Volume 25

In Malawi, where 42% of the population is aged 0–14 years, the paediatrician-to-child ratio is very low and most paediatricians work in urban areas, where only 18% of the population lives. To address this workforce inequity, the Kamuzu University of Health Sciences initiated a specialised training program in 2012, the Bachelor of Science in Paediatrics and Child Health (BSc PCH) for clinical officers (formerly often referred to as non-physician clinicians). This Original Research article investigates the workplace satisfaction of BSc PCH clinical officers and the likelihood of their retention in current positions.

Between July 2021 and March 2022, 51 experts from around the world contributed to an eight-part webinar series on rural health equity convened by the World Health Organization (WHO) and the World Organization of Family Doctor’s Working Party for Rural Practice (Rural Wonca), with inputs from partners including the Organisation for Economic Co-operation and Development (OECD) and agencies in the United Nations Inequalities Task Team subgroup on rural inequalities. The webinar series aimed to share technical/operational know-how, insights and lessons learnt for both health systems strengthening and action on social and environmental determinants of rural health inequities. This Original Research article presents an analysis of the expert narratives from the WHO Rural Health Equity webinar series that tests the framing of rural health equity, considers the drivers of rural health inequities within and beyond the health system and explores the implications for governance approaches.

This declaration, made during the Global Rural Health Summit in Bengaluru, India, on 4 April 2025, urges governments, international organisations, healthcare providers, civil society and the private sector to prioritise rural health in national and international development agendas by taking the following steps:

• Promote effective acute, preventative and continuous care in rural areas by teams of health professionals with broad generalist skills, led by Advanced Practice Rural Family Medicine doctors;
• Initiate formally recognised postgraduate rural Family Medicine training for advanced rural skills and remunerate this appropriately;
• Support the use of these skills by funding local reliable point-of-care testing and advanced digital technologies; and
• Incentivise universities, colleges and rural health services that support extended exposure of medical students and junior doctors to rural practice, and include rural teachers as faculty.

Social relationships are crucial for mental health, providing emotional support and facilitating access to care. However, individuals living in rural areas are often challenged by a culture that discourages open discussion of mental health issues. To date, there has been a paucity of research examining mental health discussion networks focused specifically on rural settings. This Original Research article examines the characteristics of rural people, relationships and networks that make mental health discussions more likely.

Carers play multiple roles in palliative care, and provide physical, emotional, social and spiritual support while contributing to healthcare economics. In rural areas, carers can fan face location-related challenges including late involvement of palliative care services, lack of trained providers and paucity of local health care, information and bereavement services. However, they may also be positively supported by rural attitudes, such as resilience, acceptance of death and engagement in community support networks. This Original Research article presents a conceptual framework to inform reflections and discussions to provide meaningful support for carers involved in palliative care in rural areas.

A fully staffed and skilled allied health workforce is imperative to manage and improve the poorer health experienced by rural and remote populations but complex challenges in recruitment, retention and turnover of allied health practitioners (AHPs) affect the provision of services. Although several reviews have explored health professional retention factors, findings and recommendations have largely been drawn from studies examining the medical profession. To date, findings relating to the allied health workforce have been isolated and have not been synthesised collectively. This Scoping Review explores gaps in evidence by examining the length of employment of AHPs and significant factors and costs associated with the recruitment, retention and turnover of the rural and remote allied health workforce.

In response to the need to attract and retain more physicians in rural family medicine, much research has focused on the traits of medical students that choose to practice in rural settings. Being a rural doctor has been described as requiring ‘clinical courage, the adaptability and willingness to work at the limits of, or beyond, training and experience to meet the needs of patients. Among other characteristics, clinical courage requires self-efficacy: elements of which include confidence and self-belief. Although there have been no studies looking at rural practice self-efficacy at different stages of medical training, it is expected that this measure could be impacted by the medical school experience. This Original Research study proposes a rural practice affinity model in which general self-efficacy leads to rural practice intentions when mediated by medical training to develop emergency medicine competency and rural practice self-efficacy.

During 2021–2022, corresponding with above-average rainfall and flooding in the region, several critically unwell patients with necrotising fasciitis were admitted to the Hervey Bay Hospital (Qld, Australia) intensive care unit. All patients had been in saltwater rivers hunting for green mud crabs or descaling barnacles from their vessels. Cultures revealed Vibrio species to be the agents of infection in four of the patients. Necrotising fasciitis caused by Vibrio species carries a high morbidity and mortality, and often progresses rapidly into a life-threatening soft tissue infection, multi-organ failure and fatal sepsis. This case series reviews the clinical documents for each patient, and data from Pathology Queensland, to highlight a potential public health issue that could become more common with future floods caused by climate change and the cyclic return of the La Niña.

Research demonstrates rural clinical placements during medical school – especially extended rural placements and especially if they are positive experiences – improve clinical skills and likelihood of practising in rural or remote locations later in a doctor’s career. This Original Research article reports on specific clinical learning experiences during a rural placement that contribute to final-year medical students reporting them as ‘high quality’,  with a focus on whether the supervising doctor’s background and training influences the quality of students’ clinical learning experiences.

Training registrars in rural and remote settings is essential for developing GPs with the relevant skills for the scope of practice and context required. Although many rural and remote doctors may be too busy with their own clinical practice to supervise a registrar, evidence has shown that remote supervision can be effective. Good supervision is more than clinical advice; it also includes attending to the registrar’s wellbeing, supporting them through challenging situations, and brokering their relationship with the practice and the community. Guidelines for remote supervision have been developed by the Royal Australian College of General Practitioners (RACGP) to facilitate supervision and learning. This article reports on the practicality, safety, effectiveness and efficiency of the guidelines for the remote supervision of registrars in pilot locations.

The shortage of health professionals in rural areas is a global issue. One effective approach for increasing the rural health workforce is to establish rural medical education programs involving engagement in rural communities and highlighting rural practice that prepares medical students for careers in rural medicine. In Papua New Guinea, the Divine Word University Bachelor of Medicine and Bachelor of Surgery programs have introduced rural clinical placement blocks for each medical student in the fourth year of study. This Original Research study evaluates medical students’ perceptions of rural clinical placement in Papua New Guinea, including their preference to work in rural locations.

The USA has a shortage of primary care providers in rural areas, especially those trained in pediatrics and mental health. Concerningly, chronic health conditions occur in one out of four children and pediatric mental health diagnoses have increased significantly since the pandemic. Pediatric nurse practitioners in primary care can provide high-level care, positive patient outcomes, lower medical costs, and higher quality of life among patients but the transition to practice in rural settings is challenging and requires training and support. Nurse practitioners who enter practice through residencies or fellowships have better adjustment to practice, reduced burnout and greater intent to stay in their roles. This Project Report uses a pediatric primary care fellowship example to outline the needs of graduate nurse practitioners, describe the rationale for postgraduate training, highlight program content and structure, and identify ways to collect data for evaluating the quality and efficacy of primary care fellowship programs.

Inter-hospital transfers from rural to urban hospitals in Aotearoa New Zealand are often essential for diagnostic investigations or specialist care that is unavailable rurally. Clinical information is coded and stored for health system analyses, including rural-urban differences in health outcomes. Anecdotally, clinical coding is often performed by clinicians or reception staff without formal coding training in many NZ rural hospitals, and by a designated hospital clinical coding team with university or sub-tertiary coding training in urban hospitals. No NZ literature has been found comparing the accuracy of clinical coding between rural and urban hospitals. This Original Research article examines whether any discrepancies exist in primary diagnosis codes for patients who underwent an inter-hospital transfer from a rural to an urban hospital.

Over the past 20 years, nearly half of Australia’s birthing centres, predominantly in rural areas, have closed. This substantial reduction in number of rural birthing centres has correlated with a 47% increase in births occurring before reaching hospitals. Evidence highlights the comparably poorer outcomes for both mothers and neonates in unplanned out-of-hospital births, with increased incidence of post-partum haemorrhage, perineal tears, delayed third stage of labour and need for neonatal resuscitation. This Scoping Review explores paramedics' confidence in managing prehospital obstetric emergencies, identifies influencing factors and examines the implications of confidence on patient and paramedic welfare.

Artificial Intelligence (AI) is permeating every industry, including health care, and has the potential to help address common challenges in primary care settings through increasing workforce capacity, optimizing resource allocation, enhancing health research, and reducing burnout. Many Canadian healthcare settings have begun piloting AI scribes, tools that transcribe patient–PCP interactions and create electronic medical record notes, in the hope that they might significantly alleviate administrative burden. This Commentary outlines the administrative burden on primary care providers and the benefits and challenges of AI scribe technology within the context of northern, rural, and remote primary care settings.

South Africans with disabilities, especially in rural areas, are subjected to poorer access to health care and are more likely to report illness and experience a greater need for healthcare services compared with their non-disabled counterparts. Rehabilitation services in South Africa prior to the pandemic were already considered low priority, but they halted during COVID-19 lockdowns because they were considered non-essential health services. This Original Research article explores the perspectives and experiences of Eastern Cape rehabilitation practitioners who served persons with disabilities in this region during the COVID-19 pandemic.

Adaptation over many generations of living in the harsh and extreme conditions of the Russian Arctic has produced a ‘northern’ type of metabolism, characterized by increased protein–lipid metabolism and minimization of carbohydrate metabolism. Increasing urbanization in the region has resulted in less reliance on traditional diets and lifestyles, leading to increased incidence of obesity and non-communicable diseases. This Original Research study investigates the status of lipid metabolism and variability in body mass related to ethnicity and lifestyle in Russian Arctic residents.

Intimate partner violence (IPV), any behaviour within an intimate relationship that causes physical, sexual or psychological harm, is a major public health concern worldwide. While the violence prevention research landscape is still evolving, only in the past two decades has it started to become a high priority for practitioners and researchers to devote resources into conducting more primary prevention research. Community-based interventions, particularly community mobilisation interventions, can transform attitudes towards social norms and reduce IPV behaviours when rigorously planned, have a robust theory of change and are rooted in knowledge of local context. This Original Research study assessed the effect of a community mobilisation intervention on attitudes supportive of physical IPV, women’s experiences of IPV and men’s perpetration of IPV in rural communities of South West Nigeria.

While incarcerated, women experience multiple barriers to accessing primary and specialty health care. When women are released from prison, they face barriers to timely access to primary health care, substance use disorder support and treatment, and mental health services, compounded by the need to navigate a complex web of services and systems to access housing and food, reconnect with children and access parenting supports. This Scoping Review identifies what is known about the health outcomes and health experiences of women and gender-diverse people who are currently incarcerated or recently released from prison into rural areas.

Multiple international studies have shown that farming is one of the occupations in which workers have the lowest mental health scores. Farmers are exposed to unfavorable working conditions, such as long working hours and great physical demands, and may be more reluctant to seek help regarding their mental health than other occupational groups. This exploratory study investigates which facilitators and barriers farmers perceive as important in their everyday lives regarding their mental wellbeing.

People co-using opioids and methamphetamines are more likely to be homeless, have comorbid severe psychiatric illness and be infected by sexually transmissible infections, and are at higher risk of overdose causing death. Moreover, although medications for opioid use disorder (MOUD) are effective at preventing opioid withdrawal, use, and overdose, research suggests that concomitant methamphetamine use negatively impacts treatment retention and opioid abstinence over time. As opioid and methamphetamine co-use continues to rise in rural counties of the US, the need to understand the prognostic effects of methamphetamine use among individuals initiating MOUD in rural community treatment settings is paramount. This Original Research article examines whether positive methamphetamine urinalysis results predict worse treatment outcomes in four rural US clinics.

Ultrasonography is increasingly used across medical specialties, including family medicine, where it could reduce diagnostic delays, improve accuracy, and lower healthcare costs but ultrasonography training is not standardized in the family medicine curriculum. This Research Letter reports on the the feasibility and perceived usefulness of a one-day introductory ultrasonography course for family medicine interns at the Brest School of Medicine, France.

Australian guidelines for initial management of migraine (an episodic, debilitating form of headache characterised by pain, nausea and aura causing significant personal morbidity), include aspirin, NSAIDs or paracetamol, followed by dopamine antagonists and serotonin receptor agonists, avoiding opioids unless as a last resort. Despite these guidelines, recent Australian studies have shown inconsistency in emergency department prescribing patterns. This Short Communication looks at patterns of prescriber intervention in a rural hospital to hypothesise how rural health barriers and enablers may impact prescription decisions.

Health justice partnerships (HJPs) are integrated service models established to mitigate the impacts on health from issues that have a legal origin and that, if left unattended, can be detrimental to the health of individuals. Evidence from HJPs demonstrates the positive contribution of legal services on the mental health of program recipients, including improvements in depression, stress, anxiety and wellbeing upon delivery of legal assistance. This Project Report adds to the limited available research literature about HJPs for youth by presenting the perceptions of regional young people and workers about the impact of legal matters on health and wellbeing and the role of an HJP in the health of young people in regional Victoria, Australia.

This exploratory study presents self-reported dietary supplement use among peri-menopausal women in rural Hawaiʻi. Regular use of supplements was notably higher in this population compared with results reported in communities in other nations and different geographic regions of the US. As the majority of respondents reported receiving supplement information from a clinician, healthcare providers are encouraged to engage in thoughtful discussion with their patients regarding supplement use.

Rural doctors practising in resource-limited settings display courage when they are required to work at the limits of their scope of practice to provide the medical care that is required by their community. Although courage can be an integral part of clinical practice, the underlying attributes of clinical courage are not well described in the literature. This Original Research article contributes to the study of clinical courage in rural doctors by reporting on testing of a recently developed questionnaire. Better understanding of clinical courage may contribute to training, support and retention strategies for rural healthcare professionals.

Advanced Skills Training (AST) is an opportunity for GPs to further refine their skills across one or more medical specialties. Rural training pathways have evolved to suit the needs of rural communities, trainees, trainers, health services and medical colleges. However, current rural training opportunities may be missing the mark on bridging the gap between urban and rural health and the demands on GPs have expanded beyond traditional boundaries, necessitating a re-evaluation of the skills and competencies required to address the complex and multifaceted health needs of diverse patient populations. This Review article examines the current value and fitness for purpose of AST for rural clinical practice.

A holistic definition of wellbeing includes the physical, social, emotional, cultural and ecological dimensions of both the individual and the community. While some research has been conducted on persons with disabilities in rural settings in South Africa, there is limited research into inclusion of persons with disabilities in cultural rituals. This Original Research study explores the experiences of persons with disabilities in Xhosa rituals and traditions in rural South Africa and how these experiences contribute to health and wellbeing.

The KidsFirst North program is a maternal–child health support program in rural northern Saskatchewan, Canada. The program serves both Indigenous and non-Indigenous families, and the majority of participants in the study are Indigenous. This Original Research article takes a community-based participatory research approach to investigate factors of success and barriers, from the perspectives of families, frontline workers, and administrators alike.

Professional education for community physicians is essential but there are challenges in balancing educational responsibilities with the practical demands of clinical work. This Research Letter examines the stressors and buffers for community-attending physicians accessing professional education. These insights will be useful in ensuring the sustainability and efficacy of professional educational practices.

A lack of appropriate and sustainable resources (including workforce and supplies), inadequate infrastructure (including unreliable internet connectivity) and lack of funding and governance impact the sustainability and feasibility of healthcare delivery in isolated areas. A telehealth model or mobile model of care may be most appropriate for these isolated regions but, paradoxically, these regions are the least likely to have infrastructure and resources to support the model. This Original Research article reports on the results of a needs assessment of healthcare services in Far East Gippsland, Victoria, Australia, and outlines feasible and sustainable services as suggested by the people that live there.

This cross-sectional study examines the impacts of health promotion workshops led by a multidisciplinary student team. Results suggest these workshops are associated with positive gains in health knowledge by participants, and satisfaction by partnering agencies. Further development of similar initiatives may prove useful in extending health literacy in rural communities.

South Africa has a history of mental health care provided primarily at tertiary level in institutions. However, in line with World Health Organization guidance, attempts have been made to decentralise and streamline the integration of public mental health care into general health care systems at primary and secondary levels. The currently implemented Mental Health Care Act 17 of 2002 serves as the national guideline to implement policy into practice, thereby increasing access and the quality of care to service users. This, of course, has implications for the roles workers and facilities are now called upon to play. This Original Research article presents data from a project that investigated issues regarding access and provision of mental health care in the Eastern Cape province of South Africa. The authors studied the experiences of public health care workers at PHC clinics and the associated referral hospitals, focusing mainly on exploring their views on the ability and readiness for access to and provision of mental health care to state health service users in the area.

Research on caring for children with disabilities in sub-Saharan African contexts has primarily focused on female caregivers, leaving male caregivers understudied. This Original Research article reports on a study exploring the journeys of male caregivers in rural Kenya as they navigate the complex landscape of health care for their children with disabilities. The authors uncover valuable lessons that can inform the development of better support services and make a positive impact on the lives of children with disabilities in rural settings by improving access to quality health care.

The learning environment has proved important for medical students’ wellbeing, satisfaction and academic results. Although complex and multifactorial, positive initiatives include integration of learners as active members of communities of practice and tailored guidance by teachers to aid learners’ development. Decentralized curricular models are potentially vulnerable for learning environment deterioration due to their remote location and limited student numbers. Prior investigations of learning environments in decentralized medical curricula describe inconsistent results, and are limited to certain geographical areas. This Original Research article compares learning environment perceptions of students in a decentralized curricular model in Norway with those of their urban counterparts, and with students in international medical curricula.

Living in a rural or remote area should not limit access to healthcare services or compromise quality of health care. However, the reality is that individuals in rural and remote regions often face significant barriers to appropriate health care, leading to poorer health outcomes and exacerbation of existing health disparities. This Letter to the Editor draws attention to innovative strategies for improving access to quality care for residents of rural and remote areas, including blockchain technology for health records, drone technology for medical supply delivery, and mobile health applications (mHealth).

Deep structural inequalities between places have consequences that reach far beyond the economy and impact overall wellbeing. Rural proofing is a tool aimed at helping policy makers develop more nuanced rural-friendly policies, making them fit for purpose in rural areas and helping them avoid unintended consequences from the urban bias in policy making. It entails the early sharing of evidence about rural dynamics during the policy development process, enabling policymakers to make adjustments before finalising the policy. This Policy Report looks at how to embed rural proofing into the policy space by setting up mechanisms that systematically assess policies for their impacts in rural areas to foster more balanced results. The report is based on a literature review of published research and discussions facilitated by the OECD, focusing on rural proofing.

During the first waves of the COVID-19 pandemic, healthcare professionals around the world were scrambling to understand the risk factors for the development of a serious clinical condition of patients. Procedures were often insufficient or even incorrect. Due to recurrent waves of illness caused by the SARS-CoV-2 virus, the decreasing population of vaccinated people, and the emergence of new variants of the virus that have changed the symptoms of the disease, we are still dealing with patients in serious condition, with concomitant sepsis leading to death. This Original Research article reports on risk factors for COVID-19 deaths among patients treated in a rural community hospital in south-eastern Poland.

Low birth weight (LBW) is a major cause of neonatal death. Many factors can cause LBW, including genetic, demographic, and psychological factors, limited access to medical services (especially obstetrics and antenatal care), lack of nutrition, maternal diseases during pregnancy, and exposure to toxins. This Original Research study investigates the factors contributing to LBW in Indonesia.

Skin cancer (melanoma and non-melanoma skin cancer (NMSC)) is a major public health issue in Australia. Rural populations have a higher melanoma mortality rate than metropolitan populations but, given they are not reportable conditions, it is difficult to ascertain whether the same trends exist for NMSCs. This Clinical Review investigates the detection of melanoma skin cancer and NMSC in a rural general practice in the South West region of Victoria, Australia.

Despite decades of government and professional efforts, small rural communities across Australia continue to grapple with a chronic shortage of healthcare professionals, particularly medical personnel. In rural South Australia, where general practices had been chronically understaffed for many years, the Riverland Mallee Coorong Local Health Network (RMCLHN) created the Riverland Academy of Clinical Excellence (RACE) to focus on training a clinical workforce to ensure sustainable care for rural communities. This Personal View outlines the strategies and tactics employed by RMCLHN to address enduring medical workforce challenges and reports on the success of the RACE.

Rural people across most nations, regardless of relative national wealth and development, live shorter lives, on lower incomes, with less formal education, and experience greater poverty, illness and injury than their urban-dwelling peers. Multiple causes for this inequity have been suggested, including greater physical risk associated with farming, poorer general and health literacy, distance from infrastructure, limited public transport, internet, health service resourcing, and shortages. All these factors, at their most fundamental, are features of geography. In rural and remote health, there appears a dominant assumption that increased inconvenience and cost for accessing health care are features of rural geography that should be expected by rural people. This Review challenges this assumption by applying concepts from critical geography to suggest rural geography has been shaped to result in exactly the health outcomes experienced by rural people, and that focusing policy on reshaping rural geography through the lens of spatial justice may result in better health services and outcomes.

Diabetic foot complications and amputations are significant in Fiji, accounting for 40% of all surgeries. This may be attributed to poor education, awareness and footcare practices among patients. Despite extensive research on diabetic foot complications and management, there is a significant gap in understanding patients' perceptions. This Original Research article explores the perceptions of type 2 diabetes patients in Fiji regarding diabetic foot complications and their self-management practices.

'Perceived social support' describes the perception of adequacy of support being provided by a person’s social network. Higher perceived social support has been linked to multiple health-related, psychological, and other benefits. The Multidimensional Scale of Perceived Social Support (MSPSS) was originally developed in English and has been widely translated and used in other languages. However, a recent review found that many studies among non-English-speaking people have used the scale without attempting to understand the meaning and context or to reconcile linguistic and cultural differences. This Original Research article reports on a study that coordinated the translation of the MSPSS into Diné bizaad, the language of the Navajo tribal members, by local community groups, with a focus on developing understanding of the cultural and language-specific meaning of concepts.

Cognition, physical function and life purpose constitute an important triad for functional and successful aging. The populations of many countries are aging, so increasing our understanding of experience of aging is crucial for making future public health decisions. Most studies on the experience of aging have been in urban areas but nearly half of the world’s population lives in rural areas and can have vastly different experiences from people living in urban areas. This Systematic Review describes the main characteristics and ways of aging in rural communities around the world, focusing on cognition, physical function, functionality and purpose in life.

Cognição, função física e propósito de vida constituem uma importante tríade para um envelhecimento funcional e bem-sucedido. As populações em muitos países estão envelhecendo, portanto, aumentar a compreensão da experiência de envelhecer é crucial na tomada de decisões futuras em saúde pública. A maioria dos estudos sobre a experiência de envelhecer é de áreas urbanas, entretanto, cerca de metade da população mundial vive em áreas rurais e pode ter experiências muito diferentes das populações urbanas. Esta revisão sistemática descreve as principais características e modos de envelhecer em comunidades rurais ao redor do mundo, com foco na cognição, função física, funcionalidade e propósito de vida.

La cognición, la función física y el propósito de vida constituyen una tríada importante para un envejecimiento funcional y exitoso. Las poblaciones de muchos países están envejeciendo, por lo que aumentar nuestra comprensión de la experiencia del envejecimiento es crucial para tomar futuras decisiones de salud pública. La mayoría de los estudios sobre la experiencia del envejecimiento se han realizado en áreas urbanas, pero casi la mitad de la población mundial vive en áreas rurales y puede tener experiencias muy diferentes a las de las personas que viven en áreas urbanas. Esta Revisión Sistemática describe las principales características y formas de envejecimiento en las comunidades rurales de todo el mundo, centrándose en la cognición, la función física, la funcionalidad y el propósito de vida.

This Original Research article presents results from a study exploring young people’s perceptions of how the rural setting influences their mental health. Utilising an ecosystems approach, the study explores the complex interplay of factors that impact on rural youth wellbeing, allowing for the development of nuanced and contextually appropriate approaches to improve mental health in this at-risk demographic. Understanding the influences on rural youth mental health allows for the exploration of interventions that amplify the protective aspects of rural living while mitigating the risk factors.

In recent decades, gambling has greatly expanded globally, in particular to online markets. This has been of concern due to the potential risks of gambling, such as problem or pathological gambling, as well as links to harms such as intimate partner violence, financial or career difficulties, association with mental health problems, and substance use. This Original Research article reports on differences in the prevalence, format and risk of problem gambling for people living in urban and rural areas.