Volume 23

Every year, an estimated 15 million infants are born preterm worldwide. Women residing in rural and remote areas of Australia experience increased rates of adverse perinatal outcomes and are at almost twice the risk of having a preterm infant than women residing in major cities. Mortality and morbidity rates are higher for preterm infants born in non-tertiary centres, thus women are generally transferred to metropolitan tertiary centres to give birth. This study investigates the experiences of women from rural areas who have had a preterm infant admitted to a neonatal intensive care unit.

Although the output from health training institutions is increasing in most low-resource settings, the rural workforce availability remains low and suffers frequent rural–urban attrition. Improved retention – having healthcare workers stay longer in the post – is likely to alleviate the crisis. We interviewed healthcare workers and policymakers in Malawi and Tanzania to explore their perspectives on factors affecting retention. While policymakers’ views centred around the national-level retention policies, health workers considered the welfare of families and the immediate community more important in deciding to stay or relocate from a post. This article highlights the need to align retention policies with healthcare workers’ expectations.

Severe mental disorders (eg major depressive disorder, bipolar mood disorder, schizophrenia and other psychotic disorders) affect 4% of the adult population globally and account for 26.1% of reported mental disorders in South Africa. Informal caregivers are the backbone of recovery for persons with severe mental disorders, particularly in rural areas where access to mental health services is limited. This article reports on the extent of subjective and objective burdens among informal caregivers of persons with severe mental disorders in rural South Africa.

Rural populations routinely rank more poorly than urban populations on common health indicators. Although the complex interplay of various social determinants of health may partially explain this, some of this disparity may result from unique challenges healthcare providers face in rural settings. This Original Research article identifies several multidimensional barriers to healthcare access by patients and provision by healthcare providers in rural western Pennsylvania, USA. Patients experience cost-related barriers, more providers are needed to combat workforce shortage and burnout, and care delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. The authors recommend that policy efforts target all these aspects to appropriately address rural healthcare needs.

Nurses are often on the frontline of disaster management, providing care to patients with physical, mental, and emotional turbulence and acting as educators for disaster prevention. However, the literature suggests that nurses are underprepared to respond to disasters. This study examined the preparedness for disaster response among nurses in rural and urban primary healthcare settings in Tanzania. The results suggest that nurses are poorly prepared for disaster responses, while those in rural settings are at a great disadvantage.

Chagas disease (CD), a devastating infectious disease caused by the protozoan parasite Trypanosoma cruzi, affects 6 to 7 million people worldwide, with 30,000 new cases reported each year. CD is endemic to 21 Latin American countries, but has spread more widely in recent decades. In Latin America, CD is spread most often via the feces of the 'kissing bug', which can infest housing, particularly in poorer rural areas. Prevention programs therefore often focus on the interruption of household transmission. This study evaluates current knowledge of CD among youth in the three communities of southern Ecuador.

Universal access to health services and universal health coverage are needed to achieve good health for all, yet rural communities face a variety of access barriers. As part of an effort to 'rural proof' health systems, it is therefore imperative to identify and act on the factors limiting access to health services by rural and Indigenous communities. This article provides a comprehensive overview of the wide range of access barriers faced by rural and remote communities and discusses the potential for barrier assessments to contribute evidence for rural proofing of national health policies, strategies, plans and programs.

Various reactions of the body are activated during stress, including activation of the hypothalamo-pituitary-adrenal endocrine axis and the autonomous nervous system. This activity can be assessed by the measurement of biological stress marker molecules – salivary α-amylase and cortisol – as well as heart rate, and blood pressure monitoring. This article reports on the stress levels produced by the daily professional routines of rural general practitioners in Bulgaria.

People residing in rural areas of New Zealand have poorer health outcomes than those living in urban areas and this is accentuated for Māori. Internationally, in high income-countries, rural hospitals have been recognised as important healthcare providers, improving access to and integration of health services for rural communities. It is estimated that around 15% of New Zealanders rely on rural hospitals for health care, but there is no current description of rural hospital services and little published research regarding their role or value. This Original Research article presents the results from an exploratory study of the perspectives of rural hospital leadership on the place of rural hospitals in the New Zealand health system.

With the worldwide shortage of physicians living and practicing in rural and remote areas, it is important to understand better the nature of rural practice. A recent study that investigated the lived experience of rural doctors introduced the concept of clinical courage: a rural doctor’s adaptability and willingness to undertake clinical work at the limits of their training and experience to meet the needs of their patients. This article describes the steps taken to develop a sound clinical courage questionnaire and presents the questionnaire, ready for testing with rural clinicians and refinement.

Attracting and retaining healthcare workers in remote and rural areas is still a global challenge, but is critical for achieving sustainable development goals. In Indonesia, to meet the target of universal health coverage, the government has established the National Social Security System – Healthy Indonesia Card with the Social Security Administering Agency managing health insurance and services for the community. To support this, it is necessary to have an equal distribution of health workers, including specialist doctors in hospitals. This Original Research study analyses the contextual factors that influence the retention of specialist doctors in rural Indonesia.

Delivering high-quality medical education in rural areas is of critical importance for producing skilled graduates who may be more inclined to later practice rurally. However, little attention has been given to understanding how rural clinical training may impact patients, host organisations, and rural communities where students undertake their training, despite engagement from these stakeholders being crucial to the success of rural training opportunities. This article describes how a series of consecutive student placements in a single practice of a small rural community have driven a series of clinical audits and interventions that continuously fed into the next placement, resulting in improved management of chronic disease. This evidence is important in demonstrating the impact that rural clinical training can have on health care and local health outcomes, while maintaining a high-quality student experience, and for identifying the program elements contributing to its success so that similar strategies can be more widely adopted.

In general practice, technical procedures have many areas of application, including prevention (eg vaccination or cervical smear), diagnosis (eg group A streptococcus testing), and treatment (eg wound dressing). These procedures require specific skills that are based on both knowledge and manual abilities. Along with communication, knowledge, clinical reasoning, emotions, values and reflection, technical skills are a dimension of medical competence and a part of the general practice curriculum in many countries. Lists of core technical procedures have been developed in Canada, the USA and Australia to serve as bases for training general practice students, but none is currently available in France. This study uses data collected as part of the ECOGEN study from 20,613 patient–GP encounters in rural and urban locations to describe the frequency and type of technical procedures in French general practice.

This unique population-based study explored the role of wage differentials among allied health professionals across urban, rural and remote settings. Important imbalances were found in the gender and geographic distribution of the allied health workforce, although the impact of wage was not demonstrated as a financial incentive for rural and remote practice. This paper adds considerably to the rural healthcare literature by focusing on AHPs, a critical asset for the healthcare system.

The general principles of healthcare quality are well articulated internationally, but less has been written about applying these principles to rural contexts. Research exploring patient and provider views of healthcare quality in rural communities is limited. This study investigated what was important in healthcare quality, particularly for hospital-level care, for rural New Zealand communities.

The supply of new general practitioners (GPs) sufficient to meet the population’s health needs, particularly in rural and remote areas, continues to be a major global workforce distribution challenge. In Australia, despite substantial investment in rural workforce support, insufficient medical graduates are choosing a general/rural practice career. Medical training at postgraduate level remains strongly reliant on hospital experience in larger hospitals, potentially diverting interest away from general/rural practice. The Rural Junior Doctor Training Innovation Fund (RJDTIF) program offered junior hospital doctors (interns) 10 weeks in a rural general practice, aiming to increase their consideration of general/rural practice careers. This study evaluates the educational and potential workforce impact of the RJDTIF program.

The SARS-CoV-2 (COVID-19) pandemic brought about instability in healthcare providers worldwide, including in rural settings. In 2020, non-urgent elective care was suspended to free up hospital capacity in response to the pandemic. This Original Research article reports on the impact of COVID-19 on the surgical services offered at the Balfour Hospital, Orkney Islands, Scotland.

In Papua New Guinea (PNG), tuberculosis (TB) is the leading cause of death from an infectious agent and many cases are multidrug-resistant. Optimising models of care for TB patients living in the Torres Strait/PNG international border region has been particularly difficult; geographical, geopolitical and socioeconomic challenges in the region have created healthcare disparities that affect diagnosis, referral pathways, treatment and management of TB patients. Delays between symptom onset and commencement of effective treatment contribute to ongoing TB transmission. This study assessed improvements in time to commencement of effective treatment in patients diagnosed with drug-resistant TB in the Torres Strait/Papua New Guinea cross-border region.

Bootheel Counties (Dunklin, Mississippi, New Madrid, and Pemiscot) experience some of the worst health outcomes in Missouri. In this study, a collaborative team of academics, practice partners and community health workers were engaged in a participatory strategy development process to identify social and organizational determinants of accessing health care in the Bootheel counties and to collectively prioritize identified issues and develop strategies for change. Participants identified several individual, social, community, and organization-level barriers to accessing health care, including cost, lack of transportation, lack of information about services, lack of coordinated care, lack of trust, and racism and classism in local healthcare systems.

People do not receive regular dental care for several reasons. This may result in tooth loss and other health effects. Dental care may be a bigger challenge in rural settings, where there are several barriers to care. This study used Behavioral Risk Factor Surveillance System (BRFSS) data and examined dental visits and tooth loss for US Indigenous American Indian/Alaska Native (AI/AN) adults in rural vs. urban settings. In adjusted analyses, AI/AN adults in rural vs. urban settings had a similar frequency of dental visits in 2020 with 33% higher odds of having missing teeth. The author recommends interventions to maintain teeth in AI/AN adults in rural settings.

Debriefing following a critical incident is utilised across many different fields, including the military, aviation and health care, and is associated with clear benefits for team performance. Healthcare professionals working in rural and remote areas face a variety of unique barriers that may make debriefing challenging. This Commentary presents an example that illustrates the complexities of a critical incident in a remote service and outlines evidence-based strategies to support team members in rural and remote areas to debrief effectively, including the use of technology, formal teaching in university curriculums and regular practice via simulation.

This conference declaration, the Limerick Declaration on Rural Health Care, an outcome of the 19th World Rural Health Conference in Limerick, Ireland in 2022, is designed to inform rural communities, academics and policymakers how to achieve the goal of delivering high quality health care in rural and remote areas most effectively, with a particular focus on the Irish healthcare system. Congruent with current evidence and best international practice, the participants of the conference endorsed a series of recommendations for the creation of high quality, sustainable and cost-effective healthcare delivery for rural communities in Ireland and globally.

Despite the availability of preventive medication, tuberculosis (TB) kills millions of people every year. People in vulnerable populations (eg people with HIV/AIDS, health professionals, and those living in poverty) in low and middle-income countries are at particularly high risk. Practical public health strategies are required to effectively reduce the global TB burden. TB infection control measures emerged as a potential preventive public health strategy to prevent TB transmission in a health setting and spreading into the community. This review examined the current evidence for tuberculosis infection control measures, including administrative, environmental, and respiratory controls, in reducing TB transmission and explored the barriers and enablers of these measures in resource-constrained primary healthcare settings.

Poor mental health is under-recognised in rural locations. Although the prevalence of mental disorders is similar in rural and urban areas, suicide rates are 40% higher in rural communities. The level of readiness and engagement of rural communities to adapt to, or even acknowledge, poor mental health can impact effective interventions. This Review examines how community engagement, participation and empowerment were used in the development and implementation of interventions aimed at improving mental health of adults residing in rural communities of the USA, UK and Guatemala.

Despite policies aimed at universal health coverage by ensuring availability and accessibility of general practitioners (GPs), medically underserved areas (or ‘medical deserts’) are still present in Europe. This systematic review summarizes and compares literature on interventions and their potential effectiveness in GP recruitment and retention in these underserved areas.

Rural generalist anaesthetists (RGAs) are central to the delivery of elective and emergency anaesthesia and the acute care of critically unwell patients in much of rural and remote Australia. Without a well-trained RGA workforce of sufficient numbers, Australia would struggle to provide anaesthetic services outside of urban locations or make viable other crucial healthcare services that are reliant on anaesthetic support such as obstetrics, surgery, emergency medicine and critical care. This paper details a systematic review of the literature specifically asking the question: ‘What is the current evidence of the ‘safety’ of anaesthesia delivered by RGAs?’

This research reports on patient and community physician satisfaction with a teleneurology program that provided consultations to 14,241 patients at 12 community-based hospitals between 2014 and 2021. Results show high levels of satisfaction with using tablet technology for teleneurology consultation.

Significant policy initiatives have been implemented in Australia to ensure people in rural and remote areas have appropriate access to health services, with increasing interest in allied health. The allied health focus has been centred on pharmacy and physiotherapy so far, and there is limited evidence about the role osteopathy plays in rural and remote populations. In Australia, osteopaths are university-trained and government-registered allied health professionals who manage predominantly musculoskeletal complaints using manual therapy, exercise and patient education. This Short Communication reports on the demographic, practice, and clinical management characteristics of Australian osteopaths in rural and remote settings.

Access to ultrasound imaging services is limited in rural areas and point-of-care ultrasound (POCUS) has the potential to reduce this gap. This exploratory study assessed how POCUS is utilised by doctors in contemporary Australian rural general practice. Doctors reported limited confidence for certain scans and used POCUS predominantly for obstetric indications. Attention to the barriers to POCUS utilisation is needed to realise the potential benefits for the health of rural communities.

Kowanyama, a very remote community in Cape York, northern Queensland, has a very high burden of disease and is ranked among the top five most disadvantaged communities in Australia. The community has access to 2.5 days per week of fly-in, fly-out GP-led Primary Health Care (GPLPHC) for a population of 1200 people. All patients requiring higher-level health care undergo aeromedical retrieval to a larger centre. This Short Communication reports that, on the basis of a clinical audit of aeromedical retrievals in 2019, greater access to GPLPHC may lead to fewer retrievals/hospital admissions for potentially preventable conditions and it might be cost-effective and improve patient outcomes to have a full-time on-site Rural Generalist GP-led service in this and other remote communities.

Australians living in regional and remote communities face several barriers when accessing health care. Voluntary assisted dying (VAD), presents a new challenge for these communities. Western Australia is the second Australian state to implement VAD laws and, to date, is the jurisdiction with the greatest need to address such inequities due to its vast geography. This article identifies and explores initiatives introduced during the law-making and implementation stages of the law reform to address regional and remote access inequities.

Remote delivery of assessment, consultation, and therapy via digital communication technologies in mental health services is important in rural locations, and has rapidly increased due to the COVID-19 pandemic. This study investigated the factors that should be considered in the development and evaluation of digitally-mediated service provision for children and young people with social, emotional, and mental health (SEMH) needs.

Transgender patients experience a myriad of barriers to accessing health care and receiving high-quality, non-discriminatory care. In rural Appalachia, people with intersectional identities often have limited choices in providers along with other systemic barriers to obtaining competent and safe health care and experience increased risk of poorer health outcomes. This article reports on the development and implementation of a transgender healthcare provision training program for rural-serving medical residents in primary care in South Central Appalachia.

In this Letter to the Editor, which responds to an article recently published in Rural and Remote Health titled ‘The impact of politics, religion, and rurality on COVID-19 vaccine hesitancy in Oregon: a cross-sectional study'(https://doi.org/10.22605/RRH7140), the authors further consider the influence of politics, race, education, social network and religion on individual views on COVID-19 and vaccination and the role of doctors and medical scientists in this new paradigm.