Volume 11

In this heartfelt Editorial, Professor Kazuo Inoue (Teikyo University School of Medicine, Tokyo) and the Rural and Remote Health Asian Regional Editor, Associate Professor Masatoshi Matsumoto (Faculty of Medicine, Hiroshima University) salute the Japanese rural health professionals who have stayed in their regions and are struggling to provide care and comfort to rural communities suffering the effects of earthquake, tsunami and radiation.

In the 'information age' we should all be able to obtain more and better health information. How does the new technology of the internet compare with traditional methods of obtaining health education, such as the personal provision of information directly from a nurse educator?

Depressed or not depressed? Do rural men and women identify depression and what do they do about it? What is the relationship of education and gender regarding depression literacy? How do mental health care professionals and churches fit into the picture? Many questions are raised when exploring depression literacy in rural Arkansas.

Better health outcomes require a balance between research-tested interventions and population-specific application, along with adaptation, implementation and evaluation playing key roles. Appalachia is an appropriate testing ground for assessing adaptation to evidence based interventions.

Do multiple chronic health conditions affect colorectal cancer screening among vulnerable middle-aged and older US adults? In addition to the commonly expressed barriers to colonoscopy (unpleasant screening, no health insurance, shortage of gastroenterologists...), these authors found barriers specific to their Appalachian participants. Their thoughtful discussion of the barriers could be used to facilitate better care in many comparable rural areas.

A 'pig project', a library in a radio station, fun days for children... these are some of the stories told by participants about the most significant community change to come from a 2003 community radio development in Bali, Indonesia, which aimed to make an impact on the social and health needs of a village.

In rural and remote New South Wales, Australia, selected GPs, registered nurses and physiotherapists may be trained and licensed to perform a limited range of X-ray examinations in the absence of a radiographer, providing a valuable service for local residents. The survey reported on in this publication provides background information on this special interprofessional group and also defines their need for educational and other support. The strategies suggested here may well be relevant to other health workforce areas where similar 'skills transfer' is required.

Fear, trust and suspicion - common human emotions that can de-rail or contribute to the success of integrating separate rural health services to improve health outcomes in the local community. This small study, one of the first to investigate local perspectives on Australia's Multi-purpose Service Program, suggests that negotiation can sometimes save the day.

In this wide-ranging pilot study, the rural Australian participant pharmacists broached many themes and issues, including privacy concerns, the unique nature of each dispensing environment, the usefulness (or not) of technology, compliance with regulations and staff's embrace of the safety culture. Essential reading for all who have an interest in the safe supply of medicines.

Environmental degradation in the African Niger Delta has impoverished the rural population - how do they pay for urgent surgical treatment? This first study of its type in this geographic zone provides some answers.

Much has been written about the advantages of telemedicine for rural and remote patients - but what are the opinions of health practitioners who have used it in their work? In this report of one part of a larger Australian study, new information about telemed service barriers emerges that will have many nodding in agreement.

Where mental health issues are concerned, a delay in seeking help can mean a poorer outcome. Many mental health problems first appear in adolescence; however, despite recent improvements to Australian youth mental health services, rural adolescents still face barriers to obtaining professional psychological help. This mixed methods Australian study adds to our knowledge of help-seeking among rural adolescents.

This study from Gippsland, Australia, sought the views of mental health service leaders about the global human resources isssue - recruiting and retaining rural mental health workers. The reflections and creative solutions reported, grounded as they are in day-to-day management work, bring a new voice to the literature of rural health human resources.

Will the sustainability of New Zealand's rural hospitals be improved by the new (2009) vocational scope of practice in rural hospital medicine? This study establishes the current NZ rural hospital medical workforce as an indispensible baseline for future health service planning.

North versus south can provide interesting contrasts as noted in Ontario. This descriptive study notes differences in physician gender, age, and specialty. Is it possible to have reasonable levels of physicians while still leaving certain populations behind with shortages?

Nature versus Nurture is the age old question of rural workforce. How do nations address populations suffering a shortage of physicians? Studies should consider both Nature and Nurture, as well as involving multiple institutions.

It is no news to rural and remote hospital administrators that the cost and difficulty of obtaining locum consultants is burdensome. For the rest of us, this intriguing Scottish study of one rural general hospital over 8 years raises questions about the sustainability of this medical staffing model in an era of shrinking resources globally.

Rural women are important 'gatekeepers' of health for rural families. Community factors such as access interact with health decisions and the health of the entire rural community. 'Rural Families Speak' and we would do well to listen to what rural women are saying in this multi-state study.

Foreshadowing the proposed national career tracking of Australian medical school graduates, this evaluation of compulsory and elective rural medical components at the Australian National University adds to the evidence on undergraduate rural practice intention. Of interest are findings on motivation to select or decline elective year-long rural immersion.

Health human resource shortages are a common topic of discussion in clinical and policy arenas. This article offers new insights about the ethical dimensions of recruitment and retention of health care professionals for rural communities.

It may surprise you that in 2011 RRH is publishing one of the first and largest oral health studies of rural and remote Australian pre-schoolers. When Indigenous and non-Indigenous groups were compared, the prevalence and severity of decay for some (with associated suffering and morbidity) is sobering. In 2011, we might well ask: how can this be?

Is there a disparity in preventive counseling among rural women? This article explores this important issue within the Central Pennsylvania Women's Health Study.

Understanding common causes of death can guide those responsible for planning healthcare interventions. This unique retrospective chart review analysed the causes of death in a remote Sub-Sahara African district hospital over 17 years. While the methods are transferrable, the results of this study are specific to ensuring the health needs of this remote population will be considered when public health expenditure is planned.

Faecal incontinence (FI) and associated constipation and chronic pelvic pain may cause embarrassment, loss of self-respect and possible withdrawal from normal daily activities. This study from an Australian regional centre reports on the use of biofeedback as a first-line therapy to improve patients' symptoms and quality of life. The comparison of outcomes for rural and regional participants offers new information for those involved in caring for rural FI patients.

What are food deserts? What are their significance for rural families and communities? This article, based on focus groups conducted in Maine, USA, highlights this issue with policy implications for improving nurtition.

What are the potential social determinants of health among African Americans in a rural Southern area of the United States? The authors of this community-based research study appplied ecological theory to find out. Their findings are tied to the pervasive rural disparities among this population, and demonstrate the value of this approach to conducting rural, community-based research.

In a strongly patriarchal society, rural Nigerian mothers experience very high infant mortality. Using data from the 2008 Nigeria Demographic and Health Survey, this study attempts to answer the question, 'Does child survival increase in female-headed households?' In doing so the author negotiates a complex interplay of influential socio-cultural, economic, and geopolitical factors.

The tyranny of distance and terrain is a significant barrier to health care for rural populations the world over. Three years after its inception, service users of the unique Canadian 'Connections' medical transportation customised bus service were surveyed to assess whether the service reached those in social and medical need.

The rurality of farm workers in any country limits their access to health care. However, this study from Sub-Saharan Africa highlights the extreme situation of Namibian farm workers and their families, who are greatly disadvantaged in access to even basic primary health care. The solutions suggested by the authors are both locally specific and also generalizable to other agricultural sectors, worldwide.

The traditional Mediterranean diet has been protective against obesity. Why, then, has epidemic childhood obesity appeared on a remote Greek island? These authors tested a range of familial and environmental factors in a small local study with a high participation rate.

Rural populations represent a wide range of cultures and daily living patterns vary greatly. Measures of the activities of daily living need to be specific to culture and lifestyle. Pelvic organ prolapse is a significant problem for many rural females. Addressing the problem required a culturally specific assessment tool to facilitate the health care of rural women with pelvic organ prolapse in Guatemala.

With the incidence of colorectal cancer rising across populations, these authors analysed Australian National Bowel Cancer Screening Program (NBCSP) data for rural and remote South Australia, seeking factors and characteristics that impact on the uptake of voluntary screening. Although the findings are geographically specific, they are essential reading for health planners, policymakers and all others interested in the epidemiology of this high mortality disease.

Dementia is more prevalent in the Aboriginal population than among other Australians. With low access to and poor quality of care for those living with dementia in rural and remote Aboriginal communities, efforts are urgently needed to improve their situation, and that of their carers. This study makes a start by defining their predicament, and calls for a culturally safe model of dementia care.

Does Norway's Indigenous population have greater access to health care than Indigenous peoples in other world regions? This comparative geographical analysis of Norwegian municipal health expenditure offers some surprising findings.

Is telemental health an appropriate alternative for providing mental health services to isolated First Nations communities? This article discusses a collaborative research project among First Nations communities in Northwestern Ontario, Canada to examine this issue.

Rural living is a significant risk factor for the neurodegenerative disorder Parkinson's disease. However, rural patients are often disadvantaged by reduced access to disease-specific care. This small, unique study from one rural Australian area gives voice to the person with Parkinson's and their personal and professional carers as a microcosm of a widespread but largely silent group.

We all know it does people good - but the health benefits of living in a rural community are hard to define, and even harder to quantify. This small qualitative study of consecutive GP patients in Ireland provides a wealth of information to stimulate reflection.

Highly centralized and subspecialized training is a prestigious line of work with a long and glorious tradition of failing to provide the workforce needed for rural areas worldwide. Common sense indicates that training specific to rural workforce would focus on training longitudinally in rural locations. Two of these models have captured rural medical student and rural clinician impressions for review.

Bangladesh's remote, Indigenous Mru people live on cliffs and hilltops, in ravines and deep forest - far beyond the reach of the internet or even broadcast radio. It is no surprise then that Mru women's access to antenatal and postnatal care is alarmingly low. What does surprise is the absence of outreach to educate, provide maternal care and to intervene in obstetric emergencies. This study analyses local and systemic factors preventing Mru women from accessing the care they need.

What do rural African mothers know about undernutrition in early childhood - and what determines their ability to nourish their children across varying and difficult circumstances? The grounded theory approach used in this small study offers a 'ground-up' perspective on an ancient problem. Does local wisdom suggest wider solutions?

Little is known about "food insecurity" although it is an increasingly important issue among Canadian Arctic communities. This article reports on a unique "Photovoice" study in which images captured by participants assisted in determining factors that influenced the type, quantity and quality of food consumption. The study findings link social determinants of health to cultural values, adding valuable knowledge to our understanding of this significant issue.

There are few studies that examine the health of rural children. In an attempt to address this gap, the authors of this cross-sectional study used a health questionaire with rural children in Saskatchewan, Canada. Their data reveals much about participating childrens' food intake, activity levels and weight status.

The prevalence of cardiovascular disease is increasing rapidly in the developing world. This rural-urban comparative study from Pakistan, the world sixth most populous nation, aimed to identify risk factors that might shape targeted public health interventions to reduce burgeoning cardiovascular morbidity.

Before we get complacent about childhood vaccination, consider this: almost one million Indonesian children missed a measles vaccination in 2007. These investigators sought to identify why by analysing a children's dataset of the 2007 Indonesia's Demographic and Health Survey. Three key factors stood out.

The value of undergraduate rural medical placements is now funded and established as a rural workforce strategy. Will the same strategy improve the distribution of dentists to Australian rural areas? This study from New South Wales reviews local and international evidence to date, and adds to it with information from a 2009 study of dental undergraduates - to be continued.

Throughout the world, local birthing units are an integral component of primary health care in rural communities. While the transfer of a woman or her newborn to a secondary or tertiary facility for specialist care may be lifesaving, it is also disruptive and stressful. In rural New Zealand, transfer distances may not be great but the transfer is likely to be complicated by adverse terrain or severe weather conditions. In this nation-wide NZ study, the researchers explored the context of and reason for the difficult 'decision to transfer' during labour and birth.

The benefits of breastfeeding have long been established, but breastfeeding prevalence varies and some rural areas continue to lag behind. This article presents a secondary data analysis regarding breastfeeding rates in rural and urban US Applachia, with recommendations for care implications and future research.

Violence is a universal community problem but greater understanding of the factors involved in rural violence is required for this issue to be addressed at community level. These authors approach meaning, causes, consequences, and solutions by comparing male and female youth perceptions.

Rural residents want to remain in their home communities for end-of-life care, however providing palliative care in rural areas is an exercise in managing limited infrastructure and resources. This article offers a solution by focusing on community capacity development as the basis for a rural palliative care model. The authors detail the process of model development.

Decision-making is an important skill for any healthcare provider. Understanding the process of decision-making among novice rural registered nurses is the focus of this study. The findings have application for practice settings, including orientation and ongoing mentoring.

The message for those interested in improved rural health outcomes is "Ask not for your target population to come to you. Go out to meet them." While the object of this outreach was cardiovascular risk factors in a US rural population, the same strategy could be applied to health screening programs for any other specific population.

This article explores the context of rural living and its impact on the choices made by individuals with advanced disease. Their experiences and perceptions provide direction for the development of more appropriate palliative services in rural areas.

This Nigerian year-long study suggests that the multidimensional suffering of rural women affected by obstetric fistula (VVF) can be significantly reversed by successful surgical repair - if the resources are available.

Question: What can geographic methods tell us about rural health? Answer: A surprising amount! This high acuity GIS mapping approach to analysing access to dental care in Western Australia is not only fascinating reading, but also contributes to equity in workforce and service planning for the widely dispersed WA rural population.

What therapies do GPs favour when consulted by older adults with mild to moderate mental health issues? This broad question was tackled in the Scottish Highlands when the researchers investigated a low referral rate to the NHS Older Adults Clinical Psychology service. The results of this local survey will be of interest to those who provide primary care for what can be an underserviced patient group.

Following a nutritional status study on an adult Indian tribal group, these authors suggest an alternative anthropometric measure to the standard BMI when screening for clinical undernourishment.

Throughout the rural world, humans in close contact with cattle, sheep and goats are at risk of the infection 'Q fever'. Because the most common chronic manifestation for those at cardiac risk is a high mortality endocarditis, careful cardiac assessment is essential for confirmed and suspected cases. Is this being done in Australian rural/district hospitals?

In the Ukraine, scarce rural pharmacists are vital primary healthcare providers in an ailing health system. This unique study applied theories of motivation to the practice intentions of pharmacy undergraduates, adding the Ukraine view to the international rural workforce literature.

As rural medical education becomes decentralised and dispersed to distant and sometimes remote sites, is the quality of learning being maintained? This article approaches the question by analysing performance data from multiple student cohorts across the multiple sites of a dispersed Australian clinical school.

Babies with good Apgar scores are not in need of resuscitation. The Community Apgar may also indicate small communities that are likely to do well with viable workforce.

This study from Ogun State, Nigeria, touches on a number of familiar rural workforce themes - the 'brain drain' from developing countries; the depletion of remaining health workers in favour of urban positions; rural residents' access barriers despite a high burden of disease... The fresh approach of these authors, including a focus on those who chose to work rurally and those who were transferred, helps identify what attracts rural workers in this part of the world - and then what retains them.

Superficial skin infections, eczema and infestations are all well-known conditions among school children. However, which socio-economic factors, if any, contribute to such transmissible and non-transmissible skin diseases in this age group? The authors of this comprehensive study from Saudi Arabia examined many factors, including rural residence.

It is difficult to anticipate likely changes when establishing regional/rural sites for medical education. The authors' description of the Prince George site in Canada within the framework of social capital assists our understanding of what can result from collaborative health professional education efforts and what participants, partners, and stakeholders can expect.

What is known about the contribution of nutritional services from dieticians to the health and wellbeing of older rural adults? This study from the Greek Mediterranean built on MEDIS Study data to find out. The results add to our knowledge of healthy ageing in this under-researched area.

When comparing rural versus urban, which is better: comparison at the town or at the county level? These authors analyzed previously collected town-level data on pediatric brain trauma to find out.

The recent H1N1 influenza pandemic presented a challenge to health care providers and public health decision makers alike. This article documents the results of a community-based participatory approach with First Nations communities in isolated areas of Canada and highlights the barriers and recommendations to address future pandemics.

Do rural and remote patients with cancer have the highest level of unmet care needs? Suspend assumptions and read this large comparative study of rural, remote and metropolitan participants in Australia's largest but most sparsely populated state.

Access to obstetric services is fundamental to improving maternal and neonatal health outcomes, but this remains beyond the reach of many women in the developing world. These authors researched birthing practices in a remote area of Tanzania, evaluating the impact of tribal culture, distance to obstetric services and infrastructural issues on the likelihood of skilled birth attendance at delivery.

Does incomplete cultural adaptation among non-Indigenous health professionals working in Indigenous communities contribute to rural workforce shortages? This comprehensive review of the international literature offers evidence about the impact of culture shock in remote Australia, with potential application to other world regions.

Finding an approach to reducing rural suicide can seem an overwhelming task, with the large available literature just the first issue to tackle. If this is a professional concern of yours, look no further than this new literature review, which also offers a unique 'Conceptual model of rural suicide'. The model has the potential to help identify precise points for intervention that are unique to individual rural localities, making this article a 'must-read' for academic researchers, rural service-planners and healthcare staff in any rural location.

Older rural carers have different support needs from their urban counterparts. Here, their distinct barriers to obtaining that support are identified with such clarity that this review will be important for government, service planners, and all who conduct support programs for this vulnerable rural group.

In rural health, priority setting is frequently an interdisciplinary, interagency collaborative process. This review puts into words what many have experienced - that primary care partnership program negotiations can be a complex process, often burdened by the policy shifts of political cycles, and competing values, objectives and priorities among participating agencies. The model presented by these authors captures the range of factors to be considered in such an environment, providing a valuable resource for those in primary health care alliances responsible for doing the work of setting regional priorities.

One framework for understanding diabetes in developing nations and Indigenous peoples can be provided by a focus on the impact of stress. Prevention and intervention efforts should consider more than just a biomedical model.

Home-based or hospital-based cardiac rehabilitation? The evidence reported in this systematic review may benefit rural and remote cardiac patients.

Despite the challenges of location and culture, hereditary cancer syndromes can be managed for individuals and families who live in remote areas. This Lynch syndrome case report from Western Australia provides valuable advice to ensure appropriate care and follow up is available for identified at-risk individuals and their families who are difficult to reach.

Two case reports of patients with decompression sickness in remote Japan highlight the wider rural health issue of the centralization of health care with air-medical transport support. Is it always the best policy in island emergency medicine - or could there be a better local model? This concise report provides compelling reading - and evidence.

With an ageing rural population, access to primary care for rural Australians with chronic disease is a public health concern. This article begins to fill a research gap by comparing patterns of primary care usage according Victorian location, among those with defined chronic illnesses. Of particular rural relevance is the range of non-medical health professionals included in the study.

Studies of broad-scope generalist physicians indicate the influence of rural training upon rural practice location, but how does rural training impact on more specialized physicians? The authors review data from the Northeast Ontario Postgraduate Specialty program.

What do rural health and social-care staff need to know about delivering services to people with dementia? The workshop participants from remote Scotland in this short report highlighted some universal themes.

This is an era when medical educators and funders strive for quality clinical placements in expanded practice settings typified by rural and remote teaching sites. Could the proposed Australian 'meducation' card use existing infrastructure to facilitate the training of future medical practitioners?

Does rural living limit access to mental health services? This thought-provoking article analyzed the Canadian Community Health Survey, Mental Health & Well-being data cycle to find out.

Will recent Australian Government initiatives succeed in boosting the medical workforce in underserved rural locations? This short report on the work intentions of the next generation of doctors provides a tentative answer.

Much has been published in our journal about national strategies to address the worldwide shortage of rural healthcare workers, especially the scarcity of rural physicians. This first report from Thailand reveals an array of (often successful) long-standing and responsive rural health workforce strategies.

If identifying 'rural-attribute applicants' for admission to medical school was as simple as asking for 'high school graduation location', the rural-urban medical workforce gap would be narrowing. In taking a matrix approach to distinguishing potential students' rural attributes, these authors from Manitoba, Canada, acknowledged that rural-student selection is a more complex exercise, where even some urban-background applicants are considered. The result has been a promising increase in the rural-origin mix of local admissions, and a methodology that promises the same for faculty selection committees in other world regions.

Recently in Australia, human infection with swine brucellosis has been disproportionately high among feral pig hunters in some rural areas. To explore an apparent failure of established risk-reduction strategies, a grounded theory approach gave voice to this hard-to-reach group. The researchers were rewarded with some rich data, including public health strategies specific to this group - and advice on how to disseminate them.

This project report from the UK describes the challenges overcome by Keele University Medical School and its partners to establish a rural campus, bringing undergraduates into the teaching environment of previously inaccessible rural general practices and community hospitals.

Are there sociodemographic differences in high-risk behaviours for STIs and blood borne viruses among those in prison? This chart audit of 946 individuals imprisoned in metropolitan and regional Western Australia focussed on variables such as age, gender, racial group and location - and identified some distinct patterns.

Interprofesional education is a key strategy for addressing workforce issues in rural and remote areas of Canada. This article discusses the BRIDGE project which has been implememented in the interior of British Columbia to explore IPE opportunities for students and communities.

This multi-stakeholder project in Sub-Saharan Malawi shows what can be done to reach remote and severely underserved populations with just a van, supplies and staff - and good planning.

Australian medical students' vary in their motivation to take the University of Adelaide's Global Health course, from wanting to 'make a small difference', to wanting to do 'something different'. What matters most is that students' world views are challenged and altered by this elective that continues to evolve in response to local and global conditions.

How do we effectively manage environmental risks so that the public's health is safeguarded? Traditionally, standardized risk assessments and advisories have been commonplace but these authors argue for a place-baased approach to environmental risk for improved healh outcomes.

This tribute to Dr John Irwin who died on 31 May 2011 celebrates his life as a committed Canadian rural surgeon and physician.

This obituary to Ralph McLean describes him as a 'quiet contributor' to rural health.

Do Australian rural placement programs offer more than strategies to address the rural workforce crisis? This letter adds to the debate.

This letter from Japan suggests that even less formal internet learning opportunities among physicians can contribute to the health of the remote and rural community.

This Letter to the Editor from Slovakia reports on a successful recent workshop on commencing research in general practice.

This Letter to the Editor questions the effect of increasing Australian medical school cohorts on the quality of rural clinical placements.

This letter highlights the rural-urban primary care gap in Greece.

The adjusted diabetes mellitus screening criteria for a rural Japanese population reported in this letter may be transferrable to groups with similar characteristics.

The real-time video of face-to-face telemedicine consultations can dramatically improve rural and remote patients' access to specialist advice - if local conditions are favourable. This letter from the Philippines reports on the successful use of phone technology as an alternative to the now familiar web-based solutions.

Falls, occupational injuries or MVAs... the statistics speak for those unfortunate enough to suffer a traumatic spinal cord injury in rural India. The authors of this letter argue for pre-hospital care reforms.

The tsunami caused by the 2004 'great Sumatra earthquake' affected rural areas of Thailand and created serious and unexpected health outcomes. Now an earthquake and tsunami of similar magnitude have devastated rural Japan. This letter to the editor suggests Japan can learn from Thai experience in post-disaster rural healthcare management.

This new book review of the 2011 publication "Struggle for social service in Nepal" by Mrigendra Raj Pandey also provides background information on the Mrigendra-Samjhana Medical Trust, Kathmandu, Nepal.