Volume 7

At the heart of the rural construct is the concept of inside and outside. Who is included and who is left out? What is the appropriate therapy for the disease of 'perimeteritis', lacking awareness of anything outside of major metro areas? Rural health care leaders were interviewed regarding their own definitions of rural, community, health, well-being, and a healthy rural community. Rural communities and their health leaders may want to review their own definitions and how perceptions from inside and outside may impact their futures.

This article provides a great example of how junior rural health professionals can contribute to important public health research in rural communities under difficult circumstances - and you will learn some helpful facts about snake bites in rural Sri Lanka!

The determination of racially appropriate waist circumference (WC) has emerged as an important factor in the prevention, management and prognostication of a variety of disease conditions. This study of a rural population from Iraq makes an important contribution to the literature.

What do we really 'need' to ensure the community feels happy with the healthcare services available in their town? This study elegantly demonstrates that what might be perceived as satisfactory by one community is inadequate to another. The words of the community members is this Australian qualitative article should be read especially by capital-city-based health service planners.

Inaccuracy in recording the cause of death on death certificates has implications for health planning. This study from rural western Greece shows that while certifying accuracy is improving, many physicians still overlook this important epidemiological issue.

A supportive workplace is a pre-requisite for happy and productive staff, wherever they work. Trying to better understand the nature of our working relationships is an ongoing challenge. This interesting qualitative study describes how rural nurses support one another in the workplace. It brings to life additional understanding of what it takes for people to learn how to work well together.

Public health campaigns enjoy variable success. This study of obesity among rural Malaysians suggests a vital precursor to initiating public health strategies.

We all know about the problems small rural communities face in gaining access to required health professionals. In this study we learn how paramedics are offering a solution by training a volunteer community-based workforce to help manage emergencies in towns too small to support a full time paramedic.

Does a rural emergency medicine training rotation discourage the best trainees from applying to the program? This US study asks the people involved.

Children are commonly thought of as the victims of farm injuries but they are also active agents for identifying and preventing hazard risks and accidents. The authors of this article conducted focus groups with Australian rural children to determine the comprehension and attractiveness of three promotion tools addressing child farm safe. The results will surprise you - and make you rethink how to design communication programs.

Neonatal mortality is a serious concern in India, especially in rural areas. The authors of this letter highlight important but often overlooked contributing factors.

How can we help a vulnerable rural population avoid diabetes mellitus? This pilot study from Victoria Australia uses the transtheoretical model of behaviour change to evaluate the possibility of diabetes prevention.

Few physician workforce studies take a chance on attempting to understand national or regional changes in physician location. In this long-term US study, physicians were matched up in the Masterfile across a 22 year span to determine regional migration patterns. The researchers were rewarded with some interesting results.

This review from a team of medical academics in rural New South Wales, Australia, used the power of electronic data sets to track the trends in rural health publications since 1990 in Australia, Canada and the United States. It's not a race but, hey folks, the number of rural health publications are increasing every year and Australian authors are nosing to the front!

Despite acknowledged curative and preventive measures, child malaria remains a concern in many countries. Does parental empowerment and participation in control efforts offer a way forward? This review of recent literature suggests a unique approach.

From the chaos of civil war in Ethiopia in the 1990s comes a useful model of care. The authors of this letter to the editor describe a unique "grass roots" system for providing health care to large displaced and dispersed populations.

The Australian Rural Health Education Network (ARHEN) is the peak body representing the 11 University Departments of Rural Health (UDRHs) in Australia. One of ARHEN's strategic purposes is to promote national networks. This editorial provides a position statement from the network regarding Australian rural interprofessional education. Everyone knows we should try and enourage health professions to learn together. Yet, as this editorial highlights, we are still a long way from having clinical undergraduate interprofessional education implemented in any systematic way in Australia.

What is it really like to be new graduate nurse in rural New South Wales, Australia? This article uses qualitative methodology to allow the reader an insight into the real stresses that confront our junior nurses, making it a "must read" for rural health service managers who want to retrain new and much needed new recruits.

What does resilience mean for a rural community? A group from Queensland, Australia, provide us with some interesting clues.

Can rural doctors who smoke play a part in stopping their patients from smoking? This question is raised in relation to rural India.

This well written paper is a "must read" for any medical educator. The Australian College of Rural and Remote Medicine's (ACCRM) struggle to gain recognition was achieved this year, and its fellowship program is a world first in rural and remote medical education. Not only are the fellowship's underpinning principles clearly documented, but the article also provides new evidence about the effectiveness of a comprehensive and contemporary assessment system in the postgraduate medical setting.

Research over the past two decades is building evidence of a clinical correlation between diabetes and low magnesium intake. In this paper Queensland researcher draw on a range of ecological data and convenience samples to argue that low magnesium in water, and through poor dietary intake and sweat loss may be responsible for the high rates of diabetes in Indigenous Australian populations. With greater international attention on the importance of magnesium, readers will find this article's implications for rural health thought provoking.

In rural areas, working with children who have special needs can be frustrating. The resources that parents can access in the city to help maximise their child's development often do not exist. This personal view reflects on the recent case of "Amillia" , an extremely preterm infant born in the USA, where such access for children with disabilties is enshrined in law. While Amillia would not have been so fortunate if she had been born in Australia, this commentary encourages those who advocate for rural children with special needs to keep the issue in the spotlight.

Qualitative studies provide rich insights into the lives of informants and increasingly rural health research can offer many such studies. This article pulls together the findings of six qualitative studies on Australian rural women's strategies to maintain health to create a new and deeper understanding of the issues then is possible in single case studies. The article is not only about an important topic but it is also provides a clear explanation of a technique known as metasynthesis which is increasingly being used to create robust and generalisable results from multiple qualitative studies.

Rural and remote medicine is a "broad church" and although we may believe that it is a recent academic speciality, this essay tells the story of how a Clergyman, Reverend John Flynn, developed a lasting rural clinical service in Australia nearly 100 years ago. It also reveals that the father of modern cardiology, James Mackenzie, was really a generalist at heart. The essay offers a way to use the infrastructure established by the Rural Clinical School program in Australia to guide the vocational training pathways for the rural generalists and specialists of tomorrow.

For decades the Rural Physician Associate Program has been preparing physicians for the American heartland with a nine month longitudinal rural experience. Fewer medical students have had rural experiences, and even fewer have a clue regarding the challenge of transitioning from the passive basic science and clinical roles of medical centers to the wide open interactions and opportunities provided in rural practice environments. University of Minnesota rural medical educators have developed some tools to ease this transition.

In an era when the health dangers of tobacco smoking are widely understood, it is alarming that the new generation continues to smoke. By considering associated socio-demographic factors, this study of rural Zambian adolescents and their smoking history offers opportunities to intervene in adolescents' smoking behaviour.

Is rural origin a factor in reduced cancer screening uptake? This Croatian study assessed the impact of a range of social disparities, including rural origin, on the opportunistic uptake of breast, colon, and prostate screening in an adult population.

Therapy assistants, often solely responsible for the delivery of therapy health services to rural clients, are an essential part of the Australia rural health workforce. This project report that documents a scheme for their appropriate training is long overdue, and may be applicable to other states - and countries - outside its West Australian origin.

It is humbling to attempt to summarize in sentences what has taken a lifetime to compile and understand. Crosato, Ward-Griffin and Leipert have devoted such an effort to understanding the Aboriginal women caregivers of the elderly. For practitioners, systems and nations to understand health care, they must understand the richness of variation and context, simplified by the concept of Circles of Caring illustrated in the article.

A rural setting can add an layer of complexity to detecting early psychosis, potentially delaying treatment, with implications for immediate and long-term outcome. This project report from rural New South Wales, Australia, describes a novel approach to harnessing existing rural community strengths to assist those on the brink of psychosis.

Where are the children? That is the question rural paediatrician Dr Peter Jones wants answered. This letter is a part of the series from people with personal or professional insight into the emergency measures imposed on remote Aboriginal communities in response to charges of child abuse. Peter reflects on his 18 years of professional experience and questions how the 'emergency response' will actually improve the situation for abused and neglected children and their families.

The problem of staphylococcal infection is an issue that is rampant among poor rural and periurban dwellers in Nigeria, related to alternative health care. This letter argues that regulation and education are required to address the problem.

The ultimate questions in health care involve access, cost, and quality. This is a challenge for health care delivered in very different environments with different levels of resources and expertise. Translations and updates are required to understand, adapt, and transform the care. This is true for individuals, for facilities, and for nations. The earliest stages of translation and transformation involve access to the best information and research. The ethnographic study Access and Use of Research by Rural Nurses captures the Montana rural nursing environment and highlights the changes needed to transform rural nursing.

Extreme makeovers are popular today. Extreme makeovers are also required when research involves the extremes of climate and geography. Readers should enjoy this walk through problem solving far beyond the usual statistical dimensions.

The shortage of GPs in rural and remote Australia is well known to readers of this Journal. Is this just the whinging of a profession that has had it pretty good in recent years? This study from a regional centre in New South Wales, Australia, suggests otherwise. Using a unique before-and-after design, the researchers find the local GPs are very sensitive to increases in the total GP workforce. The addition of a modest number of extra GPs and surgeries, among other workforce changes, improved their perception of their workload. This suggests that monitoring GP perceptions could be a value tool in workforce planning.

The researcher development program is a relatively new Australian Government initiative intended to increase research capacity in the field of prmary health care. This report from the New South Wales Northern Rivers University Department of Rural Health tells us a little of their plans and describes what has been a successful national initiative.

Seeing is believing. As many articles in Rural and Remote Health have demonstrated, giving health students an opportunity to experience rural practice is educationally rewarding and is an effective workforce recruitment strategy. This paper from the Centre for Rural and Remote Oral Health in Western Australia may be the first to document the value of rural placements for dental students.

Are rural midwives more or less competent and confident in their practice than their urban counterparts? An exploratory study from Scotland reveals that this simple question has a complex answer.

Addressing the high rates of chronic disease among Indigenous people requires significant changes in normal practice for health professionals accustomed to caring for non-Indigenous clients. This study from New South Wales, Australia, explored community pharmacists' understandings and views about information and service needs of Indigenous people in their towns. Such research is a vital step towards improving the capacity of mainstream health services to provide accessible and culturally secure care.

How does context influence practice in remote communities? This article from Victoria, Australia, sets out a theoretical model for answering this important question.

Providing effective services to women with drug dependence is challenging in any environment but particularly difficult in rural areas. This article from northern NSW describes a program of case management that resulted in measurable improvements in women's well-being. It is a great example of good program design and implementation combined with rigorous outcome evaluation.

Circumcision is commonly practised as part of initiation ceremonies in southern Africa. Complications, particularly sepsis, are common. This case report describes an unusual consequence of such sepsis and the dangers associated with it.

One of the charachteristics of working in remote locations is that your manager may live and work a long distance from you in the regional 'centre'. This article from the Northern Territory, Australia, examines how these arrangements may be affecting the retention of remote area nurses.

How to get the anti-smoking message to remote areas in the developing world where the use of tobacco products continues to rise? This letter from India offers some simple but effective strategies.

Two more letters have just been posted on the recent Australian government response to abuse in Aboriginal communities. Written by health care providers and a researcher, respectively, with considerable experience in working respectfully and effectively with Aboriginal people, both letters call for a well-resourced but thoughtful response using proven solutions and, to quote from one letter 'the collective wisdom within the community.' Rural and Remote Health urges others to share their views and experience on this issue.

Head lice infection or pediculosis is highly prevalent - at least as common among school children in small communities as in big cities. Parents, schools and health departments alike view it as a public health issue that should be managed by parents. But this paper, based on surveys in Victoria and North Queensland, Australia, reveal that parents do not have sufficient knowledge to adequately detect and treat head lice. It is a timely reminder that requiring people 'to do something' is not enough if knowledge and supportive systems are not in place.

Australian readers will be aware of recent actions by the Commonwealth Government in remote Aboriginal communities in the Northern Territory. This letter to the editor by Juli Coffin, Senior Lecturer in Aboriginal Health in Western Australia, is a response to the sudden and sweeping government policy intervention. Rural and Remote Health encourages all readers with personal or professional experience of the complex issues facing the people who live in and serve remote Aboriginal communities to submit letters. Our intention is to provide a forum to share viewpoints from those who are affected by these latest and previous interventions.

The promotion of breastfeeding is a vital area for health professionals who work with new mothers - but what is our knowledge level? For instance, what do trainee GPs know about breastfeeding? This small qualitative study of GP-trainee perceptions provides some insight.

This letter identifies a high incidence of tuberculosis among the forest dwelling Sahariya tribe of central India.

Preventing suicide deaths in rural communities, especially among men, is a universal concern. This study from Scotland examined the association of population density with suicide - and presents some compelling conclusions.

Are you interested in the workforce outcomes of rural health professional education? This new data collection instrument from Australia will provide interesting new information.

In an overview of elements with the potential to improve health services to rural areas, this Norwegian systematic appraisal of the literature transcends national or regional boundaries.

An assured, safe water supply has been taken for granted in the developed world. This study from Tasmania, Australia raises serious issues of concern regarding inequity in the provision of safe drinking water to rural communities.

Current health professional students are our future workforce. How can we encourage them to practice in rural and remote communities? This article provides a student perspective on the role of rural health clubs at universities in Australia.

A key factor in reducing the risk of an avian influenza pandemic is having an informed general population. This study of the information preparedness of a Greek population raises questions about how to deal with this serious public health threat in any country.

In developed countries effective treatment of hypertension in diabetic patients has led to a significant decline in cardiovascular disease morbidity and mortality. In this multicentre study, primary care physicians clarify whether these benefits are apparent in a rural Greek population.

Rural medical practices are increasingly taking on a major undergraduate teaching role. But could you sustain five students studying for the whole year in your practice? Experience from South Australia suggests you can!

This letter offers an Albanian perspective on the prevalence of type 2 diabetes in a rural population.

This article highlights Australian Aboriginal people's high rates of disease and mortality but low use of prescription medications. Explored as a potential solution to this low access to medication is the expansion of the special S100 scheme of the Australian Pharmaceutical Benefits. Cruicial to including Aboriginal medical services and Aboriginal health workers in this scheme will be the input of pharmacists.

It takes a village to make a healthy community. In Papua New Guinea the sense of belonging to a village is so strong that it remains a part of the fibre of people who have migrated to the capital Port Moresby. This fascinating article describes a novel health promotion program that was initiated by villagers transplanted to the city to keep their rural families and other language group members free of malaria. Do you know of evaluated projects that empowered urban residents to promote health and well-being of rural kin folk? Rural and Remote Health would like to hear about them. Add your comments to the discussion board accessed next to the article. Even better, submit a paper on the topic!

India's health system offers a model for postgraduate outreach training.

This book review alerts readers to free, useful WHO family planning tools.

What are the education, training and support needs of Australian medical graduates and international medical graduates in rural practice. This small study from rural New South Wales has some surprising findings.

Could something as simple as encouraging shoes to be worn more often be a sentinel public health intervention among diabetic patients in poorer rural communities? This article provides thought provoking evidence.

Continuing medical education might be about professional growth but, in retaining rural health professionals, this commentary suggests that addressing needs is more than just addressing CME.

Studies can be used to promote rural health, primary care, or generalism. A much better focus of research is to attempt to understand a number of changes and relationships. In a time of rapid change this can be important. The authors examine changes between 1995 and 2001 to consider the impact of the patient relationship to a physician.

Often students perceive differences in health practice and express themselves quite eloquently. This English medical student, on an elective, discovered the charm and challenges of practising obstetrics in Armidale, a rural town of just over 20,000 population, located in the New England region of northern New South Wales, Australia.

Increasingly health promotion initiatives targeting Aboriginal and Torres Strait Islander people are being evaluated. In this timely paper the authors review 21 recent evaluations. Their findings provide a valuable bluprint for improving the ethical conduct and impact of future evaluations. A "must read" for everyone working with the Indigenous in every nation.

Is a compulsory undergraduate rural attachment a strategic way to encourage interest in rural medical practice? This article from Australia raises some interesting questions.

This article adds to the body of literature that suggests encouraging students to move to a rural area for a 12 month period is a challenge, even in Victoria, Australia, where "rural" is only a 2 hour drive from the heart of Melbourne, the state capital. These results from Melbourne University Rural Clinical School students speak for themselves. A time may come when such studies are not needed, but until then, this article provides valuable insights as to what prospective RCS students are looking for.

How can it be that a national public health intervention can fail to prevent disease in a rural community, despite clear evidence that the community know exactly how to prevent it and appear to have the means to do so? This article from Thailand gives evidence that should not be ignored.

In a world that considers journalism supreme, especially the most abbreviated forms, it is very difficult to understand that there are other approaches to the effective communication of vital information. Approaches that are more likely to lead to better levels of understanding. Ethnography represents such an approach. The work is time-consuming and involves a complete immersion in the subjects and their way of life, while maintaining the ability to observe important differences and similarities. Good ethnography compares and contrasts. Going beyond good ethnography takes great perception, analysis, and writing. Great ethnography brings you into the lives and families and communities of the subjects to understand their experiences and decisions and more. Hopefully the authors of "Seeking serenity: living with HIV/AIDS in rural Western Canada" will expand their works into a book version on a par with "The Spirit Catches You and You Fall Down" by Anne Fadiman, a similar effort highlighting what is often a clash of cultures and beliefs among patients, families, communities, and the medical culture.

One of the barriers to successful implementation of public health initiatives in rural communities is the non-participation of significant groups. This article raises this issue in relation to reproductive health in an Indigenous community in India.

Do you need to influence policy and planning at a national level to increase primary health care activities in your rural communities. This review from Cambodia provides great insights from those who have been intimately involved with this process.

Do you have evidence of disease mongering by vested interests in your rural community? These authors in Nepal raise legitimate concerns for us to consider.

This research from rural Sarawak has found that women have a longer time between onset of symptoms and diagnosis of TB than men. What other factors may be involved? Could this be happenning in your community?

This letter gives an Australian medical student's reflections on his experience with a rural volunteer ambulance service.

Indigenous communities worldwide suffer many health inequities. Is infertility one of them? This short article from India provides further concerning evidence.

The Northern Territory Clinical School based in Darwin is now 10 years old and was precursor to more recently developed Rural Clinical Schools. This paper shows promising evidence that clearly supports the link between rural clinical training and a desire to work rurally. It also demonstrates that graduates from the RCS program need to have the opportunity to work as Interns rurally if the Rural Clinical Schools are going to improve the rural medical workforce in the long term.

Is rural medical practice different to the way city GPs practice? This article provides clear insights from medical students who have observed both.

Dental caries is an important cause and indicator of poor health. This article provides the first data on the difference in prevalence of this condition in Indigenous and non-Indigenous children in a rural South Australian centre.

Most rural practitioners should be familiar with the diagnosis and management of epilepsy. However, abnormal presentations and uncontrolled seizures should alert one to the possibility of unusual causes. This case report describes a patient who presented to a rural hospital in South Africa with a rare brain abnormality.

The pathways to the most needed careers and locations involve many turns and twists and bends. Individual efforts can overcome many, but not all obstacles. Some trails are blazed by those who go before. Others are laid out by those desiring to reach out by building new paths. Distributions of income, education, and training make pathways more challenging and these complexities are multiplied by individual and family situations and by locations. Some individuals, families, and communities have greater levels of organization and some have less. It is a complex interplay of factors at multiple levels.

Research involves more than just statistics, it involves the collected stories of those who share similar pathways to health or to health careers. The language of research may be different, but the stories remain true. Good research captures the stories. Great research translates from those living the pathway to those building pathways.

The Indian Ocean Territories of Australia do not immediately come to mind as important examples of the impact of the lack of workforce and declining services for remote Australians. This novel paper looks at the impact the lack of obstetric services has had on the Christmas and Coco Islands over the last decade. In doing so, Roach et al. provide an article that may be relevant to many other remote communities on mainland Australia.

94% of rural doctors recognise that the provision of and access to continuing medical education in rural areas is a vital factor in the retention of rural doctors and helps with feelings of professional isolation. Dr Colin White and colleagues present new research in their paper.

The current medical workforce in Australian rural emergency departments is a mixture of specialists, vocationally registered GPs, overseas trained doctors and doctors with no particular qualification. This study provides a snapshot of the current workforce. It also presents a range of opinions about options for developing rural emergency doctors in Australia.

In this article Somers et al. try to quantify what makes first year medical students "rural origin" and thus more likely in their future medical careers to work in rural areas. The data presented in this article are even more important to ensure that the outcome of the Australian Government's decision to invest by doubling the number medical student places leads to rural communities having the medical workforce they need in the future.

Interested in how technology can overcome the tyranny of distance? See what's happenning in New Zealand.

Rural health needs direction and purpose. To move beyond isolated and individual attempts that characterize rural health; to guide local, state, and regional planning; to increase capacity; to influence resource distribution; and to improve the efficiency and effectiveness of rural health, there must be sufficient organization and capacity in rural health research. Take a moment to review the development of the Canadian Rural Health Research Society and then share their ideas for creating capacity through connections.

Mental health is regarded as a high priority area for rural health. But are there enough qualified professionals to provide psychological intervention, support and counselling? This study from rural Queensland suggests not.

This letter to the editor highlights the potentially lethal complication of external otitis: malignant or necrotizing otitis externa. The diagnostic and role of family physicians is of vital importance. Guidelines are offered.

Could an after-hours triage system benefit your rural health service? Before you start, it may be helpful to learn from the experience of this group from rural Victoria, Australia.

Obesity is becoming recognised as a major risk factor for rural communities. This letter points out its association with disability associated with knee arthritis.

As good as they can be, are vaccine vial monitors enough to ensure effective immunisation substrate is available to rural communities? This short letter argues, from considerable experience, that other factors also need urgent consideration.

A rural nursing program has a vital role in improving the recruitment and retention of nurses in rural and remote settings. This small South Australian pilot study explored the views and experiences of recent rural undergraduate nursing students. Their highlights and disappointments are presented, resulting in some interesting recommendations.

How do we advance the rural health agenda in Europe? Our European Regional Editor provides some thought provoking suggestions.

There is no universal definition of a rural area, making comparisons of data from differently defined areas problematic. Read this discussion of the issues involved, and helpful suggestions, from an African perspective.

The strength of the international rural medical education movement lies in North America and Australia, where rural communities are recognised as having specific health care needs and initiatives have been introduced to improve rural health status. In Europe the need for a different approach in rural health is less well recognised. This article explores the relevance to Europe of developments elsewhere.

A voice of hope in perilous times? Our North American Regional Editor provides some disturbing statistics on the effect of current medical student selection processes on the current and future numbers of rural physicians in the USA and provides some options for a way forward.

Medical education does well in developing academic skills, however medicine is much more than academics. Few medical students are prepared for the challenges that await them after the completion of formal training.

Relationships with patients, staff, and communities are a particular challenge. Elite origin students need better awareness. Humble origin students need improved organization skills. The needs of both can be addressed in a single model.

The Community Medical Outreach program at Florida State University is a different and earlier model. CMO is organized by college students as part of their premedical preparation prior to admission to medical school. All participants benefit including the communities in need, the students in need of medical school admission, the health agencies and organizations in need of resources, and the college in constant need of evidence of public benefit.

Replication is up to those of us in the academic arm. Through this article, through discussions with colleagues, and in conversations with future students, we can share an opportunity. In the process we might just shape the students admitted, the training, and the distribution of physicians and resources in future years.

The model is young, but it is already influencing states and nations. One of the students, Mehran Heravi, was awarded the Howard R. Swearer Student Humanitarian Award in 2004. However the real winners will be the communities and peoples that will be served by replicating this program, now and in generations to come.

What attracts and retains dental professionals to the remotest parts of Australia? This research provides important evidence to inform workforce policy.

Adolescent mental health is a significant issue for rural communities in Australia. But why do those most affected not always seek help?

The prevention of communicable diseases thru immunisation is critically important for rural and remote health. But how effective are our systems for implementation? This article from India provides cause for concern.

Are we targetting the right people for blood donation in rural communities. This letter from Thailand provides an interesting perspective.

This letter to the editor reports on the contribution of rural GPs in the management of patients with type 1 diabetes treated with insulin pumps.

Could rural health workforce shortages be addressed through training outside the university sector? This article examines the potential for such solutions.

Is videoconferencing a cost-effective way to support rural carers? This article from Western Australia provides useful evidence supporting this approach.