Volume 21

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the decision that an article about people in any country or region without authors from that country or region will not be published and a recent RRH article provides an excellent example of how communities can be meaningfully engaged in research.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 population in Japan continues to age, and this is more pronounced in rural than urban areas. The relationship between rural elderly patients’ improvement in motor and cognitive function in relation to activities of daily life (ADL) through rehabilitation and their discharge to home has not been clarified in rural communities. This study investigated whether an improvement in ADL for elderly hospitalized patients allows them to be discharged to their home in a rural community.

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.

The use of Implantable Cardioverter Defibrillators (ICDs) is increasing in both New Zealand and Australia, but little is known about the experiences of ICD recipients living in rural contexts. This study investigates whether living rurally impacts the ICD recipient experience and that of their partners.

Physical activity can make significant differences in supporting the prevention or treatment of chronic diseases, ensuring that people experience active old age. This study investigates the relationship between the physical activities of adults living in rural areas of Turkey and each component of the Transtheoretical Model, an integrative theory of therapy that assesses an individual's readiness to act on a new healthier behavior.

In long-term care, effective communication among healthcare professionals is vital to reduce inappropriate emergency transfer and eventual death in hospitals. As nursing homes lack adequate healthcare resources in rural areas, information and communication technology (ICT) can reduce the burden on professionals. This study investigated whether the application of ICT-based communication can reduce the number of emergency transportations to, and death in, hospitals in rural facilities.

This study examined rural healthcare bypass behavior in the United States – assessing patients' use of health care outside of their local community resources. Findings suggest that policymakers and healthcare workers can utilize the social vulnerability of place index (SoVI) to better understand and address bypass behavior in rural areas.

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.

Turkey, which suffers from both undersupply of physicians, nurses and midwives and inequitable distribution of healthcare personnel, has been developing and implementing various policies to solve this problem. This study takes a closer look at the impact of policies implemented to reduce the imbalance in the distribution of human resources for health for the last fifteen years in Turkey.

Challenges to addressing workforce maldistribution for equitable rural healthcare access continue, including for dermatology services. This qualitative study explores the topic of working in a rural area from the perspectives of dermatologists and dermatology trainees.

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.

This original research article examines dual roles – when healthcare professionals experience intersections of professional and personal relationships – in rural long-term-care (LTC) settings. Based on a multi-site study of a rural LTC, the authors suggest several considerations for policy and practice.

Having a stoma after bowel surgery is associated with inferior quality of life (QoL). Care of patients with stoma-related problems is usually reliant on hospital-based stoma nurses and surgeons. This study reports on the impact of distance to nearest hospital on the QoL of rectal cancer patients who receive a stoma at index surgery.

Women in rural and regional areas encounter challenges when accessing care for gestational diabetes mellitus (GDM). This study reports on a clinical audit of women accessing the GDM service at a large regional hospital and explores the feasibility and acceptability of a telehealth venture to enhance management of GDM from the perspectives of women with GDM and health service staff.

The field of disability studies is a contested area of research that has transformed significantly over the past three decades. The move away from the medical model of disability in the early 1980s created opportunities for the voices of people with disabilities to be heard. However, research into the lived experiences of this population has historically relied on proxy accounts and, where first-person accounts have been included, people with disabilities have often been excluded on the basis of cognitive-communicative (dis)ability and language proficiency. This article explores the ways in which space and place influence the lived experience of disability in a rural South African context.

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 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.

Chronic medical workforce shortage and maldistribution continues to be a significant challenge in rural Australia. The Rural Clinical Schools (RCSs) program helps to alleviate this problem with evidence of increased rural location in graduates of rural training programs. However, rural work intent may change during the years after completing a rural placement. This qualitative study investigated the factors involved in the change of career intention from rural to urban work location among the Australian National University Medical School Rural Stream alumni.

Occupations are the everyday activities that people choose to engage in individually or as groups that bring meaning and purpose to their lives. This study explored the occupations of school-going adolescents of Pitseng, Lesotho, to gain insight into adolescent behaviour, and the strategies needed to develop sustainable health promotion programmes for adolescents in this area.

This mixed methods study sought to explore the use of dating apps amoung men who have sex with men (MSM) in rural areas of the southern United States, and the potential to use dating apps to deliver HIV prevention information. Dating app use was found to be high amongst rural MSM, with individuals using dating apps more likely to be interested in pre-exposure HIV prophylaxis (PrEP).

The early closure of the Voluntary Dental Graduate Year Program and the Oral Health Therapy Graduate Year Program by the Commonwealth Government adversely impacted NSW Aboriginal Community Controlled Health Services. This led to the co-design of a small-scale oral health therapy graduate year program known as the 'Dalang Project', which enabled oral health therapists to engage with local Aboriginal communities and implement culturally competent, practical and evidence-based oral health promotion activities. This paper provides an overview of the Dalang Project and its evaluation.

This study evaluated pilot community paramedicine (CP) programs from the perspectives of paramedics to gain program recommendations related to both rural and urban settings. Researchers distributed an online questionnaire to paramedics with and without CP experience employed at eight emergency medical services providers in northern Ontario. Results demonstrate the value of CP and indicate areas for CP program inprovement.

This qualitative study explores barriers to accessing contraceptives in a rural, culturally conservative area in the USA. The authors reflect on how a Federally Qualified Health Center adapted to their cultural setting, by integrating contraceptive services into their primary care model. This ensured that every woman seeking primary care was screened for contraceptive need, offered contraceptive counselling and comprehensive contraceptive methods. Recommendations to further strengthen the responsiveness of services are provided.

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.

Access to health care in developing countries is scarce. One solution to this problem has been for doctors from the USA to provide single-visit care through short-term medical service trips. There is interest in using ultrasound imaging as a portable diagnostic tool; however, data describing its usefulness are scarce. This study determined the usefulness of portable ultrasound imaging during a medical service trip to rural Guatemala.

O acesso aos cuidados de saúde nos países em desenvolvimento é escasso. Uma solução para esse problema tem sido os médicos dos EUA fornecerem atendimento em uma única consulta por meio de viagens de serviço médico de curto prazo. Há interesse em usar a imagem de ultrassom como ferramenta de diagnóstico portátil; no entanto, os dados que descrevem sua utilidade são escassos. Este estudo determinou a utilidade da imagem de ultrassom portátil durante uma viagem de serviço médico à zona rural da Guatemala.

Slaughterhouse workers are at high risk of accidents and pathogen contamination. Although cattle production is a big industry in Brazil, there are illegal operators in the countryside outside several Brazilian cities. This illegal activity represents severe risks to the health of consumers and slaughterhouse workers. This article reports on the first study to analyze the health of illegal slaughterhouse workers in rural Brazil.

Trabalhadores em matadouros apresentam alto risco de acidentes e contaminação por patógenos. Embora a pecuária seja uma grande indústria no Brasil, existem operadores ilegais no campo fora de várias cidades brasileiras. Essa atividade ilegal representa graves riscos à saúde dos consumidores e trabalhadores dos frigoríficos. Este artigo relata o primeiro estudo para analisar a saúde de trabalhadores clandestinos de frigoríficos no interior do Brasil.

Smear-positive pulmonary tuberculosis (PTB) requires rapid diagnosis and treatment to prevent ongoing transmission. Collection of two sputum specimens is considered the minimum requirement for the diagnosis of PTB but current guidelines in the Torres Strait Islands, Australia, recommend three sputum specimens, which frequently delays treatment. This retrospective study investigated all PTB cases diagnosed between 2000 and 2018 in theTorres Strait Islands and found that two good quality specimens ensures adequate diagnostic yield for PTB and a third specimen should only be collected from patients with two negative specimens who have persistent symptoms.

Rural hospitals in New Zealand provide broad generalist clinical services, including procedural sedation and analgesia. This study explores patterns of procedural sedation use by rural hospitals including indications, equipment, medications, logistical and medical staff support available, and whether current professional guidelines support rural sedation practice.

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.

Type 2 diabetes mellitus (T2DM) and social disadvantage are related. In Australia, this association is most pronounced amongst Indigenous people. Indigenous Australians are among the most socially disadvantaged in the country, with the worst social determinants of health (SDoH). This study combines the perspectives of Indigenous Australians with T2DM and Indigenous health workers to explore the SDoH-related barriers and facilitators to self-managing T2DM, and how SDoH could be incorporated into usual clinical care for Indigenous Australians with T2DM.

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.

This study examined healthcare utilization and access to care for rural adults with Inflammatory Bowel Disease (IBD). This manuscript reports on the qualitative findings of a larger mixed-methods study that involved patient and family advisors as active and equal team members in decision-making throughout the project. Findings suggest several methods for improving access to care in rural areas that can increase disease remission, decrease direct and indirect care costs, and promote quality of life in individuals with IBD.

The oral health of Indigenous children in Canada and globally is a major public health issue, with 80% of First Nations children and 71% of Inuit children between the ages of six and eleven having experienced early childhood caries. This focused ethnographic study used participatory research principles to explore oral health experiences and understandings of children and youths in two Anishnabeg communities in Quebec, Canada.

Access to wheelchairs for most of the South African poor population is through accessing rehabilitation services at public health facilities. This study explored access to wheelchair services from the perspective of rehabilitation therapists within the uMkhanyakude district of KwaZulu-Natal, South Africa.

Stroke patients living long distances from a hospital are unlikely to receive time-critical reperfusion treatment. This study investigated whether inexperienced transcranial ultrasound users could acquire diagnostic images after brief training, and thus facilitate acute care in remote and rural areas.

Chronic respiratory disorders are highly prevalent among Australian Aboriginal people living in the Top End Health Service region, Northern Territory of Australia. Bronchiectasis is a heterogeneous disease that features among these chronic respiratory conditions in this population. This retrospective study compares the demographics, clinical characteristics and relevant laboratory parameters among adult Aboriginal and non-Aboriginal patients diagnosed with bronchiectasis between 2012 and 2017.

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.

Rural physicians face many challenges with providing rural health care, which often leads to innovative solutions. Despite this, there is a lack of support for rural health research – an area of health care where research makes great impacts on small communities. This article describes the rural research capacity building (RRCB) ecosystem and explains how the 6for6 and Rural360 programs at Memorial University of Newfoundland address the need for RRCB.

Distance learning methods have long been an integral part of medical education in rural and remote settings, but the global coronavirus crisis has stimulated a rapid shift in medical education everywhere from predominantly face to face to being delivered online. As thinking and practice in distance learning have developed, the idea of distance learning (in which the central institution delivers teaching and learning resources to remote learners) is changing to distributed learning (where the institution itself distributes its functions to be near those students). This Commentary examines the design and management of distributed learning.

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.

Indigenous Peoples around the world are disproportionately affected by mental health challenges due to intergenerational and collective trauma stemming from historical losses and ongoing colonialism. Mental wellness initiatives may be more successful and sustainable when they are developed for and with Indigenous communities using community-driven approaches that prioritize and privilege Indigenous leadership, knowledge systems, beliefs and practices. This scoping review of studies on Indigenous community-based mental wellness initiatives found that culture was a central theme of such initiatives, but identified a lack of cultural leadership in many research studies. The authors argue that initiatives must be guided by local Indigenous knowledge, improved or renewed connection to land, fostering community strengths, and the sharing of roles and responsibilities among those involved in this work.

This paper considers the role of governance in Indigenous medical education research through the lens of an Australian Aboriginal research project titled Healing Conversations. The Healing Conversations Project is developing and testing a targeted educational framework for improved clinical communication between healthcare practitioners and Australian Aboriginal peoples in regional and urban locations.

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.

Due to global nursing shortages, recruitment and retention of nurses is a major international concern, exacerbated in rural and remote areas. This review explores the influences on nurses’ decisions to work in rural and remote healthcare settings to inform recruitment and retention strategies.

Virtual trauma supports, coined teletrauma, is one solution to address gaps in rural trauma care. This scoping review of the literature identified benefits of teletrauma services for rural and remote areas. The authors also identified a number of factors associated with teletrauma use, such as patient age, injury type and severity. The authors reflect on gaps in current teletrauma research, including how different teletrauma technologies may support or hinder rural trauma care and how interprofessional relationships influence teletrauma encounters.

This rapid literature review aimed to inform the development of a new sustainable, evidence-based service delivery model for ear, nose and throat services across Cape York, Australia. The study investigates the research question ‘What are the characteristics of successful outreach services that can be applied to remote-living Indigenous children?’.

A 5-year-old girl presented to the coronavirus assessment centre on a remote Scottish island with symptoms consistent with COVID-19, including an irregular pulse. To minimise potential spread of coronavirus in the healthcare setting, a portable ECG device was immediately delivered to the patient with the ECG tracing being sent electronically to the cardiologist, who was then able to communicate a diagnosis to the parents within 2 hours of the initial contact.

Women in the climacteric period present a wide variety of symptoms that can affect their daily life. Latin American women tend to report more severe climacteric symptoms compared with other parts of the world. In Peru, the severity of symptoms might be intrinsic to the community in which the women live, such as altitude or lifestyle. Understanding the variation of climacteric symptoms among geographically distinct communities could contribute to improving women’s quality of life. This study evaluated the severity of climacteric symptoms among two Peruvian communities.

Las mujeres en su climaterio presentan una gran variedad de síntomas que pueden afectar su vida diaria. Las mujeres latinoamericanas tienden a reportar síntomas climatéricos más severos que en otras partes del mundo. En Perú la severidad puede ser intrínseca de la comunidad donde las mujeres viven y sus condiciones como altitud o estilos de vida. La comprensión de la variabilidad de estos síntomas entre comunidades geográficamente distintas podría contribuir a mejorar la calidad de vida de las mujeres. Este estudio evalúa la severidad de síntomas climatéricos entre dos comunidades peruanas.

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.

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.

Paederus dermatitis (PD) is a skin reaction to paederin, a chemical produced by beetles of the genus <i>Paederus</i>. This Short Communication investigates the clinical manifestations and progression, seasonal variation and environmental factors associated with PD among patients attending the outpatient dermatology clinic of Siriraj Hospital, Thailand.

Delivering safe, reliable quality health care involves ensuring the workforce has access to the right training at the right time wherever healthcare workers are practising, a particular challenge for rural and remote health practitioners. This paper shares the development of a national Managed Educational Network for clinical skills and how its principles were used to analyse the performance of a mobile simulation delivery unit.

According to global estimates, 39 million people suffer from blindness and 285 million are at risk of severe vision loss, with a significant portion of this burden in Sub-Saharan Africa. Some African nations like The Gambia are beginning to tackle vision impairment by addressing the problem through a health system lens. This study reports on the use of a health system framework, focusing on system areas of leadership and governance, resources for vision care and vision care access, to understand and analyze how The Gambia has increased access to vision care using a public&ndash;private pilot partnership.

As a result of the COVID-19 outbreak in Tasmania, Australia, two hospitals were closed, all patients discharged or moved and the entire staff furloughed for 14 days. During the furlough period, a decommissioning, terminal clean and recommissioning process was undertaken. This paper describes the process undertaken from the perspective of a small management group to close, clean and reopen the hospital, providing a foundation for site-specific adaptation to include in pandemic escalation plans in other regional and rural settings.

Cancer is a leading cause of death in Samoa. Cultural beliefs shape attitudes towards disease and disease prevention in Pacific countries, and are a barrier to engaging in cancer screening services. This article reports on the results of a survey of Samoan adults about their beliefs about cancer causation.

Older adults are at significantly higher risk for morbidity and mortality associated with COVID-19, and are hesitant to seek health care due to fear of exposure. This project report describes an outreach effort to older adults living in rural West Virginia by their established healthcare providers. The project demonstrates the older adults' preference for, and the appropriateness of, telephone calls compared with more complex teleconference methods. The authors suggest that systematically calling older rural patients during the COVID-19 pandemic represents an effective care strategy.

This project report assesses current practice and future plans for physicians' delivery of maternity care services in rural areas of Kansas. Findings suggest serious shortages in rural maternity care. The authors also suggest a need for further research to investigate the need for incentives and affects on maternal and newborn health.

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.

International electives and exchange programs for medical students have sometimes been criticized as providing little benefit for host institutions. This personal view is offered as an example of how international electives may contribute a helpful comparative perspective on a local healthcare systems, in this case, primary care.

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.

Responding in the Scottish Outer Hebrides presents a number of challenges above and beyond standard prehospital work owing to its remoteness and the limited resources available on the island. As a prehospital physician, it is important to have an excellent working relationship with all local emergency services and with the wider community. One’s emotional resilience will be tested when responding and living in a rural setting, when you are far less removed from the tragedies you encounter.

Aboriginal people are less likely to access dental services and have twice the rate of untreated dental caries compared with other Australians. This study compares two models of service delivery designed exclusively for Aboriginal people: (1) fixed clinic in a major city with visiting services to rural areas; and (2) clinicians within rural communities and existing community facilities.

This Research Letter reports that health professionals in rural areas of Japan support interprofessional collaboration and education, and this may contribute to retaining health professionals in rural clinical settings.