A systematic review of the measurement properties of aspects of psychological capacity in older adults.

OBJECTIVE: to examine the measurement properties of instruments that have been used to measure aspects of psychological capacity in adults aged 60 years and over. METHODS: the databases PsycINFO, MEDLINE, EMCARE and Scopus from 2010 were searched using search terms related to psychological capacity, older persons and measurement properties. Both data extraction and risk-of-bias assessment were conducted using the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria using Covidence software. RESULTS: the full text of 326 articles were reviewed and a total of 30 studies were included, plus two further articles identified from reference lists (n = 32). No single instrument measuring psychological capacity was identified. Twenty (n = 20) instruments were identified that measure seven constructs of psychological capacity: Resilience; Sense of coherence; Hope; Mindfulness; Optimism; Attachment to life; Emotional regulation. CONCLUSIONS: this systematic review identified potential measures of psychological capacity in older adults. The review will inform further work to develop a single comprehensive measure of psychological capacity in older adults.

Australian rural medical students' perceived readiness for work as a junior doctor: A cross-sectional national survey.

OBJECTIVE: To report self-perceived readiness for work as a junior doctor in a national cohort of rural clinical school students. DESIGN: Cross-sectional study using a self-report questionnaire. Independent variables included 14 individual readiness items related to clinical and professional tasks, sociodemographic data and reported experience of rural clinical school (RCS) training. Participants were 668 medical students (55.3% females) completing a full academic year in rural Australia. Multivariable analysis explored factors associated with overall readiness for work as a junior doctor. FINDINGS: 86% agreed that RCS experience prepared them to undertake the roles and responsibilities of a junior doctor. Self-ratings for specific clinical and professional tasks varied from a mean score of 5.9-8.0 out of 10, and 13 of the 14 items were associated with the outcome (p-value <0.001, except for performing spirometry). Lowest readiness scores were seen for some aspects including raising concerns about a colleague (mean score 6.1) or responding to workplace bullying (mean score 6.0). Aspects of the RCS experience that were strongly associated with overall readiness included: feeling a valued team-member (OR 9.28, 95%CI 2.43-35.39), feeling well-supported academically (OR 6.64, 95%CI 3.39-13.00), having opportunity for unsupervised but supported clinical practice (OR 4.67, 95%CI 1.45-15.00), having a rural mentor (OR 3.38, 95%CI 1.89-6.06) and having a previous health professional qualification (OR 2.7, 95%CI 1.32-5.54). DISCUSSION: Most RCS students felt ready for work as a junior doctor. Important aspects of RCS experience are likely to include students feeling integrated within the clinical team and having opportunities for authentic clinical roles. There remains a significant challenge for medical school curricula to address professional areas where graduates felt less prepared.

Impact of the COVID-19 pandemic on student experiences during rural placements in Australia: findings from a national multi-centre survey.

BACKGROUND: The aim of this national study was to explore the learning experiences of Australia's medical students who trained rurally during the COVID-19 pandemic in 2020. METHODS: A cross-sectional, national multi-centre survey was conducted in 2020, through the Federation of Rural Australian Medical Educators (FRAME). Participants were medical students who had completed an extended Rural Clinical School (RCS) training placement (≥ 12 months). A bespoke set of COVID-19 impact questions were incorporated into the annual FRAME survey, to capture COVID-19-related student experiences in 2020. Pre-pandemic (2019 FRAME survey data) comparisons were also explored. RESULTS: FRAME survey data were obtained from 464 students in 2020 (51.7% response rate), compared with available data from 668 students in 2019 (75.6% response rate). Most students expressed concern regarding the pandemic's impact on the quality of their learning (80%) or missed clinical learning (58%); however, students reported being well-supported by the various learning and support strategies implemented by the RCSs across Australia. Notably, comparisons to pre-pandemic (2019) participants of the general RCS experience found higher levels of student support (strongly agree 58.9% vs 42.4%, p < 0.001) and wellbeing (strongly agree 49.6% vs 42.4%, p = 0.008) amongst the 2020 participants. Students with more than one year of RCS experience compared to one RCS year felt better supported with clinical skills learning opportunities (p = 0.015) and less affected by COVID-19 in their exam performance (p = 0.009). CONCLUSIONS: This study has provided evidence of both the level of concern relating to learning quality as well as the positive impact of the various learning and support strategies implemented by the RCSs during the pandemic in 2020. RCSs should further evaluate the strategies implemented to identify those that are worth sustaining into the post-pandemic period.

Person-centered, non-pharmacological intervention in reducing psychotropic medications use among residents with dementia in Australian rural aged care homes.

BACKGROUND: High rates of psychotropic medications are prescribed in aged care homes despite their limited effectiveness and associated adverse effects. We aim to evaluate the changes in prescription patterns for elderly residents with dementia in the 'Harmony in the Bush Dementia Study'. Harmony in the Bush is a person-centered model of dementia care in nursing homes, based on the principles of Progressively Lowered Stress Threshold and person-centered music intervention. METHODS: Our larger study (12 weeks period) was a quasi-experimental design conducted in five rural nursing homes in Australia. Medication charts (n = 31) were collected retrospectively from three rural aged care facilities. Medication data for each resident was collected from a three-month medication charts, pre-intervention, and post-intervention. Fifty-three staff participated in 31 semi-structured interviews and 8 focus groups at post-intervention, and at 1-month and 3-months follow up. RESULTS: The median age of the participants was 83 years, and 68% of them were female. Polypharmacy was measured in 87% (n = 27) of the participants. Hypertension, hyperlipidemia, diabetes, and the Alzheimer's disease were the major comorbidities identified in residents. None of the residents received more than the maximum dose of psychotropic medications recommended by the guidelines. There was a reduction of 22.4% (77.4% vs 55%) in the use of at least any psychotropic medications, 19.6% (39% vs, 19.4%) reduction in antipsychotics and benzodiazepines (39% vs 19.4%), and 6.5% (42% vs 35.5%) reduction in antidepressants prescription medicines, when comparing residents' medication charts data covering 3-months pre- and post-intervention, however, these changes were not statistically significant. Additionally, there was a decreasing trend in the use of inappropriate medications. Psychotropic medications were prescribed in up to 43% and anti-dementia medications in 44% of participants for more than 6 months. Three themes extracted from qualitative data include decrease behavioral and psychiatric symptoms of dementia due to medication weaning or dose tapering, other strategies to reduce medication use, and environmental or noise control. CONCLUSIONS: Our findings indicate that the Harmony in the Bush model as a non-pharmacological approach reduces the prescription of psychotropic medications in rural nursing homes as supported by findings from both quantitative and qualitative data. TRIAL REGISTRATION: ANZCTR, ACTRN12618000263291 . Registered on 20th February 2018.

The outcomes of a person-centered, non-pharmacological intervention in reducing agitation in residents with dementia in Australian rural nursing homes.

BACKGROUND: There is limited best- practice evidence to address behavioral and psychiatric symptoms for those with dementia in Australian rural nursing homes. This study aims to evaluate the outcomes of a person-centered, non-pharmacological dementia care model, 'Harmony in the Bush', based on the Progressively Lowered Stress Threshold principles and person-centered music in rural Australia. METHODS: A quasi-experimental (nonrandomized, pre-post) intervention study was conducted in five rural nursing homes in Queensland and South Australia. Seventy-four residents with dementia participated in this intervention study, which yielded a sample power of 80%. Eighty-seven staff completed the Caregiver Stress Inventory at pre-post four-weeks of intervention. Staff training workshops focused on the theory of the Progressively Lowered Stress Threshold principles and delivery of person-centered care plan with integrated music intervention. We used reported changes in agitation of the residents, measured using Cohen- Mansfield Agitation Inventory, and staff's caregiving stress, using Caregivers Stress Inventory. This study adheres to the CONSORT guidelines. RESULTS: Mean age of residents with dementia was 82.4 (7.7) years and 69% were females. The mean age of admission was 80.1(8.4) years. Baseline measures indicated that 32.7% had mild- severe pain and 30.5% reported mild-severe sadness. The results showed statistically significant decline in aggressive behaviors, physically non-aggressive behaviors, verbally agitated behavior and hiding and hoarding. There was similar reduction in staff stress in the domains of aggressive behaviors, inappropriate behaviors, resident safety, and resource deficiency. CONCLUSIONS: The Harmony in the Bush model is effective in reducing agitation among dementia residents with significant reduction in staff stress levels in nursing homes in rural Australia. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) on 20/2/2018 (Registration No: ACTRN12618000263291p). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374458.

Factors associated with medical students' interest in remote and very remote practice in Australia: A national study.

OBJECTIVE: To investigate the factors that are associated with medical student interest in remote and very remote practice in Australia. DESIGN: Aggregated data of an annual cross-sectional survey from 2013 to 2017. SETTING: Australia. PARTICIPANTS: Medical students from 17 medical schools, at the point of finishing one year of clinical training in a rural or remote location in Australia. MAIN OUTCOME MEASURES: Intention for working in a remote or very remote location as a doctor. RESULTS: Responses were analysed from 3328 medical students. From this cohort, 37.6%, 54.0% and 7.0% of students reported future career intent in capital or major cities; regional Australia; and remote or very remote Australia respectively. Multivariable analysis indicated students interested in remote and very remote practice compared to those interested in regional practice were more likely to be from a rural background, have prior generalist intentions, felt as though their rural clinical school (RCS) experience increased interest in remote and very remote practice, and had higher rural practice self-efficacy. Odds ratios were larger for these factors when students interested in remote or very remote practice were compared with students interested in practicing in capital or major cities. CONCLUSIONS: Rural background, prior generalist intentions, rural practice self-efficacy and the overall influence of the RCS experience are associated with interest in remote and very remote practice.

Rural disability workforce perspective on effective inter-disciplinary training-A qualitative pilot study.

OBJECTIVE: Inter-professional education is a growing area of importance that enables training of health care professionals and students to develop skills in collaborative clinical practice, a critical aspect of disability care. However, research is limited on appropriate on-site inter-professional training for the rural and remote disability workforce. This paper aims to explore the features of an effective inter-professional training approach for rural disability workforce. SETTING: Riverland, South Australia. PARTICIPANTS: Clinical educators, allied health professionals, health and service providers and students. DESIGN: A qualitative-explorative research design, involving focus group discussion and a thematic analysis method were employed in this study. Participants of the focus group discussion completed a capacity building training program centred on inter-professional education, cultural-safety and the National Disability Insurance Scheme. National Disability Services Social Impact Measurement Tool was used to evaluate and explore the features of effective inter-professional training program for existing and emerging disability workforce in rural regions. RESULTS: Four themes emerged from data analysis: inter-professional education focus; structured inter-professional training; building collaborative learning environment; and culturally appropriate care practice. Inter-professional supervision was identified as a key enabler for capacity building in an area with limited health workforce. Inter-agency collaboration and professional network were identified as important elements to support disability health workforce retention and the transition from novice to practitioner. Prior knowledge about the needs of persons with disability and empathetic relationships influenced the quality of practice. CONCLUSION: In situ training programs, which provide real-life rural practice context and harness inter-agency collaboration, improve effectiveness of rural disability workforce readiness for practice.

Personalised music for residents with dementia in an Australian rural aged-care setting.

OBJECTIVE: Personalised music reportedly has a positive effect on behaviour and mood in people living with dementia. This intervention has not been conducted in low-resourced or rural aged-care settings. We evaluated the effect of a non-therapist-led personalised music listening intervention on residents with dementia and workplace culture in a rural aged-care facility in South Australia. DESIGN: Qualitative pilot study. SETTING: Rural aged-care home in South Australia. PARTICIPANTS: Ten residents with dementia and 15 aged-care staff participated in this study. INTERVENTIONS: Ten residents participated in an 8-week music program. Four focus groups were conducted with aged-care staff post-intervention. A thematic analysis was used to identify emerging themes. MAIN OUTCOME MEASURE: Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care. RESULTS: Three themes emerged: quality of life, personalised care and better aged-care environment. Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care. CONCLUSION: Personalised music program is an effective, low-cost intervention to improve quality of life and personalised care of residents living with dementia, staff well-being, and a workplace and culture in low-resourced or rural aged-care settings.

Correlation Between E6 and E7 Oncogenes and Malignant Transformation of Laryngeal Papillomatosis (LP) with Human Papillomavirus (HPV) in Pediatric Population.

INTRODUCTION: Laryngeal papillomatosis (LP) is the most common benign neoplasm affecting the upper respiratory tract mucosa in children. The most common genotypes of HPV associated with LP are types 6 and 11. Methods: Among 187 patients identified in our institution with LP, four cases showed malignant transformation to invasive squamous carcinoma. Results: These patients had tumors with HPV viruses that showed high expression of oncogene E6 and E7 and low expression of E2. Conclusion: Malignant transformation of LP is associated with oncogenic expression of E6 and E7.

Exploring the relationship between body mass index, mental health and outcomes of a regional physiotherapy-led post-arthroplasty review clinic.

OBJECTIVE: To determine whether 12-month hip and knee outcomes of a regional arthroplasty clinic were comparable to results from metropolitan-based clinics, and to explore a possible relationship between body mass index and depression to identify groups at risk of not achieving optimal outcomes. DESIGN: A prospective observational study. SETTING: A regional physiotherapy-led post-arthroplasty review clinic. PARTICIPANTS: Patients after hip or knee replacement. INTERVENTIONS: Patients underwent either total hip or total knee joint arthroplasty. MAIN OUTCOME MEASURES: SF-12 Health Survey, Oxford Hip/Knee Scale, 10-minute walk test, knee range of motion, body mass index and the Hospital Anxiety and Depression Scale. RESULTS: Physical outcomes were comparable to those reported by metropolitan-based clinics. People with a high body mass index showed most improvement in the severity of depression compared to those with a lower body mass index. CONCLUSION: It is important to consider the long-term effects of obesity on arthroplasty outcomes.

Doctors' rural practice self-efficacy is associated with current and intended small rural locations of practice.

OBJECTIVE: Key factors which positively influence recruitment and retention of doctors to rural practice include rural background and positive rural training experience. Despite this knowledge, there is no well-established conceptual framework to explain how these factors influence intention. The aim of this study was to consider rural practice self-efficacy and its influence on rural career choice by doctors. Questions relating to self-efficacy were formulated using Bandura's four proposed sources of self-efficacy, which include mastery experiences, vicarious experience, social persuasion and emotional and physical response to experiences. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Medical school graduates from Flinders University, who completed a rural year as a part of the clinical component of the course between 1997 and 2015. MAIN OUTCOME MEASURES: Rural self-efficacy; current and intended location of practice in small rural communities (<25 000 people). RESULT: It was found that 28.5% of participants were currently working in communities of <25 000 people. Levels of intent for future small town rural practice were consistent across career stages after internship. Higher rural practice self-efficacy scores were found in doctors working in smaller towns (<25 000) and small communities (<10 000). Higher self-efficacy was also associated with rural background, more senior career status, earlier speciality decision time and smaller expectation-experience gap. CONCLUSION: An independent association exists between rural self-efficacy and intention to remain or return to small rural practice. The article offers rural clinical schools the opportunity to consider how they can influence future rural career outcomes.

Associations between health-related self-efficacy and suicidality.

BACKGROUND: Few studies have focused on exploring the association of self-efficacy and suicidal behaviour. In this study, we aim to investigate the association between health-related self-efficacy and suicidality outcomes, including lifetime/recent suicidal ideation, suicidal attempts and future intent of suicide. METHODS: A computer-assisted telephone interview (CATI) system was used to draw potential respondents aged over 15 in Taiwan via telephone numbers, which were selected by a stratified proportional randomization method according to the distribution of population size in different geographic areas of Taiwan. We obtained available information on suicide behaviours for the analysis of 2110 participants. Logistic regression was applied to investigate the independent effect of health-related self-efficacy on life-time suicidal thoughts and attempts. RESULTS: Suicidality measured as suicide ideation and attempted suicide was reported as 12.6 and 2.7% respectively in the sample. Among those with suicide ideation, 9.8% had thoughts of future suicide intent. Female gender, low education, people living alone or separated, history of psychiatric disorders, substance abuse, poor self-rated mental health and physical health were associated with suicidality factors. Low health-related self-efficacy was associated with lifetime suicide ideation, prior suicide attempt and future suicidal intent. Among those with recent suicidal ideation, low health self-efficacy was independently associated with future suicide intent after adjustment of gender, age, education, marital status, substance abuse, psychological distress, poor mental and physical health. CONCLUSION: Health-related self-efficacy was associated with suicide risks across different time points from prior ideation to future intention. Evaluation of the progress of self-efficacy in health may be long-term targets of intervention in suicide prevention strategies.

Block versus longitudinal integrated clerkships: students' views of rural clinical supervision.

CONTEXT: Medical students undertaking longitudinal integrated clerkships (LICs) train in multiple disciplines concurrently, compared with students in block rotations who typically address one medical discipline at a time. Current research suggests that LICs afford students increased access to patients and continuity of clinical supervision. However, these factors are less of an issue in rural placements where there are fewer learners. The aim of this study was to compare rural LIC and rural block rotation students' reported experiences of clinical supervision. METHODS: De-identified data from the 2015 version of the Australian national rural clinical schools (RCSs) exit survey was used to compare students in LICs with those in block rotations in relation to how they evaluate their clinical supervisors and how they rate their own clinical competence. RESULTS: Multivariate general linear modelling showed no association between placement type (LIC versus Block) and reported clinical supervision. The single independent predictor of positive perception of clinical supervisors was choosing an RCS as a first preference. There was also no association between placement type (LIC versus Block) and self-rated clinical competence. Instead, the clinical supervision score and male gender predicted more positive self-ratings of clinical competence. CONCLUSIONS: The quality of clinical supervision in block placements and LIC programmes in rural Australian settings was reported by students as equivalent.

Self-efficacy reduces the impact of social isolation on medical student's rural career intent.

BACKGROUND: Social isolation in medical students is a subjective experience that may influence medical career decision making. Rural self-efficacy has been shown to influence rural career intentions following a rural clinical placement, however its impact on social isolation during a rural clinical placement has not been previously modeled. The objective of this study is to explore whether self-perception of social isolation is associated with rural career intent in rural medical students. Secondly, to determine whether self-efficacy influences the association between social isolation and rural career intent. METHODS: 2015 data, from a cross-sectional survey of the National Federation of Rural Australian Medical Educators (FRAME) study. Among 619 medical students attending rural clinical schools (RCS), rural career intent was assessed. This included intended rural location for either postgraduate medical specialist or generalist training or completion of that training. Self-efficacy beliefs in rural medical practice were based on a validated scale consisting of six questions. Social isolation was measured asking students whether they felt socially isolated during their RCS placement. RESULTS: 31.3% of surveyed students self-reported feeling socially isolated during their rural placement. Social isolation was associated with reduced rural career intent after controlling for gender, rural background, RCS preference, RCS support and wellbeing. In step-wise logistic regression the association between social isolation and rural intent disappeared with the inclusion of rural self-efficacy. CONCLUSIONS: Social isolation during a rural clinical placement is commonly reported and is shown to reduce rural career intent. High levels of rural clinical self-efficacy reduce the effects of social isolation on future rural workforce intentions.

The influence of rural clinical school experiences on medical students' levels of interest in rural careers.

BACKGROUND: Australian Rural Clinical School (RCS) programmes have been designed to create experiences that positively influence graduates to choose rural medical careers. Rural career intent is a categorical evaluation measure and has been used to assess the Australian RCS model. Predictors for rural medical career intent have been associated with extrinsic values such as students with a rural background. Intrinsic values such as personal interest have not been assessed with respect to rural career intent. In psychology, a predictor of the motivation or emotion for a specific career or career location is the level of interest. Our primary aims are to model over one year of Australian RCS training, change in self-reported interest for future rural career intent. Secondary aims are to model student factors associated with rural career intent while attending an RCS. METHODS: The study participants were medical students enrolled in a RCS in the year 2013 at the University of New South Wales (UNSW) and who completed the newly developed self-administered UNSW Undergraduate Destinations Study (UDS) questionnaire. Data were collected at baseline and after one year of RCS training on preferred location for internship, work and intended specialty. Interest for graduate practice location (career intent) was assessed on a five-variable Likert scale at both baseline and at follow-up. A total of 165 students completed the UDS at baseline and 150 students after 1 year of follow-up. RESULTS: Factors associated with intent to practise in a rural location were rural background (χ2 = 28.4, P < 0.001), two or more previous years at an RCS (χ2 = 9.0, P = 0.003), and preference for a rural internship (χ2 = 17.8, P < 0.001). At follow-up, 41% of participants who originally intended to work in a metropolitan location at baseline changed their preference and indicated a preference for a rural location. The level of interest in intended practice location was significantly higher for those intending to work in a rural area than those with intention to work in a metropolitan (urban area) location (t = -3.1, P = 0.002). Initial rural career location intention was associated with increased interest levels after 1 year of follow-up (paired t = -2.3, P = 0.02). CONCLUSION: When evaluating the success of RCS outcomes with respect to rural workforce destination, both rural practice intentions and level of interest are key factors related to projected career destination. RCS experience can positively influence practice intent (toward rural practice) and interest levels (toward greater interest in rural practice).

Evaluation of lived experience Peer Support intervention for mental health service consumers in Primary Care (PS-PC): study protocol for a stepped-wedge cluster randomised controlled trial.

BACKGROUND: The demand for mental health services in Australia is substantial and has grown beyond the capacity of the current workforce. As a result, it is currently difficult for many to access secondary healthcare providers. Within the secondary healthcare sector, however, peer workers who have lived experience of managing mental health conditions have been increasingly employed to intentionally use their journey of recovery in supporting others living with mental health conditions and their communities. Currently, the presence of peer workers in primary care has been limited, despite the potential benefits of providing supports in conjunction with GPs and secondary healthcare providers. METHODS: This stepped-wedge cluster randomised controlled trial (RCT) aims to evaluate a lived experience peer support intervention for accessing mental health care in primary care (PS-PC). Four medical practices across Australia will be randomly allocated to switch from control to intervention, until all practices are delivering the PS-PC intervention. The study will enrol 66 patients at each practice (total sample size of 264). Over a period of 3-4 months, 12 h of practical and emotional support provided by lived experience peer workers will be available to participants. Scale-based questionnaires will inform intervention efficacy in terms of mental health outcomes (e.g., self-efficacy) and other health outcomes (e.g., healthcare-related costs) over four time points. Other perspectives will be explored through scales completed by approximately 150 family members or carers (carer burden) and 16 peer workers (self-efficacy) pre- and post-intervention, and 20 medical practice staff members (attitudes toward peer workers) at the end of each study site's involvement in the intervention. Interviews (n = 60) and six focus groups held toward the end of each study site's involvement will further explore the views of participants, family members or carers, peer workers, and practice staff to better understand the efficacy and acceptability of the intervention. DISCUSSION: This mixed-methods, multi-centre, stepped-wedge controlled study will be the first to evaluate the implementation of peer workers in the primary care mental health care sector. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001189617. Registered on 17 November 2023, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386715.

Associations between elevated homocysteine, cognitive impairment, and reduced white matter volume in healthy old adults.

OBJECTIVES: Elevated homocysteine has emerged as a risk factor for cognitive impairment even in healthy elderly persons. Reduced brain volume and white matter hyperintensities also occur in healthy elderly as well, but the interrelationships between these have not been well studied. We report these interrelationships in non demented, relatively healthy, community-dwelling older adults from a single East Asian population. METHODS: Two hundred twenty-eight right-handed participants age 55 years and above were evaluated. Persons with medical conditions or neurological diseases other than well-controlled diabetes mellitus and hypertension were excluded. Participants underwent quantitative magnetic resonance imaging of the brain using a standardized protocol and neuropsychological evaluation. Plasma homocysteine, folate, vitamin B(12), and markers for cardiovascular risk: blood pressure, body mass index, fasting blood glucose, and lipid profile were measured. RESULTS: Elevated homocysteine was associated with reduced global cerebral volume, larger ventricles, reduced cerebral white matter volume, and lower cognitive performance in several domains. Elevated homocysteine was associated with reduced white matter volume (ß = -20.80, t = -2.9, df = 223, p = 0.004) and lower speed of processing (ß = -0.38, t = -2.1, df = 223, p = 0.03), even after controlling for age, gender, and education. However, the association between homocysteine and lower speed of processing disappeared after controlling for white matter volume. Elevated homocysteine was not associated with white matter hyperintensity volume or with hippocampal volume. Although homocysteine and folate levels were correlated, their effects on white matter volume were dissociated. CONCLUSION: In non demented, relatively healthy adults, elevated homocysteine is associated with lower cognitive scores and reduced cerebral white matter volume. These effects can be dissociated from those related to white matter hyperintensities or reduced folate level.

A Qualitative Study of Rural and Remote Australian General Practitioners' Involvement in High-Acuity Patients.

This study aimed to understand the experiences, barriers, and facilitators of rural general practitioners' involvement with high-acuity patients. Semi-structured interviews with rural general practitioners in South Australia who had experience delivering high-acuity care were audio-recorded, transcribed verbatim, and analyzed through content and thematic approaches incorporating Potter and Brough's capacity-building framework. Eighteen interviews were conducted. Barriers identified include the inability to avoid high-acuity work in rural and remote areas, pressure to handle complex presentations, lack of appropriate resources, lack of mental health support for clinicians, and impacts on social life. Enablers included a commitment to community, comradery in rural medicine, training, and experience. We concluded that general practitioners are a vital pillar of rural health service delivery and are inevitably involved in disaster and emergency response. While the involvement of rural general practitioners with high-acuity patients is complex, this study suggested that with the appropriate system, structure and role supports, rural general practitioners could be better empowered to manage high-acuity caseloads locally.

Understanding Unmet Care Needs of Rural Older Adults with Chronic Health Conditions: A Qualitative Study.

BACKGROUND: Rural populations experience poorer access to the necessary health services for chronic health conditions. Although studies of rural healthcare access continue to expand, most are based on quantitative data, yet normative views and lived experiences of rural adults might offer a better understanding of healthcare access and their specific unmet needs. This qualitative study sought the views of both rural-centric older people and healthcare professionals to understand health needs, barriers, and enablers of accessing health services, with a focus on chronic health condition(s). METHODS: Between April and July 2022, separate in-depth interviews were conducted with 20 older people (≥60 years) in a rural South Australian community. Additionally, focus group interviews were conducted with 15 healthcare professionals involved in providing health services to older adults. Transcripts were coded using the NVivo software and data were thematically analysed. RESULTS: Participants described a range of unmet care needs including chronic disease management, specialist care, psychological distress, and the need for formal care services. Four barriers to meeting care needs were identified: Workforce shortages, a lack of continuity of care, self-transportation, and long waiting times for appointments. Self-efficacy, social support, and positive provider attitudes emerged as crucial enabling factors of service use among rural ageing populations. DISCUSSION: Older adults confront four broad ranges of unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. There are potential facilitators, such as self-efficacy, provider positive attitudes, and social support, that could be leveraged to improve healthcare services access for older adults.