Volume 18

This Editorial celebrates the contribution of rural programs to the longitudinal integrated clerkship (LIC) movement by examining the contributions of articles published online in Rural and Remote Health to the LIC discourse.

In Papua New Guinea, a public–private partnership (PPP) between the National Department of Health in Papua New Guinea, the Australian Government and the Oil Search Foundation allowed the formation of a Reproductive Health Training Unit to provide health worker training in obstetric care. This study evaluates how well the PPP meets the target of improving the competence of front-line health workers in obstetric care service provision in Papua New Guinea.

Specific and targeted intervention is needed to reduce the relatively high maternal mortality and morbidity in Indonesia, especially for socially disadvantaged women and women living in rural areas. This study assessed patterns and sociodemographic determinants of self-reported maternal morbidity in rural and urban areas.

This study explores factors that impact women physicians' professional satisfaction and commitment to rural medicine. Three key influences were identified: professional relationships, practice characteristics and support during times of transition. The authors suggest these findings could be used to improve retention of women physicians in rural practice.

A uniform certified basic training program for interns started in Japan in 2004. Following this change, more interns chose to train in community settings, including in rural areas. This article reports on geographic and demographic variations in attitudes towards interns from this new training system.

Rural emergency departments (EDs) and urgent care centres (UCCs) are often the first point of care for consumers experiencing acute mental health issues. Rural nurses working in EDs and UCCs require a diverse clinical skill set to manage complex presentations, often with limited support and resources. This study found that although rural generalist nurses are the frontline providers of care for mental health consumers in rural EDs and UCCs, they feel ill-equipped for assessing and managing mental health presentations.

There is evidence that medical students with rural backgrounds are more likely than their urban peers to enter rural practice, but what happens to career intentions during medical school is less well established. This study assessed how rural intentions persist or change during medical school and sought factors associated with either persistence or change in rural intention.

In Mongolian provinces affected by the dzud, a winter disaster that occurs in Mongolia following drought in dryland areas and results in the death of a large number of livestock, children under 5 years suffer increased mortality rates. This study evaluated the health risks for children during the dzud.

Patients who experience an ST-elevation myocardial infarction due to an occluded coronary artery require prompt treatment. Geographical and organisational barriers may influence access to treatment in remote areas, but these are not well understood. This study compares the characteristics of treatment delivery in central and remote locations in the North of Scotland and identifies potential barriers to optimal care with a view to service redesign.

To address the lack of Australian data examining mental health in same-sex-attracted rural adolescents, this study examined experiences of stressors, symptoms of depression and suicidality, and perceptions of barriers to seeking mental health support, comparing same-sex-attracted adolescents with heterosexual adolescents living in rural Australia.

This study comprised two cross-sectional population-based surveys comparing the prevalence of diabetes mellitus between Sami and non-Sami inhabitants of Northern Norway. The total age standardised prevalence of diabetes mellitus was 10.0% and 11.2% respectively in 2003-2003 and 2012-2014 with no ethnic difference.

The Solomon Islands presents a unique profile of challenges to surgical practice, including the impact of Dengue infection, dispersal of patients across the islands and difficult access to pathology services. This study reports on the gynaecological conditions affecting women in the Solomon Islands.

Managing outpatients with chronic diseases like hypertension in resource-poor settings is challenging. This study determined the factors associated with where and how people obtain their anti-hypertensive medicines in rural villages in Indonesia.

Tuberculosis (TB) remains a major public health problem in many countries. Health services can be TB ‘hot spots’ and, in the absence of good TB infection control (TBIC), a clinical service may actually promote the spread of TB, rather than contain it. This research explores rural health workers’ perspectives of barriers and facilitators to effective TBIC practices in rural health facilities in Madang Province, PNG.

The prevalence of chronic disease, mortality and suicide rates is higher in rural Australia than in urban centres. This study compared barriers to help-seeking for physical and mental health issues among rural South Australian adults.

In Sudan, home birth remains a strong preference and village midwives are the only option for maternal and neonatal care for many rural women. This study examined the factors that improved service delivery and strengthened the capacity of community midwives for home births.

Many primary healthcare staff have a role to play in health promotion practice, but their ability to integrate health promotion into practice is influenced by their previous training and experience. For primary healthcare staff working in rural and remote locations, access to professional development can be limited by what is locally available and prohibitive in terms of cost for travel and accommodation. This study provides insight into how staff at a large north Queensland Aboriginal community controlled health service access skill development and health promotion expertise to support their work.

Obesity has become one of the major health risks in childhood, significantly affecting children’s health and physical fitness. Although the marked increase of obesity in urban areas is well established, evidence is limited in remote and isolated areas with adverse socioeconomic features. This study examined the prevalence of obesity and its association with physical performance indices in school-age children on remote and isolated Greek islands.

Rural recruitment and retention of physicians is a global problem. This retrospective cohort study examined the practice locations of graduates from Memorial University of Newfoundland's medical school and found they were more likely to practice in rural areas compared to graduates from other Canadian medical schools. The success of the Memorial program is attributed to the comprehensive, rural focused, social accountability approach to medical education.

This study utilised the South Carolina Behavioral Risk Factor Surveillance System to examine differences in Adverse Childhood Experiences (ACE) exposure between rural and urban adults, and their relationship to adult health behaviours and chronic health conditions. Findings provide insight in ACE exposure and impacts in adulthood among rural residents as well as suggestions for further research, policy, and program development.

The increasing shortage of rural physicians is an issue in most western countries. This study explored physicians’ subjective perceptions of rurality and reports on strategies to resolve the physician shortage in rural areas.

Twenty public health nurses who worked during the flood season in the years 2014 and 2015 in a rural area in southern Brazil were interviewed to identify primary health care nurses’ competencies when responding to flood disasters in rural areas.

Aboriginal children living in rural and remote communities in NSW experience high rates of dental caries. This study was a collaboration with local Aboriginal communities to determine the oral health needs of Aboriginal children, the knowledge and attitudes towards oral health of parents/guardians and the perceived barriers and enablers towards oral health promotion for school children. The results of this collaboration will inform a community-owned oral health promotion program.

In response to rural medical workforce shortages in Thailand, the Collaborative Project to Increase production of Rural Doctors (CPIRD) is seeking to develop a Thai Rural Community-Based Medical Education (RCBME) program in the Southern region of Thailand. This study explores stakeholder expectations of the Southern Thai RCBME.

Advanced Care Planning (ACP) and Advanced Care Directives (ACDs) play a vital role in preparing for end-of-life care. However, current literature suggests that uptake of ACP and ACDs in rural Australia is low. This study provides a current perspective on the attitudes and practices of healthcare workers from Residential Aged Care Facilities towards ACP and ACDs in the Central West, Far West and Orana regions of NSW, Australia.

Public health doctors (PHD) in South Korea serve the medically underserved region of South Korea as part of national service duty, but their number has been declining in recent years due to changes in medical education. This study investigates the appropriateness of PHD tasks in South Korea.

Increased publication of clinician-led health research is important for improving patient care and health outcomes. This study determined the impact of a writing for publication program delivered by teleconference on the publication rates and skill acquisition of novice researchers.

This study is one of very few investigating the characteristics of smoking and tobacco exposure exclusively in a rural population in Greece. Both the high prevalence of smoking and the high levels of exposure to tobacco show a population at increased risk for tobacco-related disease. These findings call for immediate action to reduce smoking prevalence, help smokers quit and protect the health of non-smokers.

Shortages and maldistribution of dermatology services have negative impacts on the quality of care for patients with skin problems. The study examined the urban–rural distribution of dermatologists and office-based dermatology services in Taiwan.

The Personal Helpers and Mentors (PHaMs) service is a non-clinical, community-based Australian Government initiative aimed at increasing opportunities for recovery for people whose lives are severely affected by mental illness. This study examines how these strengths-based recovery services are developed and function in low resource rural settings and what outcomes are achieved.

This article describes incidence rates and characteristics (gender, age group, severity of injury, vehicle and environment and geographical remoteness) of low-speed vehicle run-over events among children aged 0–14 years residing in Queensland from 1999 to 2009.

Many medical faculties are responding to rural workforce needs by extending clinical training from the traditional academic teaching hospital to include rural and remote sites away from the central training institution. Medical schools need to consider how to offer faculty development that might support these clinicians as they take on a teaching role. This new research sought to develop an understanding of how clinicians working at distant resource-constrained and new training sites view their early experiences of clinical teaching.

The Rural Primary Health Services Delivery Project aims to improve the quality and coverage of health services to rural populations in Papua New Guinea, but there are limitations in measuring the performance of such projects. This article describes a performance assessment framework that might be applied to evaluations of other health service delivery programs in similar contexts.

Community participation is a collaborative process aimed at achieving community-identified outcomes. This article reported factors that facilitated community participation undertaken in the Smart and Deadly initiative, a community-led initiative to develop sexual health promotion resources with young Aboriginal people in regional Victoria, Australia.

Remote communities across Australia lack the ready access to medical care generally afforded to metropolitan populations. The Royal Flying Doctor Service Medical Chest Program provides medical resources to these communities allowing medications to be dispensed in conjunction with a telehealth consulting service. This study reveiewed the use of the medical chest model within the state of Queensland.

Rural health workforce shortages are a global phenomenon. Some of Australia’s most severe rural workforce shortages, particularly among early-career health professionals, are in public sector community mental health. This study investigated how employment and rural-living factors impacted the turnover intention of early-career, rural-based community mental health professionals in their first few years of working.

In Canada, rural-based family medicine residency programs were established largely in response to a shortage of rural physicians and the perception that urban-based training programs were not meeting the needs of rural populations. Examinations of practice patterns of physicians trained in rural and urban programs are lacking. This study compared the scope of practice of family medicine graduates who completed a rural versus an urban residency program as assessed by practice location.

Rural health care has been traditionally provided in New Zealand by medical general practitioners (GPs). However, the number of GPs has been declining, leading to the development of the rural nurse specialist (RNS). The RNS is a registered nurse with advanced nursing skills that enable independent, autonomous practice within rural areas. The health needs of each rural community are specific to that area and the RNS role has been developed according to local healthcare needs. This article provides a description of the RNS role in New Zealand.

Extended lifespans, urbanization, a sedentary lifestyle and changes in nutritional habits following medical and technological developments have all increased the prevalence of diabetes, making it a significant public health problem worldwide. This study aimed to determine the disease management self-efficacy level for patients with type 2 diabetes living in a rural area of Turkey.

Since 2010, the Chinese government has been introducing a selective admission policy to recruit rural students for undergraduate medical education in order to improve the medical services in the rural townships of western China. This study analyzed the selective admission policy in western China from the perspective of medical students' attitudes towards a rural career choice.

‘Socially accountable, community-engaged’ health professional education (SAHPE) has contributed to increased medical coverage across rural and/or economically disadvantaged areas in two Philippines regions. The extensive community-based medical student placements associated with SAHPE likely play a significant role in graduates choosing to practice in rural and/or economically disadvantaged communities.

This study identifies geographic differences in HIV-related stigma experiences among women in the Canadian HIV Women's Sexual & Reproductive Health Cohort Study. Region-specific strategies to reduce stigma, and to support those impacted by it, are recommended, particularly for those living in geographically isolated areas.

General practitioners (GPs) participate in a patient’s cancer care to different extents at different times, from prevention and diagnosis to treatment and end-of-life care. Traditionally, the GP has had a minor role in cancer treatment, but oncological and surgical services frequently delegate limited cancer treatment tasks to GPs, especially in rural areas. This study explored the extent of GP participation in cancer treatment in Norway.

In Japan, the community medicine clerkship was introduced to foster positive attitudes towards rural practice and encourage rural recruitment. This study measured attitudes towards rural practice in a group of medical students at a Japanese university.

Rural children with a disability seldom participate in the recommended 60 minutes of moderate-to-vigorous physical activity per day. This investigation of parents’ perceptions indicates that this population faces multiple barriers to participation, including access, ability and isolation, and suggests that support structures aimed at promoting physical activity should be enhanced.

This article examines Employment Related Mobility (ERM) and its impact on families, particularly new mothers. This research carries implications for nurses and other healthcare providers who have the opportunity to interact with or provide support to families experiencing ERM.

Research on wellness in rural older people is scarce. This study tests an ecological model of wellness that includes intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy.

Sensory impairment and associated disability is a significant global health concern. This study evaluated the effect of a brief educational intervention for rural community nurses to enhance their knowledge, skills and attitudes about sensory impairment and subsequent impact on referral practices.

Diabetes mellitus (DM) is a growing health concern worldwide and is associated with a high risk of developing diabetic retinopathy (DR). Preventive care through regular eye examinations and proper management of DM and hypertension can reduce the risk of vision loss from DR, though knowledge of these conditions is low. This research examines the knowledge, attitude and practice related to DM, hypertension and DR of patient populations at different levels of a pyramidal model of eye health care in Hyderabad, India.

Geographical differences in the prevalence of dental caries and periodontal disease can be attributed to variation in diet, availability of fluoridated water and social and cultural factors, such as access to health services and level of income. Adolescents experience an increased risk for caries, traumatisms and periodontal diseases compared with younger children, and also tend to have poor nutritional habits. This study compared the oral health status of adolescents from rural and urban areas in central Chile.

Child-care centers with good quality standards can be effective in reducing the risk of diseases being easily spread from person to person. Our program, adapted from a method used by the United Nations Development Program, aimed to increase the capacity of local administrators and heads of child-care centers to improve quality standards.

The University Department of Rural Health (UDRH) program aims to provide education and training facilities in non-metropolitan centres, thereby helping to attract health professionals to practise in rural and remote communities. Since their inception 20 years ago, UDRHs have become well-integrated entities, effectively embedded within their regional communities. This evaluation shows that UDRHs are making a difference based on an assessment of geographical coverage and activity, relevant contribution, and engagement in rural and remote communities.

This qualitative study explores the efficacy of using a High Acuity Response Team model to transport rural patients to urban centers for critical care in Canada. The findings suggest that while this model reduced the need for rural physicians and nurses to accompany patients during transfer, it was associated with other challenges. The authors recommend systems level changes to better integrate the model.

This article describes a First Nations specific model for a community-based palliative care program. It demonstrates how local, federal and provincial health care providers and organizations collaborated to build capacity, fund and deliver community-based palliative care in rural Ontario, Canada.

Remotely Supported Prehospital Ultrasound (RSPU) is a process in which an ultrasound operator performs a scan and sends images to a remote expert for interpretation. As part of an investigation assessing the capability of RSPU to improve patient outcomes and standard of prehospital care in the Highlands of Scotland, this study explores the views of emergency medicine consultants and paramedics.

The high-risk nature of offshore work and inherent occupational hazards necessitate that offshore workers engage in behaviours that promote health and wellbeing. This study identifies key areas relating to the health, quality of life, mental wellbeing and self-care of the offshore workforce that warrant addressing.

Rural healthcare resource limitations can affect the choices people make and their quality of life during the end stages. In rural Australia, district nurses working in generalist community roles provide access to care by visiting people in their homes. This survey tested how district nurses advocate successfully for the end-of-life goals of rural Australians.

This qualitative study explores rural adolescents perceptions of health issues and health needs. Findings identify issues beyond difficulty accessing health care, and highlight these adolescents desire for health promoting role-models within their social sphere.

Although education is a key component in the management of type 2 diabetes, group sessions are less feasible in rural areas because of distance, participant numbers and access to appropriately trained healthcare professionals. This study assessed the access and delivery preferences of remote and rural service users in the Scottish Highlands and Islands to structured diabetes education programs.

In Japanese medical schools, a special regional quota (chiikiwaku) system has been widely implemented to increase the number of physicians in medically underserved areas. This study investigated the willingness of final-year regional quota students to remain in medically underserved areas after their obligatory practice period.

Health professionals performing their social health service (SHS) in rural communities could be at risk of developing depression. This study evaluated the association between place of origin and the presence of depressive symptoms in health professionals performing rural SHS in Ancash, Peru.

This article reports on the results of a cross-sectional study examining factors influencing smoking behaviour among women in rural areas. Findings might assist in the design of tobacco control interventions for rural women.

Farmers are a high-risk group for carcinogen exposure. However many studies investigating the risk of cancer in farmers focus on pesticide exposure alone. This study determined to which carcinogens Australian farmers are exposed, the prevalence and circumstances of those exposures and the use of protective equipment. 

A health visitor’s ability to assess and analyse aspects of family resilience in daily practice is essential to enable practitioners to support families, facilitate positive lifestyle choices and improve child health and developmental outcomes. This study explored the concept of family resilience as understood by health visitors in Wales, generating data for use in a Family Resilience assessment tool and instrument.

Over the past 25 years, there has been significant attrition of small volume rural surgery in Western Canada. This commentary describes a program, collaboratively designed by key stakeholders, to overcome challenges in building effective networks for the sustainable delivery of rural surgical care.

In 2012, the new profession of Aboriginal and Torres Strait Islander health practitioner (ATSIHP) was registered under the Health Practitioner Regulation National Law Act 2009. This commentary shares a north Queensland experience of the process of training and registering ATSIHPs in Queensland through accredited skills recognition and upskilling training.

This narrative review of paramedic models of service delivery focuses on models that have the potential to improve the health and well-being of frontier and remote populations. The authors conclude that a change in orientation from an emergency response system to a health service providing clinical care, will require paramedic services and paramedics to take a more patient-centered approach to service delivery and strengthen their community engagement activities.

Rural clinicians in small communities face the situation of always being “on-duty” as well as the challenges of increased social proximity. Conducting insider research in these communities involves similar issues. This commentary describes the challenges and management of insider-research in small rural communities.

There is an urgent need to preserve antibiotics so that they will still work against infections into the future. Hospitals can put in place a program called Antimicrobial Stewardship (AMS) to help make sure that antibiotics are being used properly. AMS programs can be more difficult to run in a rural hospital. This paper describes the different ways that rural hospitals have set up their AMS programs so that other rural hospitals can learn from their experiences.

Cardiac rehabilitation (CR) referral, access and attendance are low for all people who live in rural and remote areas. This integrative review identifies barriers, enablers and pathways to CR for adults living independently in rural and remote areas of high-income countries, including Australia.

Although interprofessional collaboration and effective teamwork are core to optimising rural health outcomes, little is known about the opportunities available for interprofessional education (IPE) in rural clinical learning environments. This integrative literature review identifies, analyses and synthesises the research available about the nature of and potential for IPE provided to undergraduate students undertaking rural placements.

This scoping review examines the literature on decentralised training platforms (DTPs) for medical education, with particular attention to rural context. Findings highlight DTP strategies and models as well as areas for further research to examine DTP impact on health services and human resources outcomes.

Agricultural accidents are a prominent cause of mortality and morbidity in rural areas, but are little studied. This case report describes a subtotal leg amputation that occurred after a hoeing machine accident in 2015 in Malatya, eastern Turkey.

This article reports on the rare case of an elderly female patient from a rural village with chronic massive pericardial effusion due to subclinical hypothyroidism. Subclinical hypothyroidism rarely shows signs and symptoms and can be underdiagnosed, but should be included in the differential diagnosis of pericardial effusion, especially in a case of unexplained pericardial fluid.

Given challenges in access to speciality care in rural and remote regions, it is critical to examine team-based and telemedicine approaches for treatment of dermatological conditions. This case study examines the Dermatology ECHO (Extension for Community Healthcare Outcomes) approach in treatment and management of complex and common skin diseases.

This clinical case report describes the presentation and management of a person experiencing an ST-segment elevated myocardial infarction (STEMI) in a rural Australian hospital emergency department (ED) setting and discusses the telemetric technology utilised in the management of STEMIs in the rural ED, the diagnostic ability of the modern electrocardiogram and the role of the frontline rural emergency clinician in the utilisation of such technology.

This Clinical Case Report describes low selenium level affecting thyroid function in an elderly man. Although the soil in the mid-western region of Western Australia is known for its richness in various minerals, parts are selenium deficient. Physicians should be aware of trace mineral deficiencies as bedside presentations.

Due to demographic changes, growing demands, technological developments and rising healthcare costs, analysis of resources in rural and urban primary care clinics is crucial. This study examined the urban–suburban differences in the indications for lumbosacral spine radiographs in a public primary healthcare centre in Malta.

Given the new Commonwealth and State interest in encouraging rural training pathways after graduation in Australia, it is important to gauge pre-graduate students’ level of interest in rural options. This study asked pre-graduating Western Australian medical students about levels of interest, and factors associated with interest in a full time rural internship.

Accessing relatively small populations spread over large geographical areas is a challenge of conducting research in rural and remote areas. This study investigated whether meaningful and informative data could be obtained from short responses from open-ended survey questions using an automated data analysis technique.

This study examines the extent to which rurality modifies the likelihood for acute healthcare use among veterans who use both Veterans Affairs (VA) and non-VA healthcare systems. Rurality appears to modify the effect of dual use on rates of ED visits for patients with heart failure. The authors suggest that additional attention to care coordination across healthcare systems is needed.

This study reviews the prevalence of pit and fissure sealing after its inclusion in the list of treatments covered by national health insurance in South Korea and investigates whether there is a difference in number of treatments between rural and urban areas.

This policy report describes how Memorial University of Newfoundland's rural focused medical school program is achieving its social accountability outcomes related to producing rural doctors. The authors use a geospatial approach to provide an in-depth look at their rural generalist pathways to rural generalist practice. They highlight lessons learned, including the importance of a collaborative commitment from government, university, practicing physicians, healthcare providers, patients, rural communities and their leaders.

Patients in rural China have long had inadequate access to quality medical services because of a concentration of medical resources in major hospitals in cities. This article reports on the Medical Service Unity approach, trialed in Funan county to tackle these issues by taking into account considers funding, patient and resource flow.

Small rural hospitals face challenges in attracting and retaining physicians. Over time, many have moved towards a hospitalist model of staffing. This project report describes an alternative model that has been successfully implemented for several years in a ten-bed rural hospital in Washington State. The author identifies increased physician satisfaction and potential cost savings associated with adoption of the model.

This Project Report describes the implementation of an expanded-scope physiotherapy service in a regional hospital emergency department in Australia and discusses the lessons learnt in terms of long-term sustainability of these roles in regional areas.

In the last 5 years, there has been a rapid rise in numbers of overseas trained medical graduates returning to country to work as interns across the Western Pacific. The varied level of clinical knowledge and skill of these graduates led to the development of workshops to equip clinical staff with the education and supervision skills to optimise teaching and learning opportunities in clinical settings for these new graduates of foreign medical programs.

This personal view article provides critical commentary on the current state of end-of-life care for First Nations persons living on reserve. They identify a need to raise awareness regarding culturally sensitive care for this population.

This Personal View is a student's reflections on her rural placements in the Shetland Islands.

Many guidelines outline best practices for health program monitoring and evaluation (M&E), but best practices are often not resourced or feasible. This paper describes how M&E has been conducted for a health service delivery improvement program in remote Papua New Guinea and outlines lessons learned.

Telepsychiatry has become an important component of rural health care, but cultural factors influence how comfortable patients are with telepsychiatric services. Considering cultural factors when planning and implementing telepsychiatric services may contribute to the success of these services and increase their use in rural and remote populations.

A review of Appalachian Health and Well-Being, edited by Robert L. Ludke and Phillip J. Obermiller.

The WHO recommends delaying umbilical cord clamping until 1 min after birth for term and pre-term infants who do not require positive-pressure ventilation, increasing an infant’s blood volume and birth iron stores. This Research Letter reports on a project to promote delayed umbilical cord clamping in a rural Mexican hospital.

This study highlights the fact that those GPs and specialists  who choose inland and coastal regional centres may have different location drivers. Environmental attributes such as the beach, in addition to  professional factors like work variety and work place culture, have high rankings for GPs and specialists resident in coastal locations. In contrast, their inland counterparts have significantly lower values for locational factors but share high values for professional factors. Recruiting for inland locations should consider concentrating on factors promoting professional satisfaction because this may be the most potent issue for these clinicians.