Primary health care in the Amazon and its potential impact on health inequities: a scoping review.

INTRODUCTION: Health studies of the Amazon often focus on diseases and infections prevalent in the region, and few studies address health organizations and services. In this sense, this study fills a gap by reviewing the studies aimed at primary healthcare (PHC) implementation in the nine Amazonian countries. This review addresses a need to explore the forms in which PHC is implemented in the Amazon areas outside the urban centers and its potential to reduce health inequities. This study contributes to improvements in the practices of managers and health professionals and research on the topic. METHODS: Scoping review methodology was applied to peer-reviewed articles. The databases searched were PubMed, Scopus, Lilacs, Embase and Web of Science. Selected studies included peer-reviewed publications, published between January 2000 and November 2019, that focused on PHC or one of its components in the Amazon, and were published in English, Spanish and Portuguese. The study used Arksey and O'Malley's scoping review guidelines, supported by Levac, and included five steps: (i) identification phase, where search queries were applied to the databases followed by the removal of duplicates; (ii) screening phase, where titles and abstracts of articles were screened to exclude irrelevant articles; (iii) eligibility phase, where the full texts of articles were read to assess their relevancy to this study; (iv) data extraction, using a spreadsheet designed to capture relevant information required in this review, using an iterative process; (v) summarizing and classification of each article according to content. The second and third phases were conducted independently by two reviewers. If a disagreement arose between the reviewers, a third reviewer was consulted to help decide whether to include or exclude a study. RESULTS: This review included 25 studies. Of these, 11 presented promising results regarding PHC functioning in the Amazon region, and 14 presented challenges and difficulties in its functioning. Some PHC strategies implemented in the Amazon showed the potential to reduce inequities, mostly when they involved actions that increased access to PHC in the region when they developed a culturally adapted role and engaged community members in the decision-making and in the collaborative construction of health services. Actions that exposed challenges and difficulties were related to ill-prepared healthcare professionals, inadequate service approach and the inability to adapt to cultural issues. CONCLUSION: The findings reveal information about PHC implementations that have had promising results in the Amazon region and, at the same time, show the challenges and difficulties of the PHC actions. The findings also highlight and synthesize knowledge about the potential that PHC strategies have to affect existing inequities in the Amazon region and gaps in the studies that have been undertaken, or at least published, including a lack of studies of PHC implementation and examination of strategies aimed at health determinants.

Community co-produced mental health initiatives in rural Australia: A scoping review.

INTRODUCTION: Inaccessibility of mental health services in rural Australia is widely reported. Community co-produced mental health and well-being initiatives could fill gaps and complement other services. OBJECTIVE: This scoping review summarises findings from peer-reviewed articles to identify the key features of co-produced Australian rural mental health initiatives that engage communities in their design, delivery or evaluation processes. DESIGN: Between 2009 and 2019 inclusive, 14 articles met inclusion criteria and were reviewed using Arksey and O'Malley's review methodology. FINDINGS: Communities co-produced initiatives through informing, collaborating and instigating them. Some initiatives operated in specific places, for example an art gallery, while others operated across regions. Only two initiatives involved community members in multiple activities targeting prevention, early intervention, education and service accessibility; other initiatives were more focused, for example designing a new service. Over half of initiatives found were targeted at Aboriginal and Torres Strait Islander Peoples. Most articles discussed evaluation approaches, though methods were diverse. DISCUSSION: Published peer-reviewed evidence about Australian rural community co-produced mental health initiatives appears scant. Evidence found suggests they generate a range of supports that could complement or mitigate for lack of, public health services. The overall lack of evidence, diversity of initiatives and inconsistent evaluation makes it difficult to assess effectiveness and which activities might be scaled-up for wider benefit. CONCLUSION: Rural communities have limited resources, and evidence of what constitutes best practice in co-producing mental health services would help to avoid 'reinventing the wheel.' Greater efforts in evaluating and publishing about initiatives would be helpful.

Collaboration with community connectors to improve primary care access for hardly reached people: a case comparison of rural Ireland and Australia.

BACKGROUND: This study presents a way for health services to improve service access for hardly reached people through an exploration of how staff can find and collaborate with citizens (referred to as connectors) who span socio-cultural boundaries in their community. The study explored the local socio-cultural contexts of connectors' boundary spanning activities and if they are health related; boundary spanning occurring between connectors and health professionals at the interface of health systems and community; and the opportunities and barriers to actively seeking out and collaborating with community connectors to access marginalised and hardly reached people. METHODS: We conducted a qualitative case comparison from rural Ireland and Australia. Following purposive snow-ball sampling techniques to recruit participants, semi-structured interviews were conducted with 34 community informants, 21 healthcare staff and 32 connectors. Transcripts were coded and analysed using an inductive approach to ascertain categories and overall themes. RESULTS: We found a diverse sample of connectors relating to heterogenous, small and locally distinct groups of hardly reached people. Overall 26 connectors were active at the interface between health services and the community, with variation in how this occurred between cases. The majority (21) described one or more health related activities with hardly reached people. All connectors expressed a willingness to develop a relationship with local health services on issues they identified as relevant. Barriers to collaborations between connectors and health services related to bureaucracy, workload, and burnout. CONCLUSIONS: Collaborating with connectors has potential as one strategy to improve access to health services for hardly reached people. To enact this, health staff need to identify local socio-cultural boundaries and associated connectors, facilitate two-way connections at the boundary between health services and community and enable collaboration by attending to activities in the community, at the interface between health services and community, and within the health system.

The Orange Declaration on rural and remote mental health.

Rural mental health outcomes have been persistently poorer than those in larger cities suggesting that the prevailing investments to improve matters are not working. Mental health researchers and service providers from New South Wales, Victoria, Western Australia and the Australian Capital Territory met in Orange in October 2018 to explore issues pertaining to rural mental health and well-being. The group recognised and acknowledged that rural residents experience a series of interconnected geographical, demographic, social, economic and environmental challenges which are not addressed adequately by the current mix of services. This declaration has been endorsed by those listed below and we welcome further support. We list ten interrelated problems and ten solutions. As a group, we take this declaration as an opportunity to invite discussion about how we can collectively improve the mental health of rural residents through research, service design and delivery. We invite the reader to consider endorsing this declaration. A short summary of supporting evidence is available online at https://www.crrmh.com.au/.

Identifying support needs to improve rural dementia services for people with dementia and their carers: A consultation study in Victoria, Australia.

OBJECTIVE: The support and service needs of people with dementia and their carers are not always addressed in rural regions, yet family carers play an important role in supporting the person living with dementia to remain living in their own home. This study sought to identify and prioritise service and support needs of people with dementia and carers. DESIGN: A two-phase mixed methods study involving qualitative focus groups and a survey. SETTING: A rural region in Victoria, Australia. PARTICIPANTS: People living with dementia, carers and health professionals. RESULTS: Focus groups identified 12 areas of need. A follow-up survey reached consensus on the priority areas for service improvement. These included diagnosis and information access, dementia training, community understanding and carer support. CONCLUSION: Living in a rural region imposes significant challenges on people with dementia and carers. We need to find ways to address gaps in service provision for carers and people with dementia in rural settings and examine their applicability in other rural regions more broadly.

Community boundary spanners as an addition to the health workforce to reach marginalised people: a scoping review of the literature.

BACKGROUND: Health services in high-income countries increasingly recognise the challenge of effectively serving and engaging with marginalised people. Effective engagement with marginalised people is essential to reduce health disparities these populations face. One solution is by tapping into the phenomenon of boundary-spanning people in the community-those who facilitate the flow of ideas, information, activities and relationships across organisation and socio-cultural boundaries. METHODS: A scoping review methodology was applied to peer-reviewed articles to answer the question: "How do health services identify, recruit and use boundary spanners and what are the outcomes?" The review was conducted in seven databases with search terms based on community-based boundary spanning, marginalised people and health services. FINDINGS: We identified 422 articles with the screening process resulting in a final set of 30 articles. We identified five types of community-based boundary spanning: navigators, community health workers, lay workers, peer supporters and community entities. These range from strong alignment to the organisation through to those embedded in the community. We found success in four domains for the organisation, the boundary spanner, the marginalised individuals and the broader community. Quantifiable outcomes related to cost-savings, improved disease management and high levels of clinical care. Outcomes for marginalised individuals related to improved health knowledge and behaviours, improved health, social benefits, reduced barriers to accessing services and increased participation in services. We identified potential organisational barriers to using boundary spanners based on organisational culture and staff beliefs. CONCLUSIONS: Community boundary spanners are a valuable adjunct to the health workforce. They enable access to hard to reach populations with beneficial health outcomes. Maintaining the balance of organisational and community alignment is key to ongoing success and diffusion of this approach.

The state of health services partnering with consumers: evidence from an online survey of Australian health services.

BACKGROUND: Involving consumers in producing health services is mandated in many countries. Evidence indicates consumer partnerships lead to improved service design, quality and innovation. Involving participants from minority groups is crucial because poor understanding of distinctive needs affects individuals' service experiences and outcomes. Few studies consider service compliance with consumer partnering requirements or inclusion of minority group participants. METHODS: An online survey structured by domains of the Australian National Safety and Quality in Health Service Standards (NSQHS, 2013), was conducted. Questions covered consumer partnering in service planning, management and evaluation plus patient care design and inclusion of consumers from minority groups. Approximately 1200 Australian hospital and day surgery services were identified and 447 individual email addresses were identified for staff leading consumer partnerships. Quantitative data were analysed using SPSS. Qualitative responses, managed in NVivo, were analysed thematically. Frequencies were produced to indicate common activities and range of activities within question domains. RESULTS: Comprehensive responses were received from 115 services (25.7%), including metropolitan and non-metropolitan, private and public service settings. Most respondents (95.6%) "partnered with consumers to develop or provide feedback on patient information". Regarding inclusion of participants from minority groups, respondents were least likely to specifically include those from socially disadvantaged backgrounds (23.6%). Public health services were more likely than private services to engage with consumers. CONCLUSIONS: The survey is the first to include responses about consumer partnering from across Australia. While many respondents partner with consumers, it is clear that more easily-organised activity such as involvement in existing committees or commenting on patient information occurs more commonly than involvement in strategy or governance. This raises questions over whether strategic-level involvement is too difficult or unrealistic; or whether services simply lack tools. Minority views may be missed where there is a lack of specific action to include diversity. Future work might address why services choose the activities we found and probe emerging opportunities, such as using social media or online engagement.

Applying social innovation theory to examine how community co-designed health services develop: using a case study approach and mixed methods.

BACKGROUND: Citizen participation in health service co-production is increasingly enacted. A reason for engaging community members is to co-design services that are locally-appropriate and harness local assets. To date, much literature examines processes of involving participants, with little consideration of innovative services are designed, how innovations emerge, develop and whether they sustain or diffuse. This paper addresses this gap by examining co-designed initiatives through the lens of social innovation - a conceptualisation more attuned to analysing grassroots innovation than common health services research approaches considering top-down, technical innovations. This paper considers whether social innovation is a useful frame for examining co-designed services. METHODS: Eighty-eight volunteer community-based participants from six rural Australian communities were engaged using the same, tested co-design framework for a 12-month design and then 12-month implementation phase, in 24 workshops (2014-16). Mixed, qualitative data were collected and used to formulate five case studies of community co-designed innovations. A social innovation theory, derived from literature, was applied as an analytical frame to examine co-design cases at 3 stages: innovation growth, development and sustainability/diffusion. RESULTS: Social innovation theory was found relevant in examining and understanding what occurred at each stage of innovation development. Innovations themselves were all adaptations of existing ideas. They emerged due to local participants combining knowledge from local context, own experiences and exemplars. External facilitation brought resources together. The project provided a protective niche in which pilot innovations developed, but they needed support from managers and/or policymakers to be implemented; and to be compatible with existing health system practices. For innovations to move to sustainability/diffusion required political relationships. Challenging existing practice without these was problematical. CONCLUSIONS: Social innovation provides a useful lens to understand the grassroots innovation process implied in community participation in service co-design. It helps to show problems in co-design processes and highlights the need for strong partnerships and advocacy beyond the immediate community for new ideas to thrive. Regional commissioning organisations are intended to diffuse useful, co-designed service innovations. Efforts are required to develop an innovation system to realise the potential of community involvement in co-design.

Evaluating community participation: A comparison of participatory approaches in the planning and implementation of new primary health-care services in northern Australia.

Community participation is increasingly seen as a prerequisite for more acceptable and sustainable health services. It is difficult to evaluate the extent of participation in health planning and implementation of services, and there are limited tools available to assist in evaluating such processes. Our paper reports on community participation as part of the implementation of 2 primary health programs in regional north Queensland, Australia. We define community participation as collective involvement of people, including consultation, from a community of place or interest in aspects of health service development. We pragmatically evaluate and compare the extent of participation by using a framework developed by Rifkin and colleagues in 1988 and subsequently refined. Data collected from the implementation of each program were analyzed and ranked on a spidergram against 5 process indicators: needs assessment, leadership, resource mobilization, management, and organization. Community participation was found to vary across the programs but was most extensive in both programs in identifying need and potential solutions. Both programs demonstrated high levels of integration of the implementation of health programs with preexisting community structures. Involving local communities in genuine opportunities in managing the programs and mobilizing resources was more challenging. Key differences emerged in the people involved in the programs, the settings and frameworks used to facilitate implementation. We conclude that Rifkin's process indicators are a useful starting point for assessing community participation, particularly for health planners who are required to include participatory approaches when planning and implementing services. We suggest areas that require further consideration.

A modified Continuous Quality Improvement approach to improve culturally and socially inclusive care within rural health services.

BACKGROUND: The sickest Australians are often those belonging to non-privileged groups, including Indigenous Australians, gay, lesbian, bisexual, transsexual, intersex and queer people, people from culturally and linguistically diverse backgrounds, socioeconomically disadvantaged groups, and people with disabilities and low English literacy. These consumers are not always engaged by, or included within, mainstream health services, particularly in rural Australia where health services are limited in number and tend to be generalist in nature. OBJECTIVE: The aim of this study was to present a new approach for improving the sociocultural inclusivity of mainstream, generalist, rural, health care organisations. DESIGN: This approach combines a modified Continuous Quality Improvement framework with Participatory Action Research principles and Foucault's concepts of power, discourse and resistance to develop a change process that deconstructs the power relations that currently exclude marginalised rural health consumers from mainstream health services. It sets up processes for continuous learning and consumer responsiveness. RESULTS: The approach proposed could provide a Continuous Quality Improvement process for creating more inclusive mainstream health institutions and fostering better engagement with many marginalised groups in rural communities to improve their access to health care. CONCLUSION: The approach to improving cultural inclusion in mainstream rural health services presented in this article builds on existing initiatives. This approach focuses on engaging on-the-ground staff in the need for change and preparing the service for genuine community consultation and responsive change. It is currently being trialled and evaluated.

Assessing the value of rural community health services.

Rural health services are challenging to manage, a situation perhaps exacerbated by necessity to comply with one-size-fits-all performance frameworks designed for larger services. This raises the questions: do we know what rural health services are doing that is valuable and how should that be evaluated? Twenty-eight qualitative interviews with CEOs and staff of seven Victorian rural health services were conducted, exploring what they value about their 'best practice'. Themes emergent from analysis were compared with 19 government-produced health planning and performance documents. It was found that most dimensions of rural services value aligned with current performance frameworks, but a significant theme about 'community' was missing. Highlighting the relevance of this theme, achieving community-oriented goals accounted for one-third of best practice case studies identified by health services personnel. It is concluded that generating community outcomes is a significant area of value aimed for by rural health services that is missing from current performance measurement frameworks applied to Victorian health services. In this study, a new Evaluative Framework is outlined and further steps needed are suggested.

Citizen participation in health services co-production: a roadmap for navigating participation types and outcomes.

Primary healthcare managers are required to include citizens in service co-design and co-production. Health policy guidance appears deceptively simple and largely outlines how people could participate in a range of health services activities. Policy tends to neglect outcomes assessment, and a multidisciplinary academic literature corpus is large and complex to navigate for practical, time-poor managers. In this paper, we set out to provide a summary 'map' of key concepts in participation to assist managers in aligning participants, activities, expected outcomes and outcome indicators, and to consider contextual factors that could affect participation processes and outcomes. The intention is a practical tool for planning and evaluation of participation. The map is built drawing on policy guidance, literature and authors' experiences of implementing and researching health services participation.

Consumer perspectives of a community paramedicine program in rural Ontario.

OBJECTIVE: To evaluate a community paramedicine program in rural Ontario, Canada, through the perceptions and experiences of consumers. DESIGN: An observational ethnographic approach was used to acquire qualitative data through informal discussions, semi-structured interviews and direct observation of interactions between consumers and community paramedics. SETTING: The study was conducted in rural Ontario where a community paramedicine program has been established consisting of four components: ad hoc home visiting, ageing at home, paramedic wellness clinics and community paramedic response unit. PARTICIPANTS: Fourteen adult consumers participated, representing all program components. MAIN OUTCOME MEASURES: Consumer satisfaction and perceived benefits. RESULTS: Three main interlinked themes were identified: (i) improved health monitoring and primary health care access close to home; (ii) improved sense of security and support for vulnerable residents in the community; and (iii) improved consumer education and empowerment for enhanced health management. CONCLUSIONS: Consumers' reflections on their experiences and perceptions of a rural community paramedicine program indicate acceptance of paramedics in non-traditional preventative health care roles. This supports the desirability of investigating the potential development of community paramedicine programs in rural Australia to meet identified health service needs.

A scoping review of the association between rural medical education and rural practice location.

BACKGROUND: Inequitable distribution of the medical workforce is an international problem that undermines universal access to healthcare. Governments in many countries have invested in rural-focused medical education programs to increase the supply of rural doctors. METHODS: Using a structured five-step approach, a scoping review was conducted to map the existing evidence on the relationship between professional entry-level, pre-vocational medical education delivered in rural settings and rural workforce outcomes. Key search terms were developed, with database searches yielding 37 relevant articles. During data charting, a set of types of studies emerged, and we developed a typology to assist with article sorting and information structuring. RESULTS: Medical students attending a rural campus or spending time in a rural area are more likely to practise in non-metropolitan areas upon graduation than students studying at a city campus. In many cases, these positive findings could be confounded by students having a rural origin or being predisposed to want rural work. There is some evidence to suggest that the longer a person spends time as a medical student in a rural area, the more likely they are to work rurally following graduation. Overall, the articles located had limitations related to small sample size, inconsistent definition of rurality and lack of attention to controlling for variables that might influence rural practice decision, for example, rural background. Comparative data were lacking, and most studies were conducted by staff from the medical schools that were the focus of the research. There was no consideration given in any study found to the cost-effectiveness of entry-level medical education delivered in rural settings versus other ways of producing rural practitioners. CONCLUSIONS: Given limitations, available evidence suggests that medical education in a rural location does increase the number of medical graduates that will work in a rural place. There are indications of a gradient effect where increased rural practice exposure during medical education leads to more rurally located graduates; however, robust studies are needed to verify this finding. Given the significant funding being directed to universities to increase graduates that will work rurally, appropriate future research is recommended.

Community participation for rural health: a review of challenges.

CONTEXT: Internationally, community participation is highlighted in health policy reform as good for rural communities. Implicit in this policy is the message that the complexities of the rural environment are too difficult for easy solutions and that community participation will somehow build resilient, self-determining communities capable of dealing with complex rural access and equity issues and poorer health outcomes. The underpinning proposition is that by giving decision-making powers to community members, health care will be locally responsive, costs will be contained, and health outcomes will improve. What happens in the practice of enacting community participation in health-care decision making is less clear. OBJECTIVE: Despite the growing body of work that documents different levels and models of community participation, significant gaps that outline the practical challenges inherent in rural community participation remain. In this article, we draw on a body of literature to outline the practical considerations in implementing community participation policy in health settings in rural areas. Through a critical review, we aim to stimulate debate, progress ideas and provide a conceptual representation of the somewhat 'messy' nature of rural community participation at a grass-roots organizational level. DISCUSSION AND CONCLUSION: Based on our analysis of the current literature, we provide a summary of challenges and practical strategies that might mitigate some of these challenges. Our review highlights that despite policymakers suggesting that community participation is good for rural communities, policy enactment must move beyond mandated tokenism for there to be a recognition that meaningful participation is neither easy nor linear.

Nepalese dental hygiene and dental students' career choice motivation and plans after graduation: a descriptive cross-sectional comparison.

BACKGROUND: This is the first study of its kind to provide data regarding the self-reported career choice motivation and intentions after graduation of dental and dental hygiene students in Nepal. The findings of this study can be used to inform future oral health workforce planning in Nepal. METHODS: A cross-sectional survey of dentistry and dental hygiene students attending a large accredited dental college in Kathmandu, Nepal. Quantitative data were analysed using IBM® SPSS® 22. The respondents were given the opportunity to provide clarifying comments to some of the questions. RESULTS: Two hundred questionnaires were distributed, and 171 students completed the anonymous survey (response rate 86 %). Working in health care and serving the community were the most important initial motives for career choice, with significantly more dentistry students selecting their degree course because of the possibility to work flexible working hours (p < .001) compared to dental hygiene students. A majority of the students expressed concern about finding a suitable job (58 %) after graduation. Almost a quarter (23 %) reported intent to seek a job immediately after graduation, while 46 % plan further studies. Dentistry students were more likely to report planning further studies (p = .007) compared to the dental hygiene students. Dental hygiene students express a higher interest in going abroad (p = .011) following graduation. Only 10 % of all students plan to live or work in rural areas after study. Most common preferred locations to live after graduation are urban (33 %) or abroad (38 %). Data suggest a preference to combine working in a hospital with working in their own practice (44 %) while interest in solely working in their own practice is low (<2 %). CONCLUSION: Many students, though enthusiastic about their profession and expressing the ambition to serve the community, fear unemployment or envision better chances abroad. Most of the students in this study expressed a preference to live in an urban area after graduation. Findings indicate that strong measures are required to incentivise students to consider rural work.

Community participation to design rural primary healthcare services.

BACKGROUND: This paper explores how community participation can be used in designing rural primary healthcare services by describing a study of Scottish communities. Community participation is extolled in healthcare policy as useful in planning services and is understood as particularly relevant in rural settings, partly due to high social capital. Literature describes many community participation methods, but lacks discussion of outcomes relevant to health system reconfiguration. There is a spectrum of ideas in the literature on how to design services, from top-down standard models to contextual plans arising from population health planning that incorporates community participation. This paper addresses an evidence gap about the outcomes of using community participation in (re)designing rural community health services. METHODS: Community-based participatory action research was applied in four Scottish case study communities in 2008-10. Data were collected from four workshops held in each community (total 16) and attended by community members. Workshops were intended to produce hypothetical designs for future service provision. Themes, rankings and selections from workshops are presented. RESULTS: Community members identified consistent health priorities, including local practitioners, emergency triage, anticipatory care, wellbeing improvement and health volunteering. Communities designed different service models to address health priorities. One community did not design a service model and another replicated the current model despite initial enthusiasm for innovation. CONCLUSIONS: Communities differ in their receptiveness to engaging in innovative service design, but some will create new models that fit in a given budget. Design diversity indicates that context influences local healthcare planning, suggesting community participation impacts on design outcomes, but standard service models maybe useful as part of the evidence in community participation discussions.

The experience of community first responders in co-producing rural health care: in the liminal gap between citizen and professional.

BACKGROUND: The involvement of community first responders (CFRs) in medical emergencies in Scotland, and particularly in remote and rural areas, has expanded rapidly in recent years in response to geographical and organisational challenges of emergency medical service access. In 2013 there were over 120 active or developing schemes in a wide variety of settings. Community first responders are volunteers trained in First Person on the Scene (FPOS) first aid, administered prior to the arrival of an ambulance. Although there is limited literature which describes the role of first response, little academic literature has been published about the complexities of their specific role in both the community and organisational contexts. METHODS: Here we reflect on data from two mixed-methods studies into the role of CFRs in Scotland. RESULTS: We highlight findings that explore the liminal and complex role of the first responder as both 'practitioner' and community member, and how this contributes to a sense of communitas within the study areas. The rural context encompasses additional complexity in relation to the role of emergency care volunteer, having the highest levels of volunteering and this paper questions assumptions that rural areas, are more accepting of volunteerism. CONCLUSIONS: Complexities arising from the experience of blurred voluntary/practitioner boundaries emerge as a key feature of voluntary participation in medical emergencies in this setting.

Measuring oral health literacy: a scoping review of existing tools.

BACKGROUND: This article presents findings from a scoping review of tools used to measure oral health literacy. Internationally, interest in oral health literacy is driven by oral health disparities, particularly for disadvantaged groups, with conditions such as dental caries and periodontal disease contributing substantially to the global burden of disease. The increasing focus on measuring oral health literacy aligns with reasons for measuring broader health literacy, that is, by assessing oral health literacy, decisions can be made about instigating interventions at policy and practice level to improve individual and population level oral health. There are numerous tools available that measure oral health literacy using a range of indicators. METHODS: A scoping review was designed to map the existing tools designed to measure oral health literacy (OHL). Key search terms were developed and mapped. Selected databases were used that identified 32 relevant studies reporting a range of OHL tools. RESULTS: We identified 32 articles that reported a range of oral health literacy tools. Many of the studies used the Rapid Estimate of Adult Literacy in Dentistry (REALD) and/or the Test of Functional Health Literacy in Dentistry (ToFHLiD) that were developed from earlier tools designed to measure broader health literacy. These tools have been widely criticised for providing only an approximate measure of OHL based mainly on word recognition. A number of newer tools have included new measures of oral health literacy including numeracy and oral health conceptual knowledge however tools that measure important indicators of oral health literacy such as service navigation are rare. CONCLUSIONS: Findings from this scoping exercise confirm our findings from preliminary scans that the majority of tools are heavily biased towards word recognition, numeracy and reading skills, rather than what this means in terms of health behaviours and service utilisation. More recent developments have attempted to incorporate other aspects considered important, including decision making and service navigation. The incorporation of these aspects into newer tools will provide oral health researchers and policy makers with further evidence of the importance of oral health literacy when designing interventions to improve oral health.

A qualitative exploration of online forums to support resilience of rural young people in Australia.

Introduction: Prevention and early intervention are crucial strategies for improving young people's mental health and well-being. Building resilience is a key component of these strategies, especially among young individuals in rural areas who face well-documented mental health disparities. This study aimed to investigate how online mental health forums can contribute to enhancing individual resilience in young rural users. Methods: A sample of forum posts (n = 1,000) made by Australian rural users (18-25 years) on an online peer support mental health forum were qualitatively analyzed. The analysis was guided by themes derived from the literature on indicators of rural resilience. Results: Analysis of forum posts showed evidence of rural resilience in forum users. Online peer support forums offered a virtual space for individuals to establish social connections, experience a sense of belonging, share information, acquire knowledge, and offer mutual support. There were indications of increased self-efficacy among forum users, as they demonstrated their ability to implement strategies for better managing their mental health. Discussion: These findings significantly contribute to our understanding of how online forums can enhance resilience factors that are beneficial for young people living in rural communities. In the context of prevention and early intervention, this study illustrates the intricate connections between forum design and user activity with resilience outcomes, providing valuable insights into the underlying causal mechanisms. Consequently, it emphasizes the importance of incorporating such digital interventions as integral components of mental health service ecosystems.