Supporting nursing and allied health student placements in rural and remote Australia: a narrative review of publications by university departments of rural health.

University departments of rural health are Commonwealth-funded to improve recruitment and retention of the rural allied health and nursing (including midwifery) workforce, primarily through student placements. We examined publications by university departments of rural health that were focused on allied health and nursing students undertaking placements in rural Australia, to understand the characteristics, main findings and implications of the research conducted. Interprofessional learning was a key feature of placements and placement education, although other activities such as community engagement added to placement experiences. Factors such as quality supervision and being involved in the community contributed to a positive placement experience and increased rural practice intention. Tracking studies showed a relationship between rural placements, rural practice intention and rural practice. Rural placements occurred across a variety of settings and in locations consistent with the policy framework. Embedding university departments of rural health in rural communities enabled staff to build relationships and increase placement capacity.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Workplace-based health research training: a qualitative study of perceived needs in a rural setting.

BACKGROUND: The calls for increased numbers of researchers in rural health are growing. To meet this demand, training is needed. If training is to be effective, the value placed on research, the organisational need for research training and key targets for research skill development within a rural health organisation must be understood. METHODS: This qualitative study was underpinned by a critical realist perspective that allowed exploration of the organisational, cultural and structural contexts of research training and of the ability of individuals to act within these contexts. Individual interviews with purposively selected key informants from the organisation's board, executive and facility management (n = 7) and two focus groups with a convenience sample of frontline health workers with interests in research (total n = 11) were held. Data were analysed using NVivo software and thematic analysis. RESULTS: The themes emerging from this study were the fragmentation of research activity, a need for systems that support research and collaboration for expertise. CONCLUSIONS: This study has identified an overreliance on individual activity leading to a fragmented approach to research. There is a need for supportive structures, coordination and workplace leadership to overcome a longstanding culture that views research as out of the rural scope of practice. Identifying research training targets, partnering for educational expertise and planning for long-term sustainability are necessary steps toward increasing research activity in the longer term.

Patterns of emergency department use in rural and metropolitan New South Wales from 2012 to 2018.

OBJECTIVE: To explore the patterns of and investigate the factors associated with rises in emergency department presentations in rural and metropolitan New South Wales from 2012 to 2018. DESIGN: A retrospective descriptive study of de-identified data from the New South Wales Emergency Department Data Collection. SETTING: New South Wales, Australia. PARTICIPANTS: All individuals presenting to 99 New South Wales emergency departments, which continuously reported to the Emergency Department Data Collection between 2012 and 2018. A total of 2 166 449 presentations recorded throughout New South Wales in 2012 (rural 786 278; metropolitan 1 380 171) and 2 477 192 in 2018 (rural 861 761; metropolitan 1 615 431). MAIN OUTCOME MEASURES: Total emergency department presentations, plus Poisson regression modelled annual changes in emergency department presentations over the period 2012-2018. RESULTS: Growth in emergency department presentations outpaced population growth in both rural and metropolitan New South Wales between 2012 and 2018. The patterns of age-standardised rates of presentations were broadly similar between rural and metropolitan areas, with highest rates observed in the youngest (0-4 years) and oldest (85+ years) cohorts. The rural sample also displayed a distinct third peak in ages 15-39 years, and rates were higher across all age groups. Rural New South Wales displayed disproportionately higher emergency department presentations in the two most deprived socio-economic status quintiles. While rural New South Wales displayed significant reductions in triage category 5 (non-urgent cases) over time, the relative proportion remained approximately double that of metropolitan sites. CONCLUSIONS: There are differences between rural and metropolitan emergency department presentations relating to demographic factors, triage levels, acuity and admissions. Detailed local investigations are required to determine specific contextual issues that impact on emergency department demand.

The place of research in the rural health workplace structure: a content analysis of a rural health organisation's strategic and operational documents.

INTRODUCTION: Research training is conducted within rural health organisations without a clear understanding of the role of research within the structure of the organisation itself, potentially limiting the effectiveness of that training. This study sought to identify the role of research within the organisational structure of a large rural health organisation in Australia. Specifically, the study sought the answer to the following questions: Is research identified within the strategic documents of the organisation? If so at what level of the organisation is responsibility for research attributed? Is research identified within the position descriptions of staff? If so, at what level of the organisation are staff expected to conduct research? Is there evidence of research activity elsewhere within the organisational structure? METHODS: This qualitative study used a critical realist approach and content analysis to identify and contextualise the terms 'research' and 'evaluation' within publicly available and internal documents from a large rural health organisation in New South Wales, Australia. Secondary thematic analysis identified organisational factors influencing research activity. Data were sourced from strategic, operational and other documents from the 2015 calendar year, with key documents extracted from 1654 external and internal websites, 159 position descriptions and approvals for research projects active in 2015 (n=53). RESULTS: Only a third of research conducted in the organisation was locally instigated or involved local staff as researchers. Matching between positional responsibility for research and research activity was limited. Research was a strategic goal for the organisation; however, this was not well represented in operational documents. A lack of research in operational documents devolves responsibility for research to individuals. Individuals with greater levels of individual agency were more likely to be engaged in research. A low critical mass of local researchers means that collaboration, both internal and external, is essential to strengthen research capacity. CONCLUSION: Health services can create conditions for local health research in a rural environment by addressing structural barriers such as a lack of operational planning for research. Identifying research-active individuals as champions to build internal research collaboration is an important strategy, as is partnering with external organisations for necessary expertise.

A mapping study to guide a palliative approach to care.

INTRODUCTION: All healthcare providers can influence the delivery and outcome of a palliative approach to care, ensuring that everyone has 'equitable access to quality care based on assessed need as they approach and reach the end-of-life'. This study mapped the delivery of palliative care in far west New South Wales (NSW), Australia, with objectives to: identify who was involved in providing such care in the Far West Local Health District (FWLHD), how they connect, and any gaps in the network describe what care was provided and identify any challenges to care provision. The mapping process and outcomes can be used to guide the implementation of new models of care by building on the localised knowledge of current networks, provision of care and challenges. METHODS: Semi-structured interviews were undertaken with members of the specialist palliative care service and generalist healthcare providers within the FWLHD. Fifteen interviews were conducted over 7 months. Content analyses of interview transcripts identified processes and challenges as well as improvements for care. A network analysis was conducted to identify unidirectional connections and 'map' the services. RESULTS: The vast network demonstrates extensive long-term involvement in palliative care as well as established connections and opportunities for improving communication between the services and providers involved in palliative care. Palliative practice is varied and challenging within the network; challenges include communication, early identification and education. Mapping the existing networks, resources and relationships proved invaluable to guide the implementation of a palliative approach to care. CONCLUSION: The implementation of a palliative approach, as with any service model, requires agreement and engagement across relevant healthcare organisations, services and providers. Mapping and understanding the network of providers (and organisations) that support healthcare delivery before implementing new models of care will identify strengths and gaps within the network. This knowledge will then support new and integrated connections that enhance the provision of care so that it is acceptable, fit for purpose and regionally responsive.

Injury rate and patterns of Sydney grade cricketers: a prospective study of injuries in 408 cricketers.

BACKGROUND: The grade cricket competition, also known as premier cricket, supplies players to the state and national teams in Australia. The players involved are generally high-performing amateur (subelite) club cricketers. However, to date, there is no study on the injury epidemiology of Australian grade cricket. AIM: To conduct injury surveillance across all teams playing Sydney Grade Cricket (SGC) competition during the 2015-2016 season. METHODS: A cohort study was conducted to track injuries in 408 male cricketers in 20 teams playing SGC competition. Players were tracked through the MyCricket website's scorebook every week. Cricket New South Wales physiotherapists were alerted if there were changes to the playing XI from the last game. If any changes were made due to injury, then an injury incident was registered. RESULTS: During the course of the season, a total of 86 injuries were registered from 65 players, resulting in a loss of 385 weeks of play. The overall injury incidence rate was 35.54 injuries/10 000 playing hours with an average weekly injury prevalence of 4.06%. Lower back injuries (20%) were the most common injuries followed by foot (14%), hand (13.75%), knee (7.5%) and calf (7.5%). Linear regression analysis showed that the likelihood of injury increased as the mean age of the teams increased (R=0.5, p<0.05). CONCLUSION: The injury rate in SGC is lower than that reported at elite level. However, the high rate of lower back injuries (20%) highlights an area of concern in this cohort. High workloads or inadequate physical conditioning may contribute to such injuries. This study sets the foundation for understanding injury epidemiology in grade cricket and examines the links between injury and performance, these results may assist coaches and administrators to develop and implement cricket-specific injury prevention programmes.

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.

Rural and remote health research: Does the investment match the need?

OBJECTIVE: To determine the percentage of research projects funded by the National Health and Medical Research Council in the period 2000-2014 that aimed specifically to deliver health benefits to Australians living in rural and remote areas and to estimate the proportion of total funding this represented in 2005-2014. DESIGN: This is a retrospective analysis of publicly available datasets. SETTING: National Health and Medical Research Council Rural and Remote Health Research 2000-2014. OUTCOME MEASURES: 'Australian Rural Health Research' was defined as: research that focussed on rural or remote Australia; that related to the National Health and Medical Research Council's research categories other than Basic Science; and aimed specifically to improve the health of Australians living in rural and remote areas. Grants meeting the inclusion criteria were grouped according to the National Health and Medical Research Council's categories and potential benefit. Funding totals were aggregated and compared to the total funding and Indigenous funding for the period 2005-2014. RESULTS: Of the 16 651 National Health and Medical Research Council-funded projects, 185 (1.1%) that commenced funding during the period 2000-2014 were defined as 'Australian Rural Health Research'. The funding for Australian Rural Health Research increased from 1.0% of the total in 2005 to 2.4% in 2014. A summary of the funding according to the National Health and Medical Research Council's research categories and potential benefit is presented. CONCLUSION: Addressing the health inequality experienced by rural and remote Australians is a stated aim of the Australian Government. While National Health and Medical Research Council funding for rural health research has increased over the past decade, at 2.4% by value, it appears very low given the extent of the health status and health service deficits faced by the 30% who live in rural Australia.

Service-learning partnerships: Features that promote transformational and sustainable rural and remote health partnerships and services.

OBJECTIVE: To describe features that promote transformational and sustainable community engaged health partnerships and services in rural and remote Australian locations. DESIGN: A pragmatic qualitative study using focus groups and individual semi-structured interviews. Data were analysed using four stages of data comparison. SETTING: Far west New South Wales, Australia. The health partnership, initiated by primary school principals in 2008, aimed to address allied health service inequities experienced by regional children. A service-learning program was developed, aligning allied health student placements to student-led services. The program has been operational since 2009. PARTICIPANTS: Community participants included school principals (n = 7) and senior managers (n = 2) from local facilitating agencies. Campus participants included allied health students (n = 10) and academics (n = 2), one rurally located with student supervision responsibility and one metropolitan located with a strategic partnership role. MEASURES: All data were collected by an independent researcher. Four stages of data comparison were undertaken. A thematic analysis was conducted and six key features identified through Stage Four comparison, a comparison across the findings from discrete community and campus groups, reflecting transformational community engagement were identified. RESULTS: These six features are: (i) identifying and responding to community need, (ii) providing services of value, (iii) community leadership and innovation, (iv) reputation and trust, (v) consistency, and (vi) knowledge sharing and program adaptation. CONCLUSION: We propose that these features contributed to the transformational engagement of community and university participants. These features can inform health sector approaches to community engagement, enhancing rural and remote service accessibility, acceptability, and sustainability outcomes.

Beginning the trajectory to ESKD in adult life: albuminuria in Australian aboriginal children and adolescents.

BACKGROUND: Globally, disadvantaged populations suffer a high burden of chronic kidney disease (CKD). The trajectory to CKD during childhood and adolescence remains unclear due to a paucity of longitudinal studies. METHODS: This was a prospective, population-based cohort study in which since 2002 we have followed 3418 children (1469 non-Aboriginal and 1949 Aboriginal) attending participating schools across New South Wales (NSW), Australia. The albumin:creatinine ratio was measured by dipstick every 2 years together with the body mass index (BMI) and blood pressure. We used multivariable logistic generalised estimating equation models to examine whether Aboriginal children had a higher prevalence of albuminuria compared with non-Aboriginal children with increasing age and to identify potential risk factors. RESULTS: The mean age at enrolment was 10.6 years, at which time 14.2 % of the children were obese and 16.0 % overweight, with 11.5 % found to have albuminuria. Over 8 years (11,387 participant-years) of follow-up the prevalence of albuminuria increased to 18.5 %, overweight to 16.1 % and obesity to 17.2 %. The BMI standard deviation score (SDS) was found to have a differential effect on the risk of albuminuria in Aboriginal and non-Aboriginal children (P interaction < 0.01). The prevalence of albuminuria decreased as the BMI SDS increased in both groups of children, but it increased more in non-Aboriginal children, leading to a 2.5 % higher prevalence of albuminuria in overweight Aboriginal children (95 % confidence interval 1.0-4.2 %). CONCLUSION: Compared with non-Aboriginal children, Aboriginal children are of higher risk of albuminuria when overweight or obese. We hypothesise that overweight and obesity are key contributors to the development of adult onset CKD among Aboriginal Australians, which needs further exploration in future studies.

Social learning in a longitudinal integrated clinical placement.

Recent research has demonstrated that longitudinal integrated placements (LICs) are an alternative mode of clinical education to traditional placements. Extended student engagement in community settings provide the advantages of educational continuity as well as increased service provision in underserved areas. Developing and maintaining LICs require a differing approach to student learning than that for traditional placements. There has been little theoretically informed empirical research that has offered explanations of which are the important factors that promote student learning in LICs and the relationships between those factors. We explored the relationship between student learning, student perceptions of preparedness for practice and student engagement, in the context of a rural LIC. We used a sequential qualitative design employing thematic, comparative and relational analysis of data from student interviews (n = 18) to understand possible processes and mechanisms of student learning in the LIC. Through the theoretical lens of social learning systems, we identified two major themes; connectivity and preparedness for practice. Connectivity described engagement and relationship building by students, across formal and informal learning experiences, interprofessional interactions, social interactions with colleagues, interaction with patients outside of the clinical setting, and the extent of integration in the wider community. Preparedness for practice, reflected students' perceptions of having sufficient depth in clinical skills, personal and professional development, cultural awareness and understanding of the health system, to work in that system. A comparative analysis compared the nature and variation of learning across students. In a relational analysis, there was a positive association between connectivity and preparedness for practice. Connectivity is a powerful enabler of students' agentic engagement, collaboration, and learning within an LIC. It is related to student perceptions of preparedness for practice. These findings provide insight for institutions wishing to develop similar programmes, by encouraging health professional educators to consider all of the potential elements of the placements, which most promote connectivity.

What do evaluations tell us about implementing new models in rural and remote primary health care? Findings from a narrative analysis of seven service evaluations conducted by an Australian Centre of Research Excellence.

INTRODUCTION: A Centre of Research Excellence (CRE) in Rural and Remote Primary Healthcare was established in 2012 with the goal of providing evidence to inform policy development to increase equity of access to quality health care and the identification of services that should be available to the diverse communities characterising Australia. This article reports on the key findings from seven CRE service evaluations to better understand what made these primary health care (PHC) models work where they worked, and why. METHODS: We conducted a narrative synthesis of 15 articles reporting on seven CRE service evaluations of different PHC models published between 2012 and 2015. RESULTS: Three different contexts for PHC reform were evaluated: community, regional and clinic based. Themes identified were factors that enabled changes to PHC delivery, processes that supported services to improve access to PHC and requirements for service adaptation to promote sustainability. In both Indigenous and mainstream community settings, the active engagement with local communities, and their participation in, or leadership of, shared decision-making was reported across the three themes. In addition, local governance processes, informed by service activity and impact data, enabled these service changes to be sustained over time. The considerations were different for the outreach, regional and clinic services that relied on internal processes to drive change because they did not require the cooperation of multiple organisations to succeed. CONCLUSIONS: The review highlighted that shared decision-making, negotiation and consultation with communities is important and should be used to promote feasible strategies that improve access to community-based PHC services. There is a growing need for service evaluations to report on the feasibility, acceptability and fit of successful service models within context, in addition to reach and effectiveness in order to provide evidence for local dissemination, adaption and implementation strategies.

Are rural and remote patients, families and caregivers needs in life-limiting illness different from those of urban dwellers? A narrative synthesis of the evidence.

This review aimed to assess the evidence to answer the question whether palliative end-of-life care needs of patients and caregivers in rural and remote communities differs from those of urban dwellers. Peer-reviewed studies from 1996 to the present dealing with the experience of rural and remote patients and caregivers at the end-of-life compared with that of urban people were extracted for narrative synthesis. The eight studies included showed that palliative needs of rural and remote residents are related to context. Diagnosis and treatment are less well managed in rural areas. Rural differences include: people are more accepting of death and less likely to intervene to delay death; caregivers tend to be younger and include friends as well as family and local support networks are important. Rural and remote end-of-life needs are shaped by reduced access and availability of services which has a negative influence on outcomes. This is counterbalanced by an acceptance of death and local support networks. Well-designed longitudinal studies with samples comprised of rural and urban residents for comparison are required to monitor how end-of-life need might change with the approach of death. Clinicians, health services and policy makers need a better understanding of rural attitudes and of how rural community networks mobilise to support end-of-life care in their rural and remote communities.

No longer 'flying blind': how access has changed emergency mental health care in rural and remote emergency departments, a qualitative study.

BACKGROUND: Mental health presentations are considered to be a difficult aspect of emergency care. Although emergency department (ED) staff is qualified to provide emergency mental health care, for some, such presentations pose a challenge to their training, confidence, and time. Providing access to relevant and responsive specialist mental health care can influence care and management for these patients. The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) is a telepsychiatry program that was established to improve access to specialist emergency mental health care across rural and remote western NSW, Australia. METHOD: This study uses interviews with ED providers to understand their experience of managing emergency mental health patients and their use of MHEC-RAP. The lens of access was applied to assess program impact and inform continuing program development. RESULTS: With MHEC-RAP, these ED providers are no longer 'flying blind'. They are also more confident to manage and care for emergency mental health patients locally. For these providers, access to specialists who are able to conduct assessments and provide relevant and responsive advice for emergency mental health presentations was valued. Assessing the fit between the consumer and service as a requirement for the development, evaluation, and ongoing management of the service should result in decisions about design and delivery that achieve improved access to care and meet the needs of their consumers. The experience of these providers prior to MHEC-RAP is consistent with that reported in other rural and remote populations suggesting that MHEC-RAP could address limitations in access to specialist care and change the provision of emergency mental health care elsewhere. CONCLUSION: MHEC-RAP has not only provided access to specialist mental health care for local ED providers, but it has changed their practice and perspective. MHEC-RAP could be adapted for implementation elsewhere. Provider experience confirms that the program is accessible and offers insights to those considering how to establish an emergency telepyschiatry service in other settings.

Successful provision of emergency mental health care to rural and remote New South Wales: an evaluation of the Mental Health Emergency Care-Rural Access Program.

OBJECTIVE: To evaluate a rural emergency telepsychiatry program, the Mental Health Emergency Care-Rural Access Program (MHEC-RAP), which aims to improve access to emergency mental health care for communities throughout western New South Wales (NSW). METHODS: A descriptive analysis of service activity data from the introduction of the MHEC-RAP in 2008 to 2011 using Chi-squared tests and linear regression modelling to assess change and trends over time. RESULT: There were 55959 calls to the MHEC-RAP, 9678 (17%) of these calls initiated an MHEC-RAP service (~2500 each year). The use of video assessment increased over 18 months, then levelled off to an average of 65 each month. Health care provider use increased from 54% to 75% of all contacts, and 49% of MHEC-RAP patients were triaged 'urgent'. Most (71%) were referred from the MHEC-RAP for outpatient care with a local provider. The proportion of MHEC-RAP patients admitted to hospital initially increased by 12%, then declined over the next 2 years by 7% (by 28% for admissions to a mental health inpatient unit (MHIPU)). CONCLUSION: The MHEC-RAP is well established. It has achieved acceptable levels of service activity and continues to be as used as intended. Further research is required to confirm how the MHEC-RAP works in terms of process and capacity, how it has changed access to mental health care and to document its costs and benefits. WHAT IS KNOWN ABOUT THE TOPIC? Rural and remote communities have poorer access to and use of mental health services. Telehealth care is a reliable and accepted means for providing non-urgent mental health care. WHAT DOES THIS PAPER ADD? The MHEC-RAP is a practical and transferable solution to providing specialist emergency mental health care, and support for local providers, in rural and remote areas via telehealth. There is a possible impact upon the problem of recruiting and retaining a mental health workforce in rural and remote areas. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Providing reliable remote access to specialist mental health assessment and advice while supporting providers in rural communities can result in better outcomes for patients and services alike.

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial.

BACKGROUND: Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care. METHODS: This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program. RESULTS: A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance. CONCLUSION: Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals' health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation. TRIAL REGISTRATION: ACTRN12607000423415.

New South Wales and Australian Capital Territory Researcher Development Program 2005-07: modest investment, considerable outcomes.

This evaluation of the Researcher Development Program (RDP) in NSW and ACT aimed to determine whether the RDP was effective in assisting novice researchers to undertake primary health care research. In mid-2008, 47 participants of the NSW and ACT RDP during 2005-07 were invited to participate in a postal survey. The survey included questions regarding previous research training and experience, outcomes during and after participation in the program, and organisational aspects of the program. Follow-up interviews were conducted with selected participants. Interview questions covered time in the program, supervision, organisational support and placement outcomes. Thirty-seven participants responded to the survey and 23 (62%) participants took part in the semi-structured interviews. Seventy-eight per cent of survey respondents felt that the RDP helped them move from novice to a more experienced researcher with effective supervision identified by participants as a key element in determining the success of the program. Many felt that time allocation was inadequate and 20% thought their capacity to maintain their workload was adversely affected by participating. Outcomes were considerable given the modest nature of the program. Notable outcomes were that most participants published their research and presented their research at a conference. Furthermore, one-fifth of survey respondents had enrolled in higher degrees. Several interviewees reported that their research led to changes in practice. Most respondents found the RDP valuable and considered that undertaking the program increased their research knowledge.