Volume 22

Indigenous cultural identity has been suppressed by the conventions of academic publishing. This sees author and subject credibility resting on Western views of provenance, including institutional affiliation, college membership, educational qualifications and disciplinary background. This research colonialism reflects a power imbalance that must end. In this Editorial, three rural health research journals jointly announce their commitment to 'nothing about Indigenous Peoples, without Indigenous Peoples'. Articles submitted about any Indigenous community must have an Indigenous author or provide evidence of participatory engagement with the Indigenous communities.

Evidence on the association of socioeconomic deprivation with occurrence of acute myocardial infarction is available from international studies and urban settings in western Germany. This study examines this association in rural eastern Germany.

In countries such as New Zealand, where there has been little community spread of COVID-19, psychological distress has been experienced by the population and by health workers. COVID-19 has caused changes in the model of care that is delivered in New Zealand general practice. This study explores whether these changes have resulted in different levels of strain between rural and urban general practices.

The podiatry needs of rural populations are poorly addressed, partly because of workforce maldistribution. Encouraging emerging podiatrists to work in rural areas is a key solution. This study explores recently graduated podiatrists’ perceptions regarding working rurally and broader industry views of the factors likely to be successful for rural recruitment and retention.

Evidence suggests people living with Parkinson disease benefit from coordinated health care provided by a team of specialists. People who live in rural areas face additional challenges in accessing this care. This study tested the feasibility of providing a coordinated, multidisciplinary telehealth program to people with Parkinson disease living in rural areas of the USA.

Anemia is a global public health issue that mainly affects children under five years old. In Peru, despite the  reduction in the prevalence of anemia between 2010 and 2018, anemia remains a major concern, especially in high-risk zones such as rural areas. This study examines the difference in anemia prevalence between urban and rural areas and its spatial distribution in Peruvian children aged 6 to 59 months.

Although sedentary behaviour and low levels of physical activity are two of the main risk factors for non-communicable diseases, little research has been conducted to compare these behaviours in rural and urban settings, especially in low- and middle- income countries. This could be because of the misleading notion that rural people are less sedentary than urban people. This study compares differences in physical activity indicators and TV-viewing according to area of residence and sociodemographic variables in Brazil.

Rheumatoid arthritis (RA), a chronic inflammatory disease that causes functional limitation, disability, and deterioration of quality of life without adequate and timely management, is the most prevalent inflammatory arthropathy worldwide, and is estimated to affect 0.5–1% of the global population and 0.6–6.8% of the Indigenous peoples of the USA, Australia and New Zealand. This study describes attitudes, cultural knowledge, and therapeutic practices of the Misak people of Colombia concerning RA with the aims of strengthening relationships between the community and health professionals and building on an emergent culturally sensitive healthcare model.

Within an Australian health context, the fundamental diagnostic tool used by medical staff is the biomedical interview or history taking, which is based on a battery of direct questions. Similarly, many health professionals rely on patient questions to prompt the sharing of information, or to make them aware of gaps in communication. This is problematic for many First Nations peoples, including Yolηu (First Nations people of North-East Arnhem Land), who are culturally less inclined to use direct questioning as it is deemed impolite within their cultural context. This study addresses an important research gap by exploring the experiences and perspectives related to the use of questions in clinical interactions with one cultural group, speakers of Yolηu languages from East Arnhem Land. Potential strategies to overcome any identified communication barriers that questions pose are also explored.

Complications of pregnancy and childbirth are a major cause of adolescent death and babies who are born to adolescent mothers are 50% more likely to die than babies with adult mothers. The adolescent birth rate in Indonesia is high. This study identifies the determinants of adolescent birth in Indonesia.

Health professional leaders are key informants working at senior levels in various health facilities in the areas of policies and planning processes, and human resources. On the basis of a focus group discussion in three randomly selected hospitals, this study explores the factors affecting the nursing shortage in Vanuatu and recommends measures and interventions to resolve the shortage.

Community Health Workers (CHWs) are effective in sensitising people to diabetes mellitus (DM) and diabetic retinopathy (DR). In Fiji, CHWs attended a one-day DR awareness training course to provide communities with adequate basic knowledge about DM and DR to improve awareness and enhance referrals for DR screening and treatment. This study reports on the impact of this training on CHW knowledge of DR and referral practices in Fiji.

Primary health care, the cornerstone of health systems, has an important role in infectious disease control. The SARS-CoV-2 (COVID-19) pandemic has put a burden on health systems worldwide and especially on healthcare workers in remote areas of Greece. This study investigates preparedness and awareness level of primary healthcare workers and their risk perception in managing the pandemic during its initial phase.

This study contributes to understanding of the challenges experienced by rural healthcare providers in diagnosing and managing traumatic brain injury in their patients. Results from this qualitative study, involving 18 healthcare providers, point to several challenges and barriers to care as well as opportunities to overcome these challenges.

Compared with urban populations, people living in rural areas can have less access to healthcare services, essential health treatment, and health professionals in an emergency. This study explores the experiences, beliefs and attitudes of nursing students performing health screening in rural areas. Findings from this study include the positive feelings of students about rural nursing, the characteristics of rural nursing and the advantages and disadvantages of doing health screening in rural areas. The authors suggest healthcare services in rural areas should be planned by taking these experiences into account.

Pain is a common and distressing symptom in people living with cancer that requires a patient-centred approach to management. Since 2010, the Australian Government has invested heavily in developing regional cancer centres to improve cancer outcomes. This study explores patient and carer experiences of care from a regional cancer centre with specific reference to cancer pain management.

Like many countries around the world, Scotland faces a shortage of general practitioners (GPs) due to increased workload and recruitment and retention issues. Such workforce shortages are of particular concern in rural areas.To maximise the effectiveness of strategies to improve GP retention, it is vital to understand what affects the job satisfaction of Scottish GPs. This study compared the job satisfaction, job stressors, job attributes and intentions to reduce work participation of rural and non-rural Scottish GPs.

Maternal suicide is one of the leading causes of maternal death across the world and maternal depression is particularly common in low and middle-income settings. Early detection and treatment of maternal depression and suicidal thoughts are important for reducing maternal morbidity and mortality and help-seeking by pregnant women plays a crucial role in this. Limited availability and accessibility to health care, poor knowledge of depression and the help-seeking process itself can all be barriers to women seeking help. This study explores the help-seeking intention and behaviours of pregnant women with depression and suicidal thoughts in rural Sri Lanka.

Declining house-call rates have been documented worldwide; however, up-to-date data on current rates are lacking, particularly in rural settings. Systematic reviews in this area are inconsistent, but other work, principally qualitative research, demonstrates benefits for both doctors and patients. This study establishes the current rate of, and reasons for, home visits in a rural general practice setting in the north-west of Ireland.

In Bhutan, a small, mountainous country in South Asia situated between India and China, noncommunicable disease (NCD)-related morbidity and mortality have been rising. In 2019, Bhutan’s Ministry of Health introduced a set of interventions associated with the World Health Organization’s Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Income Settings (PEN HEARTS). This initiative encompassed six components: healthy lifestyle intervention; evidence-based protocols; access to medicines and technology; risk-based management; team-based care; and systems monitoring. Evaluations of PEN interventions in other countries documented barriers to implementation. This report provides the results of a 2019–2020 evaluation assessing implementation of PEN HEARTS in Bhutan and initial impacts on provision of care for NCDs and patient outcomes.

Recruiting and retaining qualified rural health workforce is of global significance. This study used a novel method, machine learning, to examine predictors of rural practice in the state of Utah in the USA. Income emerged as the most important factor associated with rural practice, followed by rural upbringing, updating earlier research and providing new insights into the literature.

Emergency Department (ED) utilisation continues to increase, particularly for primary care presentations that do not require high level ED services. The reasons for this are complex and research has focused on patient perspectives in choosing where to seek care rather than those of ED and general practice (GP) providers. This study addresses this gap by exploring the views of ED and GP providers regarding ED utilisation for primary care type health conditions in a small, remote city in Queensland, Australia.

Achieving high immunisation rates is a priority for public health units in Australia. Aspiring to 95% coverage rates for all children, regardless of financial or geographic barriers, is a national strategic aim. While immunisation is well supported in Australia, and most children are fully immunised for their age, pockets of low coverage exist. This study presents a deeper understanding of the reasons for low coverage.

Recruiting and retaining rural primary healthcare professionals is a global healthcare problem. In this qualitative study, Canadian medical educators and institutional leaders were asked about medical education approaches that helped prepare students for rural practice. The authors found that preparing students for rural careers is influenced by many factors, including interpersonal relationships, medical education curriculum, and the personal characteristics of students. The key informants suggest that future research could use the complex systems theory to improve understanding of how to support medical learners in their preparation for rural careers.

Stunting is still a prominent health problem in Indonesia, particularly in children from poor families or living in rural areas. This study examines the factors associated with stunting by socioeconomic status and area of residence in Indonesia.

This article presents the results of research that utilised Behavioral Risk Factor Surveillance System data to evaluate the prevalence of breast cancer and colorectal cancer screening by urban–rural locations. The authors present considerations for screening initiatives that can target rural regions and racial groups.

Scotland’s healthcare system includes six rural general hospitals that provide a full surgical service to the most remote and rural populations. Constraints of geography and finance, and population need, mean that local delivery of surgical services will be required for the foreseeable future, but these rural hospitals face difficulties in recruiting suitably trained general surgeons. This study describes Scottish surgical trainees’ attitudes towards training and working in remote and rural surgery, perceived barriers to recruitment and potential solutions.

Compulsory rural service is one method of addressing limitations in access to health care in marginalized areas of low- and middle-income countries, including Guatemala. This study explores Guatemalan medical students’ experiences of compulsory rural service and the impact of rural service on their professional development.

Falls are prevalent in patients with Parkinson Disease (PD). Previous work has focused on the impact of motor and non-motor symptoms on falls, but has ignored the impact of environmental factors, such as rurality of residence, economic level and quality and availability of caregiving. This study investigates the prevalence and risk factors of falls in patients with PD and explores the impact of rurality on falls.

Brazil is rapidly becoming an aged country, with 30 million of the 213 million inhabitants aged 60 years or over. Nearly 4.5 million (15%) Brazilian older adults live in rural areas. Despite the advances in primary health care coverage in Brazilian rural areas, provision of adequate health services for rural populations is particularly challenging. This study presents the methods used to design a prospective cohort study with older adults from a rural area in the far south of Brazil (EpiRural Cohort Study) and also describes the cohort profile.

There are approximately 90 Aboriginal and Torres Strait Islander community controlled art centres located across Australia, the majority in geographically remote locations. This national survey of art centres explores how they are supporting older people, including people living with dementia, if and how they are collaborating with aged care services and what challenges and opportunities they identify in these arrangements.

Lack of awareness about diabetes has been linked with a high prevalence of undiagnosed diabetes and previous research has identified poor awareness of diabetes in several low and middle-income countries. India has the second highest prevalence of diabetes globally. This study reports on awareness of type 2 diabetes and how sociodemographic factors influence diabetes knowledge in a rural population of Tamil Nadu, India.

Rural generalist (RG) doctors are broadly skilled to provide comprehensive primary care, emergency and other specialist services in small, distributed communities where access is otherwise limited because of distance, transport and cost limitations. In Victoria, Australia, the Victorian Rural Generalist Pathway (VRGP) represents a significant state-wide investment in training and growing the next generation of RGs. The first step of the VRGP is well established through the Rural Community Internship Training program; however, the second step (RG2) requires expansion by growing supervised learning in small rural communities where RGs will eventually work. This study examines enablers and barriers to the supervision of RG2 learners across a core generalist curriculum in distributed towns in three rural Victorian regions.

Vaccination is considered an key element in the prevention of COVID-19, but rural Americans are less likely to be vaccinated compared to their urban counterparts. This explorative qualitative study considers perceptions related to COVID-19 vaccination among rural Oklahomans, with the goal of informing strategies to address vaccine hesitancy. Perceived benefits of vaccination, as well as barriers to vaccination are described.

Over the course of the COVID-19 pandemic, Australian general practices have rapidly pivoted to telephone and video call consultations for infection control and prevention. Initially, these telehealth consultations were required to be bulk billed (doctors could only charge fees equivalent to the national Medicare Benefits Schedule). There was concern that bulk billing only policies could have a broader impact on rural practices, which may rely on mixed or private billing for viability in small communities where complex care is often needed. This study explores the patterns of bulk billing nationally and describes the characteristics of practices more or less likely to bulk bill patients, to identify the potential impact of a rapid shift to bulk billing only policies.

While vaccination is a key strategy in reducing morbidity and mortality from COVID-19, vaccination rates vary widely. This study examined the influence of political affiliation, religious identity, and rurality on vaccine hesitancy in the US state of Oregon. In multivariate analysis, White Christian identity and political affiliation with Trump in the 2020 election explained 84.1% of the variability in COVID-19 vaccination status in Oregon counties, with population density also found to be a significant influence. The author recommends public health agencies partner with religious leaders to address vaccine hesitancy in rural, conservative, religious communities in Oregon.

Children with deep-partial or full-thickness burns often require complicated post-surgical care and rehabilitation, including specialist occupational therapy (OT) intervention, to achieve optimal outcomes. Those from rural and remote areas rarely have access to these services and must travel to a tertiary referral hospital to access follow-up, placing them at higher risk of complications and poorer outcomes. The OT-led Paediatric Burn Telehealth Review (OTPB) Clinic, based at Townsville University Hospital in northern Queensland, Australia, was set up to address this inequity. This study investigates the experiences of family members and clinicians in using the OTPB Clinic.

Women and children in Uganda and other low- and middle-income countries are exposed to disproportionately high levels of household air pollution from biomass smoke generated by smoke-producing cookstoves, especially in rural areas. This population is therefore particularly vulnerable to the negative health effects caused by household air pollution, including negative pregnancy outcomes and other health issues throughout life. This study reports on the perspectives of midwives, Village Health Team members and mothers on the long-term impact of an education programme on lung health implemented by The Midwife Project, a collaboration between research and health teams in the UK and Uganda.

Opioid use disorder (OUD) is a major public health issue in the USA, particularly in rural communities. This study describes how a research team in Virginia used the Stakeholder Engagement in Question Development and Prioritization Method (SEED) to engage the community in creating a roadmap to address OUD in their community. Focus groups provided information that community stakeholders used to develop strategies they felt were needed in their community, and which they felt empowered to implement.

Low- and middle-income countries often face the issue of unequal distribution of healthcare services and human resources between rural and urban areas. Globally, there are many factors that negatively affect the willingness of physicians to work in remote and rural areas, including low wages, poor living conditions, poorer and sicker patients, suboptimal equipment and supplies, and a lack of quality infrastructure and transportation. This study explores the perceptions of barriers and facilitators of medical entrepreneurship and the impact of medical entrepreneurship on the served communities among the owners of private medical practices in rural and semirural areas of Armenia.

The geographic maldistribution of physicians is a serious problem around the world. Evidence suggests that increasing the number of primary care specialists will help to improve the urban–rural gap in physician supply. This study compares the geographic distribution of family physicians in Japan and the USA – two developed countries without a major system for physician allocation by the public sector, but which differ greatly in the maturity of family medicine (ie length of its history as part of the healthcare system and the population of qualified family medicine experts).

The current SARS-CoV-2 coronavirus epidemic (COVID-19) and the confinement strategies that have been implemented to stop the spread of the virus are wreaking havoc on physical activity, mental health, diet and economy at the global level. The catastrophic effects on employment, working hours and incomes that COVID-19 has had throughout the world are repeated in Latin America. This study determines the relationships between symptoms of anxiety and anhedonia and diet quality during confinement due to COVID-19 in rural populations of 11 Latin American countries.

Chronic non-communicable diseases are one of the biggest public health problems worldwide. In Brazil, the population is aging and these diseases are prevalent in 70% of elderly people. Many diseases that affect the osteoarticular system cause chronic pain. This study reports on the prevalence and associated factors of self-reported chronic lower back pain in elderly people living in rural riverside areas in the Amazon.

Rural populations have disproportionately higher injury hospitalisation rates, higher morbidity and mortality rates and higher costs than patients injured in major cities. Poorer outcomes arise from inefficiencies in one or more potentially modifiable factors in the chain of survival. This Commentary discusses the burden of injury in Australia, presents a brief history of retrieval services in Queensland and discusses how remoteness requires a different kind of service delivery from point-of-injury to definitive care.

Virtual Health Care (VH) provides new opportunities for rural healthcare delivery but also highlights and exacerbates inequities in care. This Commentary describes the implementation of equity-informed knowledge translation processes in rural British Columbia, which can help address these inequities and improve VH for rural regions.

The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems that have been perpetuated by traditional health professional education. The authors of this Commentary contend that we must seize this moment to transform medical education and produce a fit-for-purpose health workforce, ready to respond to pandemics and address social injustice and inequality.

This Commentary considers the use of spatial analysis to depict rural and remote allied health and disability services in Queensland. It suggests that such quantitative approaches to understanding 'thin markets', 'market sufficiency' and 'market diversity' are insufficient. The authors suggest additional considerations that should inform policy, funding and service planning decisions.

This paper investigates whether ‘inclusive’ health systems increase societal welfare, as expressed through estimates of healthy life expectancy (HLE). The analysis uses OECD data to explore the relationship between HLE at the age of 65 and four variables that are representative of institutional ‘inclusivity’ or ‘extractiveness’ of health systems. The development of health policies that aim to strengthen 'inclusive' institutions could have a significant positive impact on collective welfare and social cohesion – especially for populations in rural, remote and less developed parts of the world.

This review of Larry Krotz's book "Nothing Ordinary" highlights the contribution the book makes to the literature on rural medical education. The reviewer characterizes the book as an "enjoyable and informative" read that "comes alive with descriptions of places and accounts of the people closely involved" in creating "a successful socially accountable rural-focused medical school".

Rural and Remote Health, the Australian Journal of Rural Health and the Canadian Journal of Rural Medicine have committed to the editorial requirement that research published about Indigenous Peoples must genuinely engage Indigenous Peoples in all stages of the research process, including authoring manuscripts. This Commentary, published in all three journals, takes the next step. The authors propose the development of an Indigenous Cultural Identity of Research Authors Standard (ICIRAS) for health research publications. This would signpost the rights of Indigenous Peoples into academic publishing governance. It also aligns with the movement for integrating human rights into research with Indigenous and Tribal peoples. The ICIRAS is a call to action for research journals and institutions to rigorously improve research governance and leadership to amplify the cultural identity of Indigenous Peoples in rural health research and work towards genuine truth-telling and reconciliation.

Many older adults live in rural and remote communities that are experiencing population ageing at a faster rate than more urban communities, but not much is known about how to best deliver geriatric models of care in these settings. This systematic review identifies necessary key components of existing models of geriatric care serving rural or remote populations, including an evidence-based framework based on 8 distinct model characteristics that aim to support the ideal provision of effective and accessible geriatric medical care.

For rural and remote clinicians, quality education is often difficult to access owing to geographic isolation, travel, time, expense constraints and lack of an onsite educator. This integrative review investigates the telehealth education available to rural practitioners, evaluates current telehealth education models, establishes the quality of education provided through telehealth and presents recommendations for supporting and developing an education model for rural and remote health practitioners through telehealth.

Lesbian, gay, bisexual, transgender, intersex, queer and people with a diversity of sexual and gender identities (LGBTIQ+) residing in rural contexts may face additional challenges to attaining wellbeing, yet a comprehensive understanding of these experiences is lacking. This systematic review examines the wellbeing, healthcare access and experience and barriers and facilitators to health care for rural LGBTIQ+ communities.

What is known about Primary Health Care (PHC) in the Amazon? Health studies in the Amazon often focus on diseases and infections in the region, with few studies addressing health organisations and services. This scoping review explored the PHC implementations and their results in areas outside the urban centres in the nine Amazonian countries.

Providing postgraduate rural training programs has been recognized as central for successful recruitment and retention of a rural medical workforce. While there have been many documented cases of rural training program development, documented program outcome evaluations are few. This review investigates how postgraduate training and educational programs for rural and remote medicine are evaluated worldwide.

Gastroschisis, a birth defect of the abdominal wall in which the baby's intestines are found outside of the baby's body, is one of the most common congenital abdominal wall defects. Although a survival rate of up to 90% is now achievable in many settings, management remains a challenge in Papua New Guinea, where there are only 0.7 doctors and 5 nurses per 10,000 people. This Clinical Case Report describes the care of a preterm male baby born with gastroschisis in Papua New Guinea.

The COVID-19 pandemic challenged population health researchers to use remote data collection methods to avoid interpersonal interaction, but the feasibility in low-resource settings had not been investigated. This study reports on experiences from telephone interviews conducted among pregnant women in the Rajarata Pregnancy Cohort, Sri Lanka.

Coronavirus disease-19 (COVID-19), caused by the severe acute respiratory syndrome SARS-CoV-2, has become a global pandemic, giving rise to a serious global health threat. In Greece, early measures kept the first pandemic wave at a relatively small scale, but the reported morbidity and mortality caused by the second wave were among the highest in Europe, with many deaths and regions with increased incidence of COVID-19. This study evaluated the prevalence of SARS-CoV-2 infection based on diagnosis of IgG antibodies from blood serum in an observational descriptive cohort study in a semi-closed rural area of Greece after the second wave.

Seasonal influxes of influenza patients result in an increased demand for hospital beds. During peak periods, it is common for rural hospitals to experience bed block and increased risk of spreading hospital-acquired respiratory illnesses to patients and staff across the hospital, further exacerbating the bed block and placing additional strain on a system already worn thin by existing workforce shortages and limited resources. This study examines rural hospital bed management practices with a focus on the transfer of patients who are actively diagnosed with influenza and investigates the association of increased bed movement with the rate of nosocomial transmission and staff workload.

Infections bear a significant burden on healthcare costs worldwide. This Short Communication explores antibiotic and hospital-related costs of infections needing admission in a real-world setting.

Historically, some approaches to Aboriginal and Torres Strait Islander health research have been unethical. Greater accountability in the research process, transparency in reporting, and use of culturally appropriate research methodologies are key recommendations to improving the ethical integrity of research. This Project Report uses the CONSIDER statement (CONSolIDated critERia for strengthening the reporting of health research involving Indigenous peoples) to critically reflect on participatory research undertaken in partnership with an Aboriginal Community Controlled Health Organisation in the rural context and to identify lessons of value for future research.

Despite the increased understanding of Canadian rural and remote nursing in the past two decades, no nursing frameworks to guide rural and remote practice have been in place. Working with the Canadian Association for Rural & Remote Nursing (CARRN), a process was planned to develop a rural and remote nursing framework. This Project Report describes the process, the framework developed, implications of the framework and lessons learned from the development process.

Training healthcare workers is essential for Vanuatu, a Western Pacific Island nation, where the current ratio of healthcare workers is well below the WHO recommendations. In addition, the preparation of a highly skilled workforce has been shown to be essential to high quality patient care. Research evidence has consistently shown that nurses educated by bachelor degree improve patient health outcomes and reduce hospital length of stay. This Project Report describes the development and implementation of a new Bachelor of Nursing degree to provide a skilled, safe nursing workforce for the provision of health care to the people of Vanuatu.

This Project Report describes the creation of pilot program aimed at creating culturally responsive end-of-life (EOL) planning in American Indian and Alaska Native communities and offers suggestions for the development of toolkits on EOL planning with Indigenous communities.

Informed consent is the foundation for research participation. This Commentary explores how we inform patients, and challenges the Eurocentric model of an extensive written consent form. The author reflects on her experience seeking study participants in another country, culture and language, and how this shaped her perspective. She addresses the need for researchers to protect vulnerable individuals, recognizing that vulnerability comes in many forms.

In remembrance of Professor Denese Playford.

A clinical case report published in Rural and Remote Health in 2020 reported introducing an oral, centrally acting, alpha agonist sedative to the prescribed secondary prophylaxis (SP) regimen of IM penicillin for each of three Aboriginal children previously diagnosed with acute rheumatic fever (ARF). The living environments of the three children increased their risk for repeat group A Streptococcus infections and subsequent recurrences of ARF. The authors of this Comment find the clinical case report perpetuates a troubling tone about this singular priority for SP and present alternative perspectives and initiatives for consideration.

The COVID-19 pandemic affected provision of face-to-face outpatient services. Non-attendance in diabetes clinics potentially leads to suboptimal outcomes and poor utilization of resources. This Research Letter reports on the innovative solutions to service replacement during the pandemic of a paediatric diabetes service in rural Wales, including offering telephone clinics and drive-through clinics. Overall attendance for virtual clinics improved during the pandemic, although children who did not attend clinics pre-COVID were the same during the pandemic, suggesting clinic attendance for them needs further research to address reduced opportunity to access services.