Volume 24

Māori, the Indigenous Peoples of Aotearoa New Zealand, are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD treatments than non-Māori New Zealanders. Rural Māori experience additional barriers to treatment access, poorer health outcomes, and a greater burden of CVD risk factors, compared to Non-Māori and Māori living in urban areas. Inequities in CVD outcomes and access to CVD healthcare for rural Māori are similar to those experienced by rural Indigenous Peoples internationally. Despite these inequities, literature exploring access to CVD healthcare for rural Indigenous Peoples is limited. This Scoping Review identifies and summarises literature that explores the barriers and facilitators influencing access to CVD healthcare for rural Indigenous Peoples. This review offers a novel approach to summarising literature by situating the findings within an equity-and-Indigenous-rights based framework.

The current economic crisis is resulting in more Australian families having to spend more money out of their own pocket for health care, known as out-of-pocket healthcare expenditure (OOPHE). When finances are tight, families forgo food or do not attend medical appointments just to get by, which can worsen chronic conditions. In this Original Research article, the authors explore OOPHE impacts for Aboriginal patients and families living in the Far West of South Australia.

Skin and soft tissue infections (SSTIs; e.g. cellulitis, wound infections, boils and abscesses) present a substantial financial burden on Australia’s health system. A single episode of hospitalisation for SSTIs costs at least AU$670 per day and individuals living in rural and remote Australia often require aeromedical retrieval service to access emergency department and inpatient care, which also represents a sizeable financial cost. The Torres and Cape Hospital and Health Service (TCHHS) is the main, publicly funded health service in the Torres Strait, a body of water bounded by mainland Papua New Guinea to the north and Cape York, Queensland, to the south that includes 18 inhabited islands. Approximately 64% of the population of 4500 people serviced by the TCHHS identify as Aboriginal and/or Torres Strait Islander. This Short Communication defines the health service utilisation and health system costs associated with SSTIs in the Torres Strait in order to identify ways of improving the quality of regional healthcare delivery. 

Survey tools are commonly used to collect patient experience data to monitor, evaluate and improve health services and health outcomes, but the quality of data collected can be compromised in contexts where languages and cultures are different to those in which the surveys were developed. Health service improvement is imperative to address persistent disparities in health outcomes between First Nations and other Australians. Best-practice models emphasize both the time required for adapting surveys and the need for co-design through shared expertise in language, culture and context. This collaborative qualitative study explored the acceptability, relevance and translatability of two patient-experience survey tools intended for use with speakers of First Nations languages in the Northern Territory, Australia, where more than 100 First Nations languages and dialects are spoken, and the majority of First Nations residents speak one or more of these languages at home.

In many countries, the suicide rate is higher among farmers than in the general population, but farmers seem to seek help less frequently. In France, the Mutualité Sociale Agricole has developed several schemes to help farmers in difficulty (discussion groups, retraining assistance, subsidy for a replacement, and an anonymous telephone helpline) and most farmers are registered with a GP and receive reimbursement for medical consultations and treatment costs. Yet, French farmers consult their GPs less than other workers and have a higher suicide mortality rate than all other active socio-professional categories. This Original Research study analyses the perceptions of farmers in Ille et Vilaine, Brittany, about suicide and the help offered to farmers at risk of suicide.

Significant differences exist in health outcomes between rural and urban areas in Aotearoa New Zealand (NZ), and rural workforce issues (including heavy reliance on overseas-trained doctors and a maldistribution towards urban areas) compound these disparities. The medical programme at the University of Auckland has implemented several approaches to address these pressures, including providing 25–50% of general practice placements in a rural setting and admitting students of rural origin via the Regional Rural Admission Scheme (RRAS),  but there has been little indication of an increase in medical students wanting to pursue a rural career. This Original Research article reports on the results of interviews with key stakeholders that sought to identify the processes required to develop a rural strategy, including possible facilitators and challenges that need to be addressed.

Acquired brain injury (ABI) includes conditions like stroke and traumatic brain injury, and is one of the leading causes of disability in working-age adults worldwide. Depending on the extent and location of the injury, individuals with ABI may experience a complex combination of deficits in motor, sensory, cognitive, perceptual, and emotional domains and often require proactive services and persistent professional support after discharge home to help them overcome diverse challenges related to family life, social participation, the return to work, and finances (known as ‘community integration’). This scoping review maps the current research literature to identify existing models for the provision of rehabilitation services that promote community integration in rural home-dwelling adults with ABI.

The shortage and maldistribution of healthcare professionals, such as doctors, nurses and allied health professionals, continues to impact the health and wellbeing of rural and remote communities globally. Pharmacists, who do much more than dispense medication, provide access to primary health care services including vaccinations, chronic disease management, wound care, oral health care and mental health support. They are an important part of the overall health care picture and, in some cases, may be the only health professional locally available for people in rural and remote communities. This original research study develops a deeper understanding of pharmacists’ perspectives concerning factors influencing their recruitment and retention in rural and remote communities.

Infectious diseases associated with poverty disproportionately impact rural populations with limited access to health care. Cutaneous leishmaniasis (CL) is caused by infection with leishmania parasites and spread by the bite of sandflies; it is challenging to control owing to its epidemiological, clinical, and biological complexity. Colombia reported the second-highest number of CL cases in the Latin America region in 2020. Community capacity building and education is needed to achieve effective prevention and control. This article presents the learning process of implementing a capacity-building program, which sought to provide tools to the community to improve CL prevention and control in the municipality of Pueblo Rico, Colombia

Doenças infecciosas associadas à pobreza têm impacto desproporcional em populações rurais com limitado acesso à atenção em saúde. A Leishmaniose Cutânea (LC) é causada pela infecção por parasitas leishmania e é transmitida através da picada de flebotomíneos; é um desafio controlá-la devido à sua complexidade epidemiológica, clínica e biológica. Em 2020, a Colômbia notificou o segundo maior número de casos de LC na América Latina. A capacitação e a educação da comunidade são necessárias para alcançar a prevenção e o controle eficaz da LC. Este artigo apresenta o processo de aprendizagem para a implementação de um programa de capacitação que buscou fornecer ferramentas à comunidade para melhorar a prevenção e o controle da LC no município de Pueblo Rico, Colômbia.

Las enfermedades infecciosas asociadas con la pobreza afectan de manera desproporcionada a poblaciones rurales con acceso limitado a atención médica. La Leishmaniasis Cutánea (CL) es causada por una infección por parásitos leishmania y se transmite por la picadura de mosquitos flebótomos. Su control es difícil debido a su complejidad epidemiológica, clínica y biológica. Colombia reportó el segundo mayor número de casos de LC enLatinoamérica en 2020. Se necesita educación y desarrollo de capacidades comunitarias para lograr una prevención y un control efectivos. Este artículo presenta el proceso de aprendizaje de la implementación de un programa de desarrollo de capacidades, que buscó brindar herramientas a la comunidad para mejorar la prevención y el control de LC en el municipio de Pueblo Rico, Colombia.

The need to address racism in Australian health services is recognised at every level of national and state governance. Despite this, a barrier to developing antiracism is the strong emotional reactions that white people have when confronted with the topic of racism. These reactions, a result of implicit bias and intergenerational social and cultural learning, shut down critical reflection about racism, and can interrupt antiracist efforts and uphold white supremacy. Although documented mostly in universities, these reactions have been observed in the wider community, so it is likely they occur in workplaces too. With antiracism now an inherent part of professional practice guidelines in health, it is necessary to resolve this gap in the research. This Original Research article identifies how emotional reactions affect antiracism and decolonising health service delivery in Aboriginal communities.

Internationally, racism, historical and present trauma and settler colonialism are catalysts for compromised health and well-being in a landscape of community and family dysfunction. The health impacts of racism are well documented in the lower life expectancy, burden of disease and elevated levels of psychological distress experienced by First Peoples. There is evidence to suggest that the ability of health professionals to integrate cultural safety into their practice is intrinsic to dismantling racism and to improving the health of First Peoples and other marginalised groups but little is understood about how health professionals understand racism in the context of providing culturally safe care. Utilising international research, this Scoping Review explores how interdisciplinary health professionals in the aged-care sector in rural areas understand and respond to racism and understand and provide culturally safe care.

Rural and remote Indigenous communities are disproportionately affected by diabetes-related foot disease (DFD), one of the most prevalent causes of global hospitalisation and morbidity. Early identification of wounds and multidisciplinary management can significantly reduce amputation rates, but there are important barriers to health care for rural Indigenous communities, including access to culturally appropriate care, distance to care, dislocation from family and cultural support, exposure to racism, and poor communication with healthcare professionals. Telehealth has been identified as a strategy to improve access to health care for rural and remote communities and may address some of these barriers, but there is little research exploring the use of telehealth in the management of DFD in Indigenous people. This Original Research study investigated experiences of rural and remote Aboriginal and Torres Strait Islander people with DFD utilising a newly established real-time video-based telehealth service.

Rural healthcare human resources challenges persist, despite the existence of many different initiatives to increase rurally focused training opportunities. This Commentary makes the case for a paradigm shift away from specialist curricula and training in urban centres, towards decentralization of training and capitalizing on the opportunity to increase rural practitioner mentorship of trainees. The concept of rural training in place is introduced, enabled by distance learning technology, to provide an immersive, longitudinal, rural training model, that would allow learners to build and maintain community integration throughout training.

Inequalities often exist between urban and rural areas in health status and in the distribution of social determinants such as income, education and employment. Monitoring regional health inequalities can provide evidence and support for policies to reduce inequality. Much point-in-time evidence exists for Australia, but this Original Research article reports on analyses of Public Health Information Development Unit (PHIDU) data to investigate the nature of change in inequalities over 3 decades and to categorise local government areas into remoteness categories. Improved understanding of what has changed over time (or not) and diversity in health and social determinants of health both within and between remoteness categories can inform more effective policy and services to rural and remote areas.

Iron deficiency anaemia is a particular risk for pregnant women because additional iron is needed to meet the needs of the growing fetus and to supply the increased maternal red blood cell mass. Sub-optimal levels of iron during pregnancy are associated with adverse outcomes including low birth weight, preterm birth and, in more severe cases, maternal death. Reported figures of maternal and infant mortality remain high in rural populations of low-income countries. This study determined the iron status of rural-dwelling Nigerian women in the second and third trimesters of pregnancy and predicted their risk of giving birth to babies with sub-optimal iron endowment.

Canada’s rural population has diverse geographic and demographic features and accounts for 18.9% of the entire population. Longstanding inequities in service delivery for rural people, especially with respect to addiction and mental health, lead to delay in diagnosis and treatment, impacting illness severity and outcomes. Indigenous people, who are highly represented in rural communities, have additional risk factors related to colonialism, and historical and ongoing trauma. This Review article provides a national, broad look at the issue of non-psychotic mental illness across rural Canada. As well as speaking to the significant weight of the problem, factors influencing mental health across rural and remote communities and promising practices for care are described.

Addressing rural health issues requires concerted efforts by governments and other organisations to improve the health outcomes of rural populations. It would appear self-evident that young healthcare professionals (HCPs) should be attuned to this and be ready to play a meaningful role. It is, therefore, important to understand their perspectives on the current state of rural health care, the future of rural health care, and their future role in making a difference in the lives of people living in rural communities. This Original Research article is the first to explore rural health issues globally from the perspectives of young HCPs.

During the COVID-19 pandemic, remote consultations (telephone and video) have been increasingly used as an adjunct to traditional healthcare delivery techniques for management of patient conditions, assessment, treatment, monitoring and diagnosis. Not all doctors, even those in rural and remote areas where telehealth has been used for over 20 years, feel sufficiently prepared by medical education courses to deliver remote care. An online survey of Australian College of Rural and Remote Medicine (ACRRM) members was used to establish the training needs of rural doctors for the provision of remote consultations and, subsequently, to develop an online scenario-based training program (the Telehealth Clinical Skills Program, TCSP). This article reports on the outcomes of the TCSP.

The number of rural otolaryngology - head and neck surgery (OHNS) - providers is decreasing annually in Canada, the USA and Australia. Underserved and vulnerable populations are less frequently diagnosed with common otolaryngologic disorders and come to clinical attention with advanced forms of disease. In Northern Ontario, timely access to medical specialties such as OHNS is further challenged by long wait times and long distances to services. New models of care delivery are required that are efficient, cost effective and tailored to the needs of the population. This Project Report characterizes patient demographics, common clinical diagnoses and barriers to accessing otolaryngology services in a remote Northern Ontario setting, and describes a care model that provides multi-subspecialty otolaryngology services to a remote community.

Respiratory disease, usually acute hypoxaemic respiratory failure (AHRF), is the predominant reason for paediatric retrievals from remote areas in northern Australia. AHRF requires oxygen treatment using nasal high flow (NHF) therapy, but although the use of NHF therapy is ubiquitous in Australian tertiary hospitals, implementation is inconsistent in remote Australian hospitals and there is no clear guidance for its use in limited resource environments. This Original Research study developed a guideline for the use of NHF therapy in three remote hospitals in Queensland, Australia.

In South Korea, primary healthcare services are predominantly delivered through public health centers and private clinics (PCs). Approximately 98% of outpatient visits occur at PCs, which are concentrated in large cities. During the COVID-19 pandemic, primary healthcare providers faced financial challenges and potential closures due to social distancing measures and patient cancellations of clinic visits out of fear of infection. Since any changes in the number of PCs can have a significant impact on residents' access to health care, it is important to understand these pressures and closures, particularly in rural areas. This Short Communication considers spatial factors and the changes in PC openings and closures in urban and rural South Korea.

Dementia is the second leading cause of death in Australia and is currently responsible for 4.4% of the total burden of disease in the country. To identify gaps and unmet needs within the health and social care system and potentially improve the quality of care and outcomes for people living with dementia in rural and remote areas, this study investigated the needs of people living with dementia and their informal or formal care-givers in Gippsland, a rural region of Victoria, Australia. Although there are services and supports available for people living with dementia, accessing them can be complex and the wait time can be several years. People living in rural and regional Australia often face multiple additional barriers to accessing health and social care services.

People from rural riverside populations of the Amazon travel greater distances to access health care than urban people, have access to fewer dentists per individual, are less likely to have water fluoridation and tend to experience higher prevalence of dental caries and tooth loss. In Brazil, to increase access to health services for rural people, Fluvial Family Health Teams (FFHT) of health professionals visit many riverside communities monthly in a mobile unit to provide primary health care, including oral health and dental care. This study assessed the use of dental services, and the factors contributing to dental health access, by adults living in rural riverside areas covered by an FFHT.

Las personas de poblaciones rurales ribereñas del Amazonas viajan mayores distancias para acceder a la atención médica que las personas urbanas, tienen acceso a menos dentistas por persona, tienen menos probabilidades de acceder a fluoración del agua y tienden a experimentar una mayor prevalencia de caries dentales y pérdida de piezas dentales. En Brasil, para aumentar el acceso a los servicios de salud para la población rural, los Equipos de Salud Familiar Fluvial (FFHT, por sus siglas en inglés) visitan mensualmente muchas comunidades ribereñas en una unidad móvil para brindar atención primaria de salud, incluida salud y atención dental. Este estudio evaluó el uso de servicios dentales y los factores que contribuyen al acceso a la salud dental por parte de adultos que viven en zonas rurales ribereñas con cobertura de un FFHT.

Residentes de áreas rurais ribeirinhas percorrem distâncias maiores do que populações urbanas para acessar os serviços de saúde, têm menos dentistas por habitante, menor probabilidade de acesso àágua fluoretada e possuem maiores prevalências de cárie e perda dentária. No Brasil, para aumentar o acesso aos serviços de saúde por populações rurais, Equipes de Saúde da Família Fluvial visitam mensalmente comunidades ribeirinhas em uma unidade de saúde móvel para prover atenção primária em saúde, incluindo a saúde bucal. Este estudo avaliou a utilização dos serviços de saúde bucal e os fatores contribuintes para este acesso por adultos moradores de comunidades rurais ribeirinhas cobertas por uma equipe de Saúde da Família da Família Fluvial.

Access to health care for rural and remote Australians remains an issue, despite continued efforts to improve the distribution of the medical workforce. Numerous studies have shown that rural experience for medical students, particularly if they have a rural background, is effective in recruiting and retaining a rural health workforce. Until recently, this has involved short-term or extended rural clinical school placements. The Murray-Darling Medical Schools Network (MDMSN) has established a network of rurally based medical programs in New South Wales and Victoria in which students can complete the entirety of their medical degree in a rural area. The MDMSN offers a unique opportunity to explore the effect of complete rural immersion during medical school on subsequent rural practice. This article describes the establishment of a research collaboration to undertake multi-institution and longitudinal research into rurally based end-to-end medical training programs and their impact on rural workforce maldistribution.

In South Africa, only 30% of healthcare workers provide publicly funded health care to more than 40 million people who are uninsured and constitute approximately 84% of the population. In addition, rural areas have historically experienced a lack of access to healthcare providers, leading to poorer health outcomes than in urban areas. To address health worker staff shortages at rural district hospitals in KwaZulu-Natal Province, the Umthombo Youth Development Foundation (UYDF), has been recruiting and supporting rural-origin health science students with the intention that graduates would work in rural areas on completion of their studies. This Original Research study determined the effects of retention factors on whether rural-origin UYDF graduates chose to work in a rural or urban, public or private setting.

Rural people in the USA, 20% of the population, suffer higher all-cause mortality and are more likely to die of each of the 10 leading causes of death than urban counterparts. They are more likely to be uninsured, live in poverty, and be exposed to unique occupational and environmental toxicities. The ability to identify and address these disparities is directly dependent on the quality of rurality measurements, one of which is Rural–Urban Commuting Area (RUCA) Code. Although basing rurality on commuting distance may adequately measure accessibility of healthcare services, it might miss health-related behaviors and socioeconomic effects. A measure of rurality that considers individual’s perceptions of their community identity while maintaining efficiency for large-scale research is needed to better conduct patient-centered healthcare research. This study examined the concordance between people's self-identification of rurality and their ZIP code-derived RUCA of rurality among a nationally representative sample and determined patient-centered RUCA-based classifications of rurality and urbanicity.

Uruguay has an important livestock industry (cows, sheep, poultry, pigs). Predator attacks on productive species generate great concern for animal welfare and also cause economic losses for farmers but little is known about how predator attacks on productive species impact the mental health of farmers. This study explored how predator attacks on productive species during 2021 influenced the psychological distress of farmers in rural Uruguay.

Uruguay tiene una importante industria ganadera (vacunos, ovinos, avícola, porcinos). Los ataques de depredadores al ganado generan gran preocupación por el bienestar animal, pero también causan pérdidas económicas a los agricultores, y se sabe poco sobre cómo estos ataques impactan su salud mental. Este estudio exploró cómo los ataques de depredadores a estas especies productivas durante 2021 influyeron en la angustia psicológica de los agricultores de las zonas rurales de Uruguay.

O Uruguai possui uma importante indústria pecuária (boi, ovelha, ave, porco). Ataques de predadores às espécies de criação causam grande preocupação para o bem-estar animal, assim como resultam emperdas econômicas para os pecuaristas. Entretanto, pouco se sabe sobre como os ataques às criaçõesimpactam a saúde mental dos pecuaristas. Este estudo avaliou como o ataque de predadores àsespécies de criação no ano de 2021 influenciou o sofrimento mental de pecuaristas em áreas rurais do Uruguai.

Surgical care is limited in many rural areas, with a shortage of general surgeons contributing to this gap in services. This qualitative study explores the meanings surgeons associate with community characteristics to better understand the role that community plays in surgeons' practice location choices. Reflections around themes of physical environment symbolism, health resources' relationship to scope of practice, and overlap of professional and personal roles differed between rural and urban surgeons. The authors suggest that educators and rural healthcare organizations can improve recruitment and retention by better preparing potential rural surgeons for the expected role overlap and highlighting the value of the unique physical environment found in rural areas.