment tools means that there is limited clear knowledge about its prevalence. This Original Research article reports on the prevalence of sarcopenia and its associated factors among rural older adults in Brazil using European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria.

O aumento da proporção de idosos no mundo demanda grande atenção para o envelhecimento saudável. A sarcopenia, um declínio na função do sistema musculoesquelético, pode levar a desfechos adversos à saúde e a altos custos aos sistemas de saúde. Contudo, inconsistências nas ferramentas de avaliação indicam que não há clareza quanto à sua prevalência. Este artigo original apresenta a prevalência e os fatores associados à sarcopenia em idosos rurais do Brasil, utilizando o critério do Grupo de Trabalho Europeu sobre Sarcopenia em Idosos 2 (EWGSOP2).

La creciente proporción de adultos mayores en el mundo exige una mayor atención al envejecimiento saludable. La sarcopenia, un deterioro de la función del sistema musculoesquelético relacionado con la edad, puede conducir a resultados adversos y mayores costos del sistema de salud. Por otro lado, las inconsistencias en las herramientas de evaluación nos muestran que existe un conocimiento limitado sobre su prevalencia. Este artículo de investigación original informa sobre la prevalencia de la sarcopenia y sus factores asociados entre los adultos mayores rurales de Brasil utilizando los criterios del Grupo de Trabajo Europeo sobre Sarcopenia en Personas Mayores 2 (EWGSOP2).

Household food insecurity (HFI) describes inadequate food access, availability, and utilization due to insufficient financial resources and is an important social determinant of health. Other aspects of food security, such as the availability of, and physical access to, healthy foods, are uniquely challenging to achieve in remote regions. This Scoping Review provides a unique global exploration and comment on the literature surrounding HFI in remote and circumpolar remote communities. Through examining initiatives and outcomes that have been conducted to decrease HFI, and factors that contribute, a fulsome picture of the current evidence is created and critiqued. Suggestions both regarding further research, as well as informing current policy based on work done thus far, are made.

Ambulance Services within Australia frequently use a combination of first responders, volunteer ambulance officers (VAOs), registered paramedics, critical care/extended care paramedics and aeromedical rescue services. In rural regions, emergency care may be provided by a blended service of paramedics and VAOs or a complete VAO model. Many maternity units have been centralised to larger regional centres, impacting accessibility of antenatal care for rural and remote communities. Longer travel times are associated with increased risk of out-of-hospital births (OOHBs) and life threatening complications such as postpartum haemorrhage and neonatal mortality.

Registered paramedics perceive a lack of adequate training, exposure and confidence with managing OOHBs, but there is limited research about VAO experiences. This Original Research study investigates VAO perceptions of training, experience and confidence regarding management of unplanned OOHBs.

Australia’s medical workforce problem is primarily one of maldistribution, with both the geographic distribution of doctors and the relative supply of medical specialities not currently meeting the health needs of Australian rural communities. Recent studies from Australian universities that have prioritised recruiting students from the region in which they are located, rather than just the ASGS-RA or MM classifications, have demonstrated promising results for ‘grow your own’ workforce strategies, with students who grew up and also trained in a region being up to 17 times as likely to work in the same region after graduation. With growing evidence supporting strategic ‘grow your own’ approaches to recruiting, training and retaining health professionals from and for underserviced rural communities, there is a need for sound methodologies by which universities with a social accountability mandate can accurately describe their region of rural focus, or ‘footprint’. This Project Report describes the process, outcomes and lessons learned through a project undertaken to formally describe Deakin University’s rural health activity footprint.

Pakistan's government and development organizations aim to accomplish equitable access to family planning services by 2030, in line with Sustainable Development Goals, by enhancing the availability and quality of family planning services, increasing awareness and education, and addressing cultural and social barriers. These endeavors are anticipated to support reproductive health outcomes and lower maternal and infant mortality rates in Pakistan. A first crucial step in facilitating the development of effective policies and programs is to understand the diversity of fertility patterns, family planning preferences, and behaviors that exist. This Original Research article examines the factors influencing contraceptive use and family planning behaviors in rural and urban regions of Pakistan.

Magnesium is required for almost all body system functions, including cardiovascular, neurological, endocrine, musculoskeletal and immune systems. Dysmagnesemia, or disorder in serum magnesium levels (hypermagnesemia or hypomagnesemia), is associated with poor health outcomes in hospitalised patients, including the need for longer hospital stays and increased risk of mortality. This register-based study assessed the prevalence of dysmagnesemia and associated health outcomes among hospitalised patients in the Northern Territory, Australia.

Discharge against medical advice (DAMA), when a patient chooses to discharge themselves before their recommended treatment is complete, occurs in only a small fraction (<2%) of total hospital admissions in Australia but is linked with significant human and financial cost (eg higher rates of mortality and morbidity and significantly higher healthcare costs than non-DAMA cases). Reducing rates of DAMA is therefore an important goal in health service improvement. Factors associated with DAMA include a mix of patient, health service and environmental factors, and can be compounded in rural and remote areas, where health workforce shortages are common. Because a DAMA event signifies a potential breakdown in the patient-provider relationship, perspectives of both patients and providers are important to understand current practice and identify opportunities for improvement. This Original Research study explores healthcare providers' views on DAMA and identifies strategies for preventing and/or better managing DAMA cases.

COVID-19 was the leading cause of maternal deaths in Mexico and Colombia during the pandemic and many Latin American countries reported disruptions to maternal and newborn services. In Guatemala, only 10% of the population is vaccinated and there are many misconceptions about COVID-19 and the vaccine. More information is needed about misconceptions patients might still harbor about the virus and the vaccine. Lay midwives attend the majority of births in Guatemala, including most births at home, and are in an optimal position to offer front-line support to pregnant women and newborns regarding COVID-19. Lay midwives are a particularly important source of information inrural and Indigenous Mayan populations, which disproportionately suffer poor health outcomes. This Original Research article reports on a program of study that aimed to dispel myths about COVID-19 and provide culturally relevant educational activities to low-literacy Guatemalan lay midwives in Peten, which is the largest department in Guatemala, but among the most remote regions and where >60% of residents live in poverty and lack access to basic health care. 

COVID-19 fue la principal causa de muerte materna en México y Colombia durante la pandemia y muchos países de América Latina informaron discontinuidad en los servicios maternos y neonatales. En Guatemala sólo el 10% de la población está vacunada y existen muchos conceptos erróneos sobre el COVID-19 y la vacuna. Se necesita más información sobre conceptos erróneos que aún persisten en los pacientes sobre el virus y la vacuna. Las parteras no profesionales atienden la mayoría de los partos en Guatemala, incluidos gran parte de los partos en el hogar, y están en una posición óptima para ofrecer apoyo de primera línea a las mujeres embarazadas y a los recién nacidos en relación con el COVID-19. Las parteras no profesionales son una fuente de información particularmente importante en las poblaciones rurales e indígenas mayas, que tienen los peores resultados de salud, en relación al resto del país. Este artículo original de investigación informa sobre un programa de estudio cuyo objetivo es disipar mitos sobre COVID-19 y brindar actividades educativas culturalmente pertinentes a parteras no profesionales guatemaltecas con bajo nivel de alfabetización en Petén, que es el departamento más grande de Guatemala, y se encuentra entre las regiones más remotas, donde >60% de los residentes viven en la pobreza y carecen de acceso a atención médica básica.

Durante a pandemia, a COVID-19 foi a principal causa de mortalidade materna no México e na Colômbia e muitos países latino-americanos relataram interrupções nos serviços maternos e neonatais. Na Guatemala, apenas 10% da população está vacinada e existem muitos conceitos errados sobre a COVID-19 e a vacina, sendo necessárias mais informações sobre estes equívocos. As parteiras, que assistem à maioria dos partos na Guatemala, incluindo os domiciliares, estão numa posição ideal para oferecer apoio de primeira linha sobre a COVID-19 às mulheres grávidas e aos recém-nascidos. As parteiras são uma fonte de informação particularmente importante nas populações rurais e indígenas maias, que sofrem com piores indicadores de saúde. Este artigo original relata um programa de estudo que teve como objetivo dissipar mitos sobre a COVID-19 e fornecer atividades educacionais culturalmente relevantes para parteiras guatemaltecas com baixo nível de alfabetização em Peten, que é o maior departamento da Guatemala, mas que está entre as regiões mais remotas, onde >60% dos residentes vivem na pobreza e não têm acesso a cuidados básicos de saúde.