Competition or collaboration in regional Australia? A cross-border and multi-university approach to maximising rural health investments, community health and health workforce outcomes.

AIM: To describe the establishment of a cross-border and multi-university collaboration in rural Australia to mitigate potential competition, maximise Rural Health Multidisciplinary Training (RHMT) Programme investments and regional health workforce outcomes. CONTEXT: Rural Health Multidisciplinary Training programme investments have enabled the establishment of 19 Australian University Departments of Rural Health (UDRH) and 17 Rural Clinical Schools. The importance of these investments is acknowledged. However, in regional settings, due to limited clinical placement and training opportunities, there is potential for heightened competition between universities who are operating within shared geographical footprints. Competition between universities risks focusing RHMT programme activity on individual reporting requirements and activities, in preference to: regional needs; existing community-university relationships; and place-based approaches to health workforce development. PARTICIPANTS: A rural New South Wales and Victorian RHMT-funded departments, collectively known as the Sunraysia Collaboration. APPROACH: Strategic and operational processes, structures and actions underpinning collaboration formation and relationship consolidation will be described. Co-design methodologies employed to collectively define collaboration vision and aims, governance framework and guiding principles, reporting structures and co-contributions to teaching, research and service will be discussed. Collaboration sensitivity to the social, cultural, relationship and economic connectedness within the region and existing health workforce flows will also be explored. CONCLUSION: The Sunraysia collaboration demonstrates one approach towards mitigating potential competition between RHMT Programme funded universities within rural and remote Australia. The collaboration is an exemplar of co-design in action providing an alternative approach to address RHMT Programme parameters and regional needs whilst supporting rural-remote health workforce training and education innovations.

General practice training in regional and rural Australia: A cross-sectional analysis of the Registrar Clinical Encounters in Training study.

OBJECTIVE: We aimed to investigate registrar, practice and consultation characteristics associated with varying degrees of GP registrars' practice rurality. DESIGN: A cross-sectional analysis of 12 rounds of data collection (2010-2015) from the longitudinal Registrar Clinical Encounters in Training study, an ongoing, cohort study of Australian GP registrars. The principal analysis used was a generalised ordered logistic regression. SETTING/PARTICIPANTS: GP registrars in training practices within five of 17 GP regional training providers in five Australian states. MAIN OUTCOME MEASURE: Degree of rurality of the practice in which the registrar undertook training terms was calculated from the practice postcode using the Australian Standard Classification-Remoteness Area classification. RESULTS: A total of 1161 registrars contributed data for 166 998 patient consultations (response rate 95.5%). Of these, 56.9% were in major city practices (ASGC-RA1), 25.7% were in inner-regional practices (ASGC-RA2) and 17.4% were in outer-regional/rural practices (ASGC-RA3-5). Several statistically significant associations (P = < .001) were found within regional/rural practices (ASGC-RA2-5), when compared with major city practices (ASGC-RA1). These included registrar characteristics such as being in Term 1, being medically trained overseas, and having worked at the practice previously; patient characteristics such as the patient being an existing patient, being older and being Aboriginal or Torres Strait Islander; and consultation characteristics such as performance of procedures. CONCLUSION: Our findings suggest that registrars are undertaking rural practice early in their GP training and are being exposed to a rich and challenging mix of clinical and educational practice.

Determining rural learning outcomes for medical student placements using a consensus process with rural clinical teachers.

Short, longer and programmatic rural attachments have developed in a number of medical programmes around the world. However, there is limited literature on the development of the underpinning learning outcomes to guide these attachments. Rural populations are commonly under-served and the specific needs and challenges of rural health care need to be emphasised, as well as encouraging future practice in these areas. Our aim was to produce common rural-specific learning outcomes, aligned with a rationalisation of existing guiding principles and objectives, for our medical student regional-rural programmes. This was achieved through a Delphi technique involving the relevant clinical teachers and supervisors. Forty-nine consenting participants collectively provided 72 learning outcomes which were synthesised down to 16. A consensus process was used to anonymously rate and then rank to reach consensus for the top four learning outcomes. The learning outcomes were placed within the theoretical framework of a 'pedagogy of place' based on rurality and triangulated with rural learning outcomes from an Australian study. The four final outcomes were resolved around two areas of 'place': geographical and developmental. The co-design approach enabled those involved in providing the rural exposure education to generate appropriate learning outcomes.

Building research experience: Impact of a novice researcher development program for rural health workers.

OBJECTIVE: The objective of this study was to determine the effect of the Rural Research Capacity Building Program on self-reported research experience of rural health workers. DESIGN: A repeat cross-sectional study design was used to assess self-reported research experience at the commencement and completion of a novice researcher development program. SETTING: Candidates in the Rural Research Capacity Building Program are health workers employed in the rural NSW public health service who have not completed research higher degrees. PARTICIPANTS: One hundred and thirty candidates of the Rural Research Capacity Building Program from the 2006 to 2013 cohorts were participated. INTERVENTIONS: The Rural Research Capacity Building Program is an experiential learning program in which candidates gain research experience by undertaking a new, self-selected, local health service endorsed research project over a 2-year period, supported by 10 days face-to-face teaching, weekly teleconferencing and mentoring. MAIN OUTCOME MEASURES: Change in self-assessed research experience using a validated 10-item measurement tool known as the Research Spider which measures 10 domains of research experience. RESULTS: Reported research experience demonstrated statistically significant increases across all 10 domains of research experience. The largest change was 'writing and presenting a research report' and 'writing a research protocol'. CONCLUSIONS: Significant increases in Research Spider results across all 10 domains demonstrated that completing the Rural Research Capacity Building Program significantly improves self-assessed research experience. Rural health workers who are experienced and confident to undertake research are more capable of studying health problems and finding solutions unique to the rural setting.

Learning from those who have gone before: strengthening the rural allied health workforce in Aotearoa New Zealand.

Context and issues: The pipeline for the allied health, scientific and technical workforce of Aotearoa New Zealand is under growing pressure, with many health providers finding recruitment and retention increasingly difficult. For health providers in rural settings, the challenges are even greater, with fewer applicants and shorter tenures. As the health needs of rural communities increase, along with expectations of uptake of technologies and the Ministry of Health's strategy to ensure care is provided closer to home, being able to retain and upskill the diminishing workforce requires new ways of thinking. Lessons learned: Understanding the activity that has been undertaken by medical and nursing workforces in New Zealand and abroad, as well as the work of the Australian allied health workforce provides context and opportunities for New Zealand. The challenge is for educators, professional bodies, the Ministry of Health and health providers to develop new ways of thinking about developing a rural workforce for the allied health scientific and technical professions.

Challenges, success factors and pitfalls: implementation of distributed medical education.

OBJECTIVES: There are only a few descriptive reports on the implementation of distributed medical education (DME) and these provide accounts of successful implementation from the senior leadership perspective. In Saskatchewan, over a period of 4 years (2010-2014), four family medicine residency sites were established and two additional sites could not be developed. The aim of this study was to identify challenges, success factors and pitfalls in DME implementation based upon experiences of multiple stakeholders with both successful and unsuccessful outcomes. METHODS: Data were obtained through document analysis (n = 64, spanning 2009-2016; perspectives of government, senior leadership, management and learners), focus groups of management and operations personnel (n = 10) and interviews of senior leaders (n = 4). Challenges and success factors were ascertained through categorisation. Iterative coding guided by three sensitising frameworks was used to determine themes in organisational dynamics. RESULTS: Both challenges and success factors included contextual variables, governance, inter- and intra-organisational relationships (most common success factor), resources (most common challenge), the learning environment and pedagogy. Management and operations were only a challenge. Organisational themes affecting the outcome and the pitfalls included the pace of development across multiple sites, collaborative governance, continuity in senior leadership, operations alignment and reconciliation of competing goals. CONCLUSIONS: Emerging opportunities for DME can be leveraged through collaborative governance, aligned operations and resolution of competing goals, even in constrained contexts, to translate political will into success; however, there are pitfalls that need to be avoided. Our findings based upon multi-stakeholder perspectives add to the body of knowledge on deployment, carefully considering the conditions for success and associated pitfalls.

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland.

BACKGROUND: Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. METHODS: An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access -spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. RESULTS: 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. CONCLUSIONS: Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

The impact of rural outreach programs on medical students' future rural intentions and working locations: a systematic review.

BACKGROUND: Significant investment has been undertaken by many countries into 'Rural Clinical Training Placement Schemes' for medical students in order to deal with shortages of trained health care professionals in rural and remote locations. This systematic review examines the evidence base of rural educational programs within medical education and focusses on workforce intentions and employment outcomes. The study provides a detailed description of the methodological characteristics of the literature, thematic workforce outcomes and key related factors are identified, study quality is assessed, and the findings are compared within an international context. METHODS: A systematic review looking at international literature of rural placement programs within medical education between January 2005 to January 2017 from databases including; Medline, Embase, NursingOVID, PubMed and Cochrane. The study adopted the PRISMA protocol. A quality assessment of the literature was conducted based on the Health Gains Notation Framework. RESULTS: Sixty two papers met the inclusion criteria. The review identified three program classifications; Rural Clinical Placement Programs, Rural Clinical Placement Programs combined with a rural health educational curriculum component and Rural Clinical School Programs. The studies included were from Australia, United States, Canada, New Zealand, Thailand and Africa. Questionnaires and tracking or medical registry databases were the most commonly reported research tools and the majority were volunteer programs. Most studies identified potential rural predictors/confounders, however a number did not apply control groups and most programs were based on a single site. There was a clear discrepancy in the ideal rural clinical placement length. Outcomes themes were identified related to rural workforce outcomes. Most studies reported that an organised, well-funded, rural placement or rural clinical school program produced positive associations with increased rural intentions and actual graduate rural employment. CONCLUSIONS: Future research should focus on large scale methodologically rigorous multi-site rural program studies, with longitudinal follow up of graduates working locations. Studies should apply pre-and post-intervention surveys to measure change in attitudes and control for predictive confounders, control groups should be applied; and in-depth qualitative research should be considered to explore the specific factors of programs that are associated with encouraging rural employment.

Medical education in difficult circumstances: analysis of the experience of clinical medical students following the new innovative medical curriculum in Aksum, rural Ethiopia.

BACKGROUND: In 2012, 12 medical schools were opened in Ethiopia to tackle the significant shortage of doctors. This included Aksum School of Medicine situated in Aksum, a rural town in Northern Ethiopia. The new Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. The curriculum is designed to train biomedical science graduates to become doctors in 4 years, with a focus on the healthcare needs of rural people living in poverty. METHODS: This research was conducted at Aksum School of Medicine and included two hospitals (Aksum Referral Hospital and St Mary's District Hospital). This study focused on medical students during their clinical years across multiple specialities (61 Clerkship 1 students and 13 Clerkship 2 students). We used primarily qualitative research methods supplemented with quantitative measures. There were 3 stages of data collection over a 1 month period, this included qualitative group interviews, direct observation of students in a clinical setting and direct observation of skills sessions followed by a questionnaire on the sessions. We analysed the data by reconstructing the student experience and comparing it with the NIMC. RESULTS: The proposed typical week set out in the NIMC tended to differ from the real clinical experience of these students. Through qualitative group interview and direct observation of teaching, the main theme that was consistent throughout was the lack of doctors with specialist postgraduate training. Clinical need often took priority over education. However, students enjoyed taking early responsibility and gaining practical experience. Through direct observation of skills sessions and short questionnaires, these sessions were highly valuable to the students and they felt confident in carrying out the taught procedures in the future. CONCLUSIONS: The combination of poorly resourced hospitals and lack of specialist doctors provides a challenging environment for medical students to learn. However, it is a unique clinical experience that is rarely seen in developed countries and facilitates the acquirement of skills from an early stage. Supervision and specialist input is fundamental in enabling students to learn and this is a key area that was lacking in the students' clinical experience.

Two decades of building capacity in rural health education, training and research in Australia: University Departments of Rural Health and Rural Clinical Schools.

This review article reports on the contribution of university Departments of Rural Health and Rural Clinical Schools to the development of rural health and the rural health workforce and is set at the Australian Government's university Departments of Rural Health and Rural Clinical Training and Support Programs. The main outcome measures include educational infrastructure, clinical academic workforce, student numbers, community engagement, research outputs, rural health and workforce outcomes. As a result, university Departments of Rural Health and Rural Clinical Schools have established a substantial geographical footprint covering most of the rural and remote populations and regions across Australia. They have a large distributed rural clinical academic workforce that exceeds 1300. Medical student numbers on long-term placements have increased threefold from inception to 1200 annually. Allied health and nursing numbers doubled over 10 years to 4000 in 2013 and are projected to double again by 2018. In 2013, they published 363 peer-reviewed papers - half of which specifically addressed rural and/or remote health issues. High levels of intention to practise rurally and uptake of rural and remote practice following exposure to rural training have been reported, especially for medicine. Thus, university Departments of Rural Health and Rural Clinical Schools constitute a national network of academic units that deliver academically enriched clinical education and training for medical, nursing and allied health students and fulfil an essential academic role for the health system in rural and remote Australia. Community engagement and accountability to region are hallmarks of the program. Early evidence of the uptake of rural and remote practice following exposure to rural training has set expectations for the Rural Health Multidisciplinary Training Program.

Grasping the Ongaonga: When will New Zealand really integrate rural clinical education?

Compared to Australia, substantial rural-based clinical education in New Zealand started small and still has some way to go if it is to fulfil its potential in workforce retention and recruitment to under-served areas. The authors share some of their experiences in rural medical education and then speculate on how it could develop. They discuss the merits of a clinical school composed of a dispersed network of rural sites, which provide and coordinate rural health education.

Scoping the impact of curriculum and placement on the rural pharmacy workforce.

OBJECTIVE: The objective of this review was to scope the impact of university rural curriculum and rural clinical placements on students' intentions to practise rurally and rural pharmacists' choice of rural practice. DESIGN: The scoping review used Arskey and O'Malley's methodological framework, searching the following databases: MEDLINE, CINAHL, Informit and Scopus. This scoping review followed PRISMA for article reporting. SETTING: Studies were selected from those conducted in Australia, USA, Canada and Africa. PARTICIPANTS: Pharmacy undergraduate students, interns, registered and academic pharmacists were included. MAIN OUTCOME MEASURE: The pharmacy curriculum at universities and placements undertaken, specifically in rural and remote settings, were evaluated to determine their influence on intention to practise as a rural pharmacist. RESULTS: The search strategy generated 294 records, 31 of which were included in the scoping review. Key findings were mapped to two domains, which broadly included the impact of rural placements and curriculum on intention to practise rurally. Some universities have attempted to introduce a rural curriculum, but reported resources as a barrier and the lack of resulting evidence of students' intention to practise rurally. Although results indicate rural placements have had a positive influence on students' intention to work rurally, this intention has been measured immediately after exposure to rural practice and might not reflect future intentions. CONCLUSION: This review highlights significant gaps in the impact particularly of a rural curriculum and rural clinical placements in relation to the current rural pharmacist workforce. A greater understanding of this topic may guide recommendations for future strategies to address rural pharmacy workforce maldistribution.

How does studying rurally affect peer networks and resilience? A social network analysis of rural- and urban-based students.

OBJECTIVE: To examine differences in peer networks between urban-based students and rural-stream students in an Australian medical school and to examine how characteristics of networks relate to resilience. DESIGN: Cross-sectional survey asking students to signify social, academic and support relationships with students in the same year and to complete a survey on their resilience. SETTING AND PARTICIPANTS: All second-, third- and fourth-year students at the Australian National University Medical School. MAIN OUTCOME MEASURES: Social network analysis comparing peer networks, t-test comparing mean resilience of urban and rural students. RESULTS: A visual analysis of the peer networks of year 2, 3 and 4 medical students suggests greater integration of rural-stream students within the year 2 and 4 urban cohorts. Resilience is similar between year 2 and 3 students in both urban and rural streams, but is significantly higher in year 4 rural-stream students, compared to their urban-based peers. Networks of rural-stream students suggest key differences between their period spent rurally and on their return and integration within the larger student cohort. Furthermore, rural students, once reintegrated, had larger and stronger social networks than their urban counterparts. CONCLUSION: The results of the study suggest that the rural experience can instruct support systems in urban settings. However, whether the rural placement creates a more resilient student or resilient students are selected for rural placement is unclear.

Expectations of rural community-based medical education: a case study from Thailand.

INTRODUCTION: Thailand has recognised and sought to remedy rural medical workforce shortages. The Collaborative Project to Increase Production of Rural Doctors (CPIRD) has improved rural workforce recruitment through publicly funding medical school places for students with rural backgrounds. However, challenges in rural retention continue. CPIRD is seeking to develop a Thai rural community-based medical education (RCBME) program in the southern region of Thailand to improve preparation for rural practice and rural medical retention rates. Prospective stakeholder consultations will allow the understanding of expectations and concerns of stakeholders required for successful RCBME implementation. This study aims to explore stakeholders' expectations of the Southern Thai RCBME initiative. METHODS: A qualitative case study comprised a purposive sample of students, clinical educators, policymakers, rural health professionals and local community stakeholders, all likely to be involved in a new RCBME program in Songkhla Province, Thailand. Individual semi-structured interviews were audiotaped, transcribed in Thai and coded using Worley's symbiosis framework. Following this, text and quotes used in the initial analysis were translated into English, discussed and reanalysed for emergent themes across the framework. RESULTS: A total of 21 participants contributed RCBME stakeholder perspectives. They demonstrated expectations and concerns in each of the relationship axes of the symbiosis model including the clinical, institutional, social and personal axes. Three major themes emerged from the data that integrated stakeholder perspectives on the implication of RCBME in Thailand. These themes were a dramatic shift in Thai medical education paradigm, seeing rural practice as a future career, and collaboration to improve education and health in rural services. CONCLUSION: This study comprehensively describes Thai stakeholder expectations of RCBME and demonstrates that, although some principles of RCBME are universal, context does influence the expectations and capacity of stakeholders to contribute to RCBME. Prospective formal stakeholder engagement is recommended to ensure successful implementation of new educational innovations.

The road to registration: Aboriginal and Torres Strait Islander health practitioner training in north Queensland.

CONTEXT: In 2012, the new profession of Aboriginal and Torres Strait Islander health practitioner (ATSIHP) was registered under the Health Practitioner Regulation National Law Act 2009. The project in this present study evolved out of the Australian Government\'s recognition of the need for the existing Indigenous health worker (IHW) workforce to meet the minimum qualification requirements for registration as ATSIHPs through recognition of prior learning and/or further education. A total of 53 IHWs participated in the upskilling project between June 2014 and June 2015, with approximately 200 IHWs from Queensland expressing an interest in undertaking the training. This demonstrated a clear need for further training programs such as this one. The project was coordinated by the Indigenous Health Unit at James Cook University (JCU) with training being delivered by TAFE Cairns in collaboration with the College of Medicine and Dentistry, JCU. Students travelled from as far north as the Torres Strait and as far west as Mount Isa. ISSUES: The key issues for discussion were associated with the ATSIHP role being relatively new including the limited preparedness of training providers to deliver the upgraded qualification requirements and uncertainty about the registration process. Compounding this was a general undervaluing and underutilisation of the IHW role within the current primary healthcare system. Other challenges included the variations of IHW roles, scope of practice and educational standards held by individuals, as well as the associated complexities of providing training to IHWs from the large and diverse geographic area that is rural and remote Australia. Program and student evaluation was undertaken with each of the three cohorts via a course experience questionnaire, TAFE evaluation forms and opportunistic student feedback. LESSONS LEARNED: Lessons learned as a result of this project include the need to continue to recognise and promote understanding of the contribution that IHW/ATSIHPs make in improving health, the importance of conducting a comprehensive student selection process, the benefits of working collaboratively between the university and vocational education training sectors, the need to continue to strengthen partnerships between higher education and health industry, the need for flexible funding and training models that enable adequate learning support, and the identification of a significant unmet training need.

Scope of practice of family medicine graduates who completed a rural versus urban program.

INTRODUCTION: In Canada, rural-based family medicine residency programs were established largely in response to a shortage of rural physicians and the perception that urban-based training programs were not meeting the needs of rural populations. Examinations of practice patterns of physicians trained in rural and urban programs are lacking. The purpose of this study was to compare the scope of practice of family medicine graduates who completed a rural versus an urban residency program, by practice location. METHODS: This was a cross-sectional, mail-out, questionnaire survey of 651 graduates who had completed the family medicine residency program at the University of Alberta or the University of Calgary, Alberta, Canada during 2006-2011. Rural program graduates lived and trained in regional settings and spent a considerable amount of time in smaller rural and remote communities for their clinical experience. The training of urban program graduates was primarily based in large urban settings and family medicine clinical experience was based in the community. Practice location (rural, urban) was classified by population size of the town/city at which physicians practiced. Scope of practice was ascertained through four domains of care: types of care, clinical procedures, practice settings and specific populations. Items within each domain were rated on a five-point scale (1='not part of practice', 5='element of core practice'). Mean rating scores for items in the domains of care were compared between urban and rural program graduates using ANOVA. RESULTS: A total of 307 (47.2%) graduates responded to the survey, of whom 173 were categorized as urban program graduates and 59 as rural program graduates. Overall, rural program graduates exhibited a broader scope of practice in providing postnatal care, intrapartum care/deliveries, palliative care, office-based and in-hospital clinical procedures, emergency care, in-hospital care, home visits, long-term care, and caring for rural and Aboriginal populations. Irrespective of program completed, those in a rural practice location had a broader scope of practice than those in urban practice. Urban and rural program graduates in rural locations tended to have a similar scope of practice. In urban locations, rural program graduates were more likely to include intrapartum care/deliveries as part of their clinical practice. Rural program graduates were more likely to practice in rural locations than urban program graduates. CONCLUSION: A combination of site of training (rural or urban program) and location of practice appear to work together to influence scope of practice of family physicians. A conceptual framework that summarizes the factors that have been reported to be associated with the scope of family practice is proposed.

Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career.

INTRODUCTION: Since 2010, the Chinese government has been introducing selective admission policy to recruit rural students for 5-year western medicine and traditional Chinese medicine undergraduate education in order to improve rural townships' medical services system in western China. This study aimed to analyse the selective admission policy in western China from the perspective of medical students' attitudes towards rural career choice. METHODS: A cross-sectional survey was conducted and an anonymous questionnaire was used to investigate a sample of medical undergraduates chosen under the selective admission policy. RESULTS: The results indicate that medical undergraduates' enthusiasm to work in rural areas was very limited in Gansu province, western China. Extrinsic motivation played a more important role in rural career choice than intrinsic motivation. The students' attitudes were affected by socioeconomic and cultural conditions, which determined their personal and professional environment. Course major and family economic conditions were associated with their self-decisions. CONCLUSION: Further educational intervention should emphasise the students' humanistic inner qualities and recognition of professional value. Further policy adjustment should considered, for example improving social policy-based regional character and national development strategies.

Experiences of community members and researchers on community engagement in an Ecohealth project in South Africa and Zimbabwe.

BACKGROUND: Community engagement (CE) models have provided much needed guidance for researchers to conceptualise and design engagement strategies for research projects. Most of the published strategies, however, still show very limited contribution of the community to the engagement process. One way of achieving this is to document experiences of community members in the CE processes during project implementation. The aim of our study was to explore the experiences of two research naïve communities, regarding a CE strategy collaboratively developed by researchers and study communities in a multicountry study. METHODS: The study was carried out in two research naïve communities; Gwanda, Zimbabwe and uMkhanyakude, South Africa. The multicentre study was a community based participatory ecohealth multicentre study. A qualitative case study approach was used to explore the CE strategy. Data was collected through Focus Group Discussions, Key Informant Interviews and Direct Observations. Data presented in this paper was collected at three stages of the community engagement process; soon after community entry, soon after sensitisation and during study implementation. Data was analysed through thematic analysis. RESULTS: The communities generally had positive experiences of the CE process. They felt that the continuous solicitation of their advice and preferences enabled them to significantly contribute to shaping the engagement process. Communities also perceived the CE process as having been flexible, and that the researchers had presented an open forum for sharing responsibilities in all decision making processes of the engagement process. CONCLUSIONS: This study has demonstrated that research naïve communities can significantly contribute to research processes if they are adequately engaged. The study also showed that if researchers put in maximum effort to demystify the research process, communities become empowered and participate as partners in research.

Internet or dvd for distance learning to isolated rural health professionals, what is the best approach?

BACKGROUND: Distance Learning (DL) is a means to overcome the barriers that prevent health workers access to medical education and training sessions to update their knowledge. The main objective of this study is to compare the knowledge acquisition among practitioners Heads of Health Based Center (HBC) for the management of hypertension in two training modalities, one interactive, via internet (by Visio conferencing and video Conferencing), and other non-interactive, via DVD in the three regions (Miarinarivo, Moramanga and Manjakandriana) of Madagascar. METHODS: This is a quasi-experimental study comparing two distance learning methodologies, one via internet (VS or VD) and the other via DVD before and after training. Ninety-two (92) Heads of HBC participated in the training, including 56 via the Internet (24 doctors and 32 paramedics) and 36 via DVD (24 doctors and 12 paramedics). RESULTS: According to the training mode: the mean score of knowledge of the participants was 7 (+ -2) for two terms before training. It is 14 (+ -2.5) in the internet group (VS or VD) and 15 (+ -2.7) in the DVD group after training. The difference between the two groups was not significant p = 0.076. For doctors, the score was 7 (+ -3.1) via internet and 8 (+ -2.3) via DVD in pre test and 14 (+ - 2.4) via internet and 16 (+ -. 2.7) via DVD in post test, the difference between the two training methods was significant (p = 0.008). Among the paramedics, the results are the same for both conditions, 7 (+ - 2.4 to + -3.2) in pre test and 14 (+ - 2.2 to + -2.7) in post test. CONCLUSION: Both training methods have improved participants' knowledge and the DVD mode is the first choice for Heads HBC of Madagascar with the majority located in remote areas.

Rethinking registrar attributes for Australian rural general practice training.

OBJECTIVE: Despite increases in Commonwealth funded general practice (GP) Registrar training positions, workforce trends continue to show geographical maldistribution. This study aimed to identify Registrar attributes which describe a cohort choosing to work in rural practice. DESIGN: Cross-sectional self-report questionnaire for socio-demographics, prior training, current training pathway, measures of personality and resilience. PARTICIPANTS AND SETTING: GP Registrars (N = 452) training in either the general or rural pathways of three Registered Training Providers in three states, or training through the Australian College of Rural and Remote Medicine's independent pathway. MAIN OUTCOME MEASURE: Ordinal logistic regression tested the impact of key variables on the likelihood that Registrars would settle in rural practice. Univariate analysis explored differences between groups and effects of variables. RESULTS: A significantly increased interest in rural practice was to found to exist among registrars who were male, identified themselves as being rural, had a partner who identified as being rural, were enrolled in a rural training pathway and had high levels of Cooperativeness. CONCLUSION: We present a discriminating model combining socio-demographics, prior training and personality variables which challenges Australia to rethink Registrar attributes when training for rural general practice. With significant changes about to occur to GP training in Australia, this paper highlights the need for a more holistic approach which considers personal attributes such as Cooperativeness, rural identity and provision of geographically focused rural training pipelines to encourage Registrars to bond to individual rural communities and further develop their personal connectedness to country life and rural medical practice.