Predictors of remote practice location in the first seven cohorts of James Cook University MBBS graduates.

INTRODUCTION: This article describes factors predicting James Cook University (JCU) medical graduates undertaking at least 1 year of remote practice. The cross-sectional design involved point-in-time (2015) analysis of the JCU medical school's ongoing longitudinal graduate tracking database. Participants were the first seven cohorts of graduates from the JCU medical school who had completed at least their postgraduate year (PGY) 4 in Australia (n=529); that is, PGY 4 to PGY 10 graduates. METHODS: Multiple logistic regression and Classification and Regression Tree (CART) analysis of medical graduate application data (age, gender, hometown, interview score, ethnicity), undergraduate data (scholarships awarded, clinical school location) and postgraduation data (internship location, specialty training) was performed. Analysis identified independent predictors of having practised for at least 1 year in a 'remote' Australian town (Australian Standard Geographic Classification Remoteness Area 4-5). RESULTS: Forty-seven (9%) of JCU Bachelor of Medicine and Bachelor of Surgery graduates in the first seven cohorts had practised for at least 1 year in a remote location between PGY 4 and 10. Practice in a 'remote' town was predicted by undertaking rural generalist training (p<0.001; prevalence odds ratio (POR)=17.0), being awarded an 'above average' interview score at medical school selection (p=0.006; POR=5.1), attending the Darwin clinical school in years 5-6 (p=0.005; POR=4.7), being female (p=0.016, POR=3.6) and undertaking an outer-regional or remotely based internship (p=0.006; POR=3.5). CART analysis identified Indigenous graduates as another key subgroup of remote practice graduates. CONCLUSIONS: This study provides the first Australian evidence that likelihood of remote medical practice is enhanced by investment in a 'remote pipeline' - medical education via clinical schools and internships in rural/remote locations, with a later option of a rural generalist pathway. The proportion of medical graduates working in remote practice may also be increased by preferentially selecting Indigenous Australian applicants and applicants who score highly for communication, teamwork, self-reliance and motivation for rural and remote practice.

Training generalist doctors for rural practice in New Zealand.

Targeted postgraduate training increases the likelihood young doctors will take up careers in rural generalist medicine. This article describes the postgraduate pathways that have evolved for these doctors in New Zealand. The Cairns consensus statement 2014 defined rural medical generalism as a scope of practice that encompasses primary care, hospital or secondary care, emergency care, advanced skill sets and a population-based approach to the health needs of rural communities. Even as work goes on to define this role different jurisdictions have developed their own training pathways for these important members of the rural healthcare workforce. In 2002 the University of Otago developed a distance-taught postgraduate diploma aimed at the extended practice of rural general practitioners (GPs) and rural hospital medical officers. This qualification has evolved into a 4-year vocational training program in rural hospital medicine, with the university diploma retained as the academic component. The intentionally flexible and modular nature of the rural hospital training program and university diploma allow for a range of training options. The majority of trainees are taking advantage of this by combining general practice and rural hospital training. Although structured quite differently the components of this combined pathway looks similar to the Australian rural generalist pathways. There is evidence that the program has had a positive impact on the New Zealand rural hospital medical workforce.

Is remote health different to rural health?

INTRODUCTION: The study identifies the differences between rural health and remote health and describes key distinctive characteristics of remote health. METHODS: The study used a mixed method approach of interviews and questionnaires (utilising a Likert scale) with expert stakeholders in rural health and remote health. A total of 45 interviews were conducted with experts selected from every state and territory of Australia. Of these, 41 also completed a questionnaire, of which 21 respondents were female, 20 identified predominantly as academics while six, five and five indicated that they worked in policy, advocacy and as a practitioner, respectively. Thirteen worked in rural health, 10 in remote health and 18 in both; 23 participants worked in Aboriginal and/or Torres Strait Islander health. Respondents had worked in rural health or remote health for mean periods of 13 years and 8 years, respectively. RESULTS: Means for each of 15 characteristics indicated that respondents viewed each characteristic as different in remote health compared to rural health. Interviews confirmed these perceived differences, with particular emphasis on isolation, poor service access and the relatively high proportion of Indigenous residents. Those working in remote and Aboriginal health most strongly identified these distinctions. CONCLUSIONS: A detailed and rigorous description of the discipline of remote health, and the differences to rural health, will assist policymakers, health planners, teachers and researchers to develop an appropriate workforce, models of service delivery and policy that are relevant, appropriate and effective in order to ensure a more equitable distribution of resources and health outcomes across this vast continent.

Disparities in dental health of rural Australians: hospitalisation rates and utilisation of public dental services in three communities in North Queensland.

INTRODUCTION: The oral health of rural Australians continues to lag behind that of those living in metropolitan areas. Research has shown that people living in rural areas are more likely to suffer from dental caries (decay), visit the dentist less often and have poorer access to oral health services. The purpose of the study was to examine hospitalisations for dental conditions and utilisation of public dental services in three rural communities in Queensland compared with the whole of Queensland. METHODS: Aggregated hospitalisation data for dental conditions and counts of public outpatient service data were requested for residents of three rural communities in Queensland and for the whole of Queensland for the calendar year 2013. Hospitalisation rates per 1000 and risk ratios were calculated to examine the risk of hospitalisation for dental procedures for those living in the selected rural communities and the rest of Queensland. Data were grouped by gender, age and Indigenous status and comparisons made between Queensland and the rural communities. Outpatient service data were converted to percentage of all services delivered to allow comparisons between groups of different sizes. Population data were grouped into age cohorts and compared with the proportion of public oral health services delivered to each age cohort. RESULTS: Residents of the rural communities were twice as likely to be hospitalised and children aged 0-14 years living in the communities were three times more likely to be hospitalised for dental conditions compared to residents of the rest of Queensland. Outpatient oral service data showed that the proportion of services delivered to children aged up to 14 years living in the rural communities was less than the whole of Queensland. Interestingly, in one rural community where the public dental service was open to all, the distribution of public oral health services aligned with the age distribution of the population. CONCLUSIONS: The study showed that residents of these rural communities experience poorer oral health and are a greater risk of hospitalisation for dental conditions compared with the whole of Queensland. Whilst public dental services account for a small proportion of all dental care across the state, service utilisation data provide a unique insight into the population groups who may not be accessing public dental services. In the rural context, more effective use of the local workforce and a flexible approach to funding models could have a positive impact on access to dental care.

Indigenous clients intersecting with mainstream nursing: a reflection.

CONTEXT: Mental health care for Australian Aboriginal and Torres Strait Islander people living in rural and remote locations is delivered primarily by nurses. Culturally safe therapeutic interventions can promote understanding and improve care. Reflective knowledge thinking, writing and practice can support nurses to practice cultural safety. ISSUES: Two instances of mental health care for Australian Aboriginal and Torres Strait Islander clients are described in this reflective piece of writing. The care provided in both instances was culturally inappropriate and/or inadequate. I was an agent or observer in both cases, which happened during my employment as a mental health nurse in Australia. The first story, 'the traumatisation of Client A' describes an instance where I, from a place of ignorance, acted without cultural sensitivity and knowledge. I restrained and observed a client in a way that accorded with workplace policy but, at the same time, failed to take into account the circumstances and cultural safety of my client. The second story, 'the misunderstandings about Client B', occurred much later in my career. This time, I engaged with the client, acted with cultural safety, listened to his story and was able to clear up misunderstandings surrounding his presentation to hospital. LESSONS LEARNED: The two events described in this article led me to discover the nurse I was then and the nurse I have become now. In comparing the two events and my level of awareness and understanding of Aboriginal peoples, along with my own actions, I reflect on my own journey of discovery, which has informed and shaped my awareness as a culturally safe and more sensitive nurse.

Health justice partnerships: initial insights into the delivery of an integrated health and legal service for youth in regional Victoria.

INTRODUCTION: This article presents interim findings from research examining the implementation of a health justice partnership (HJP) focusing on the legal and health needs of regional young people. HJPs provide an innovative service model offering an integrated health and legal service for the community. HJPs are a relatively new service model for Australia, yet the program is well suited to meet the needs of particular population cohorts, including young people and those in regional locations experiencing complex legal issues. METHODS: Funded by the Victorian Legal Services Board and Commissioner, an HJP in partnership with three organisations was established in a large regional area in Victoria, Australia. Research is being conducted alongside the program to examine its impact on young people, and the implications on practice for staff in the partner organisations. RESULTS: Findings provide preliminary support for the HJP model with a number of young people - from predominantly disadvantaged backgrounds and with varying legal issues - having been referred to the program in the first 6 months. Referrals were received from both partner agencies and external agencies. Initial client and staff survey responses indicate that the legal problem of the young people was affecting how they feel. CONCLUSIONS: While these findings provide preliminary support for the HJP further research will offer longer term insights about HJPs within the Australian context, particularly rural and regional settings.

Long-term morbidity and mortality in survivors of critical illness: a 5-year observational follow-up study.

INTRODUCTION: This prospective observational study over 5 years aimed to quantify long-term morbidity and mortality in a prospectively recruited cohort of Central Australian survivors of critical illness. METHODS: Eligible participants are survivors of an intensive care unit (ICU) admission for a critical illness at the Alice Springs Hospital (ASH), prospectively recruited during 2009. The ASH ICU is a 10-bed unit located in Central Australia with approximately 600 admissions annually, 95% of which are emergent, and 65% Indigenous. All-cause mortality, secondary healthcare utilisation and functional outcomes were measured by 6-minute walk distance (an indicator of functional status) and the home and community care (HACC) screening tool at 5 years. RESULTS: Sixty eight percent of the cohort had died at 5 years. Median age of death was 53 years with a median time to death of 604 days following ICU admission. There was increased secondary healthcare utilisation measured by emergency department presentations and hospital re-admissions, with a median 5.22 healthcare presentations per year alive. There is evidence of ongoing functional limitation with 6-minute walk distance at 5 years significantly less than that predicted, despite high scores on the HACC screening assessment suggesting virtually full resumption of basic and domestic activities of daily living. CONCLUSIONS: A critical illness is not an isolated event, and there is evidence of ongoing high secondary healthcare utilisation, reflecting a high burden of disease. Mortality in this cohort is higher than would be expected from international data, and at a young median age, suggesting significant loss of productive life years. In addition, there is evidence of ongoing morbidity, with higher rates of healthcare utilisation than comparable international studies. This has profound implications for healthcare planners due to the ongoing economic implications, and may suggest a need for increased primary healthcare resources to pre-emptively manage chronic disease and reduce the burden of healthcare utilisation at acute care facilities.

Measuring the attractiveness of rural communities in accounting for differences of rural primary care workforce supply.

INTRODUCTION: Many rural communities continue to experience an undersupply of primary care doctor services. While key professional factors relating to difficulties of recruitment and retention of rural primary care doctors are widely identified, less attention has been given to the role of community and place aspects on supply. Place-related attributes contribute to a community's overall amenity or attractiveness, which arguably influence both rural recruitment and retention relocation decisions of doctors. This bi-national study of Australia and the USA, two developed nations with similar geographic and rural access profiles, investigates the extent to which variations in community amenity indicators are associated with spatial variations in the supply of rural primary care doctors. METHODS: Measures from two dimensions of community amenity: geographic location, specifically isolation/proximity; and economics and sociodemographics were included in this study, along with a proxy measure (jurisdiction) of a third dimension, environmental amenity. Data were chiefly collated from the American Community Survey and the Australian Census of Population and Housing, with additional calculated proximity measures. Rural primary care supply was measured using provider-to-population ratios in 1949 US rural counties and in 370 Australian rural local government areas. Additionally, the more sophisticated two-step floating catchment area method was used to measure Australian rural primary care supply in 1116 rural towns, with population sizes ranging from 500 to 50 000. Associations between supply and community amenity indicators were examined using Pearson's correlation coefficients and ordinary least squares multiple linear regression models. RESULTS: It was found that increased population size, having a hospital in the county, increased house prices and affluence, and a more educated and older population were all significantly associated with increased workforce supply across rural areas of both countries. While remote areas were strongly linked with poorer supply in Australia, geographical remoteness was not significant after accounting for other indicators of amenity such as the positive association between workforce supply and coastal location. Workforce supply in the USA was negatively associated with fringe rural area locations adjacent to larger metropolitan areas and characterised by long work commutes. The US model captured 49% of the variation of workforce supply between rural counties, while the Australian models captured 35-39% of rural supply variation. CONCLUSIONS: These data support the idea that the rural medical workforce is maldistributed with a skew towards locating in more affluent and educated areas, and against locating in smaller, poorer and more isolated rural towns, which struggle to attract an adequate supply of primary care services. This evidence is important in understanding the role of place characteristics and rural population dynamics in the recruitment and retention of rural doctors. Future primary care workforce policies need to place a greater focus on rural communities that, for a variety of reasons, may be less attractive to doctors looking to begin or remain working there.

Challenges to the provision of community aged care services across rural Australia: perceptions of service managers.

INTRODUCTION: The Australian community aged care sector is facing a growing workforce crisis, particularly in rural and regional areas. Its predominantly female workforce is ageing, and recruiting younger, skilled workers is proving difficult. The service sector, too, is proving highly complex and diverse as a result of contemporary aged care service reforms as well as ongoing difficulties in providing services to the growing numbers of older people living in Australia's rural areas. Despite these multiple challenges, there is a gap in research that explores how rural aged care services manage their day-to-day requirements for skilled workers across the diverse service sector. To address this gap, this article reports on the experiences and perceptions of a small sample of service managers whose organisations represent this diversity, and who are accountable for care provision in regional and rural locations. In such areas, recruitment and skill needs are contoured by disproportionate aged populations, distance and reduced service availability. METHODS: Eleven service managers were interviewed as part of a larger project that examined the skill and training needs of community aged care workers within the Riverina, a rural region in New South Wales. Qualitative data drawn from semi-structured interviews were thematically analysed to identify the managers' individual needs for workers and skills in the context of location, service parameters and availability of other health and community services. RESULTS: Thematic analysis of the interview data elicited three themes: services, roles and skill deployment; older workers and gendered roles; and barriers to recruitment. The findings illustrate the complexities that characterise the community aged care sector as a whole and the impact of these on individual services located in regional and rural parts of Australia. The participants reported diverse needs for worker skills in keeping with the particular level of service they provide. Significantly, their varying perceptions and practices reflect their preference for older, female workers; their reluctance to take on younger workers is negatively skewed by a lack of capacity to compete for, recruit and retain such workers and to offer incentives in the form of enhanced roles and career development. CONCLUSIONS: The findings highlight the conceptual ambiguities inherent in definitions of community aged care work as broadly skilled and uniformly sought across the sector. On the one hand, demands for more and better trained workers to meet growing client complexity locate care work as skilled. On the other, managers of narrowly defined service activities may rely on a diminishing workforce whose skills they downplay in gendered and lay terms. This contradiction corresponds with long-held conclusions about the gendered, exploitative reputation of care work, a characterisation discursively constructed by privileging the moral dimensions of the job over the technical skills required for it. Significantly, the findings raise questions about the capacity of services, as they are currently structured and differentiated, to reshape and redefine aged care work as a 'good job', one that holds appeal and tangible rewards for new and younger skilled workers.

A comparative analysis of policies addressing rural oral health in eight English-speaking OECD countries.

INTRODUCTON: Oral health is fundamental to overall health. Poor oral health is largely preventable but unacceptable inequalities exist, particularly for people in rural areas. The issues are complex. Rural populations are characterised by lower rates of health insurance, higher rates of poverty, less water fluoridation, fewer dentists and oral health specialists, and greater distances to access care. These factors inter-relate with educational, attitudinal, and system-level issues. An important area of enquiry is whether and how national oral health policies address causes and solutions for poor rural oral health. The purpose of this study was to examine a series of government policies on oral health to (i) determine the extent to which such policies addressed rural oral health issues, and (ii) identify enabling assumptions in policy language about problems and solutions regarding rural communities. METHODS: Eight current oral health policies were identified from Australia, New Zealand, Canada, the USA, England, Scotland, Northern Ireland, and Wales. Validated content and critical discourse analyses were used to document and explore the concepts in these policy documents, with a particular focus on the frequency with which rural oral health was mentioned, and the enabling assumptions in policy language about rural communities. RESULTS: Seventy-three concepts relating to oral health were identified from the textual analysis of the eight policy documents. The rural concept addressing oral health issues occurred in only 2% of all policies and was notably absent from the oral health policies of countries with substantial rural populations. It occurred most frequently in the policy documents from Australia and Scotland, less so in the policy documents from Canada, Wales, and New Zealand, and not at all in the oral health policies from the US, England, and Northern Ireland. Thus, the oral health needs of rural communities were generally not the focus of, nor included in, the oral health policy documents in this study. When the language of concepts related to rural oral health was examined, the qualitative analysis identified four discourse themes related to both causality and solutions. These ranked discourse themes focused on service models, workforce issues, social determinants of health, and prevention. None of the policies addressed the structural economic determinants of unequal rural oral health, nor did they specifically assert the rights of children in rural communities to equitable oral health care. CONCLUSIONS: This study documented the limited focus on rural oral health that existed in national oral health policies from eight different English-speaking countries. It supports the need for an increased focus on rural oral health issues in oral health policies, particularly as increased oral health is clearly associated with increased general health. It speaks to the critical importance of periodic analysis of the content of oral health policies to ensure that issues of inequality are addressed. Further, it reinforces the need for research findings about effective oral health care to be translated into practice in the development of practical and financially viable policies to make access to oral health care more equitable, particularly for people living in rural and remote areas.

A national analysis of dental waiting lists and point-in-time geographic access to subsidised dental care: can geographic access be improved by offering public dental care through private dental clinics?

INTRODUCTION: Australia is one of the least densely populated countries in the world, with a population concentrated on or around coastal areas. Up to 33% of the Australian population are likely to have untreated dental decay, while people with inadequate dentition (fewer than 21 teeth) account for up to 34% of Australian adults. Historically, inadequate access to public dental care has resulted in long waiting lists, received much media coverage and been the subject of a new federal and state initiative. The objective of this research was to gauge the potential for reducing the national dental waiting list through geographical advantage, which could arise from subcontracting the delivery of subsidised dental care to the existing network of private dental clinics across Australia. METHODS: Eligible population data were collected from the Australian Bureau of Statistics website. Waiting list data from across Australia were collected from publicly available sources and confirmed through direct communication with each individual state or territory dental health body. Quantum geographic information system software was used to map distribution of the eligible population across Australia by statistical area, and to plot locations of government and private dental clinics. Catchment areas of 5 km for metropolitan clinics and 5 km and 50 km for rural clinics were defined. The number of people on the waiting list and those eligible for subsidised dental care covered by each of the catchment areas was calculated. Percentage of the eligible population and those on the waiting list that could benefit from the potential improvement in geographic access was ascertained for metropolitan and rural residents. RESULTS: Fifty three percent of people on the waiting list resided within metropolitan areas. Rural and remote residents made up 47% of the population waiting to receive care. The utilisation of both government and private dental clinics for the delivery of subsidised dental care to the eligible population has the potential to improve geographic access for up to 25% of those residing within metropolitan areas and up to 59% for eligible country residents. CONCLUSIONS: This research finds that utilisation of the existing network of private dental practices across Australia for delivery of subsidised dental care could dramatically increase geographic reach, reduce waiting lists, and possibly make good oral health a more realistic goal to achieve for the economically disadvantaged members of the community. In addition, this approach has the potential to improve service availability in rural and remote areas for entire communities where existing socioeconomic dynamics do not foster new practice start-up.

Translating agricultural health and medicine education across the Pacific: a United States and Australian comparison study.

BACKGROUND: Populations in agricultural communities require health care that is interdisciplinary and cross-sectoral to address the high rate of workplace deaths, preventable injuries and illness. These rates are compounded by limited access to services and the distinctive personal values and culture of farming populations, which both health and rural practitioners must be aware of to reduce the gap between rural and urban population health outcomes. To address the unique health and medical characteristics of agricultural populations, education in agricultural medicine was established through the College of Medicine and the College of Public Health at the University of Iowa in the USA. The course was initially developed in 1974 for teaching medical students, family medicine residents and nurses, and a postgraduate curriculum was added in 2006 to develop medical/health and rural professionals' cultural competence to work in agricultural communities. This article reviews the adaptation of the US course to Australia and the educational and practice outcomes of students who completed the agricultural medicine course in either Australia or the USA. METHODS: Data were collected from students who completed either the Agricultural Medicine: Occupational and Environmental Health for Rural Health Professionals course in the state of Iowa in the USA or the Agricultural Health and Medicine course in the state of Victoria in Australia between 2010 and 2013 (inclusive). Data were analysed using descriptive statistics, frequencies and the χ2 test. Students were invited to make any other comments regarding the course. RESULTS: One hundred and ten students completed the survey (59 from the USA and 51 from Australia) with over a 50% response from both countries, indicating the high level of commitment to this discipline. Responses were consistent across both continents, with more than 91% agreeing that the course improved their abilities to diagnose, prevent and treat rural and agricultural populations. Further, both courses successfully enabled a multidisciplinary and cross-sectoral approach to agricultural health and medicine. CONCLUSIONS: More than 72% of previous students were practising in rural and /or mixed communities at the time of the survey, demonstrating a repeatable and transferable medical education program that supports multidisciplinary care and scholarship while addressing health inequities in agricultural populations. Findings from this study indicate there are opportunities to expand globally.

The Pituri Learning Circle: central Australian Aboriginal women's knowledge and practices around the use of Nicotiana spp. as a chewing tobacco.

INTRODUCTION: Tobacco smoking has a range of known and predictable adverse outcomes, and across the world sustained smoking reduction campaigns are targeted towards reducing individual and public risk and harm. Conversely, more than 87 million women, mostly in low- and middle-income countries, use smokeless tobacco, yet the research examining the effect of this form of tobacco exposure on women is remarkably scant. In central Australia, the chewing of wild Nicotiana spp., a tobacco plant, commonly known as pituri and mingkulpa, is practised by Aboriginal groups across a broad geographical area. Until recently, there had been no health research conducted on the effects of chewing pituri. METHODS: This article reports on one component of a multidimensional pituri research agenda. A narrative approach utilising the methodology of the Learning Circle was used to interview three key senior central Australian Aboriginal women representative of three large geographical language groupings. The participants were selected by a regional Aboriginal women's organisation. With the assistance of interpreters, a semistructured interview, and specific trigger resources, participants provided responses to enable an understanding of the women's ethnobotanical pituri knowledge and practices around the use of pituri within the context of Aboriginal women's lives. Data were transcribed, and by using a constant comparison analysis, emergent themes were categorised. The draft findings and manuscript were translated into the participants' language and validated by the participants. RESULTS: Three themes around pituri emerged: (a) the plants, preparation and use; (b) individual health and wellbeing; and (c) family and community connectedness. The findings demonstrated similar participant ethnobotanical knowledge and practices across the geographical area. The participants clearly articulated the ethnopharmacological knowledge associated with mixing pituri with wood ash to facilitate the extraction of nicotine from Nicotiana spp., the results of which were biochemically verified. The participants catalogued the pleasurable and desired effects obtained from pituri use, the miscellaneous uses of pituri, as well as the adverse effects of pituri overdose and toxicity, the catalogue of which matched those of nicotine. The participants' overarching pituri theme was related to the inherent role pituri has in the connectiveness of people to family, friends and community. CONCLUSIONS: Central Australian Aboriginal women have a firmly established knowledge and understanding of the pharmacological principles related to the content of Nicotiana spp. and the extraction of nicotine from the plant. Widespread use of Nicotiana spp. as a chewing tobacco by Aboriginal populations in the southern, central and western desert regions of Australia is attested to by participants who assert that everyone uses it, with girls in these remote areas commencing use between 5 and 7 years of age. Central Australian Aboriginal people who chew Nicotiana spp. do not consider it to be a tobacco plant, and will strongly refute that they are tobacco users. Central Australian Aboriginal people do not consider that the Western health information regarding tobacco (as a smoked product) is applicable or aligned to their use of pituri. Nicotiana spp. users will deny tobacco use at health assessment. There is a requirement to develop and provide health information on a broader range of tobacco and nicotine products in ways that are considered credible by the Aboriginal population. Health messages around pituri use need to account for the dominant role that pituri occupies in the context of central Australian Aboriginal women's lives.
Information for readers: A consultative organisation of Aboriginal women has as a strategic intent and operational agenda the improvement of Aboriginal women's and children's health across the research region. The group seeks opportunities to enhance their knowledge based on legitimate collaborative research; accordingly, they sought to participate in a range of research activities regarding the use of pituri and women's health outcomes. Of particular note, the group's participants chose to be identified by name in the publication of this research activity. In this article, the term 'Aboriginal' has been chosen by the central Australian women to refer to both themselves and the Aboriginal people in their communities; 'Indigenous' has been chosen to refer to the wider Australian Aboriginal and Torres Strait Islander people. The term Nicotiana spp. is used when referring to the plants from a Western perspective; pituri is used when referring to the plants, the tobacco quid, and the practice of chewing from a general Aboriginal perspective; and mingkulpa is used when the participants are voicing their specific knowledge and practices.

Effect of medical student preference on rural clinical school experience and rural career intentions.

INTRODUCTON: The key parameter for rural clinical schools (RCSs) is to provide at least 1 year of clinical training in rural areas for 25% of Australian Commonwealth supported medical students with the intent to influence future rural medical workforce outcomes. The objective of this study was to describe the association between a medical student's selection preference and their RCS experience and rural career intent. METHODS: Medical students completing an RCS placement in 2012 and 2013 were encouraged to complete a survey regarding their experience and future career intent. Data were analysed to compare medical students for whom the RCS was their first choice with students who described the RCS as other than their first preference. RESULTS: Students for whom RCS was their first choice (724/1092) were significantly more likely to be female, come from a rural background and be from an undergraduate program. These students reported more positive experiences of all aspects of the RCS program (costs, access, support and networks, safety) and were 2.36 times more likely to report intentions to practice in a non-metropolitan area (odds ratio(OR)=2.36 (95% confidence interval(CI)=1.82-3.06), p<0.001). This was true for students of rural (OR=3.11 (95%CI=1.93-5.02), p<0.001) and metropolitan backgrounds (OR=2.07 (95%CI=1.48-2.89), p<0.001). More students in the first-choice group (68.8%) intended to practice in a regional area (not a capital or major city), significantly higher than the 48.4% of participants in the other-preference group (χ2 (1) 42.79, p<0.001). CONCLUSIONS: The decision to choose an RCS placement is a marker of rural career intention and a positive rural training experience for students of both rural and metropolitan backgrounds. It may be important to identify other-preference students and their specific social support needs to ensure a positive perception of a future rural career.

Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability.

INTRODUCTION: With the escalating costs of health care, issues with recruitment and retention of health practitioners in rural areas, and poor economies of scale, the question of delivering people to services or services to people is a dilemma for health authorities around the world. People living in rural areas have poorer health outcomes compared to their urban counterparts, and the problem of how to provide health care and deliver services in rural locations is an ongoing challenge. Telehealth services can efficiently and effectively improve access to healthcare for people living in rural and remote areas of Australia. However, telehealth services are not mainstream or routinely available in many rural and remote locations. The barriers to integration of telehealth into mainstream practice have been well described, but not the factors that may influence the success and sustainability of a service. Our aim was to collate, review and synthesise the available literature regarding telehealth services in rural and remote locations of Australia, and to identify the factors associated with their sustained success. METHODS: A systematic literature review of peer-reviewed and grey literature was undertaken. Electronic databases were searched for potentially relevant articles. Reference lists of retrieved articles and the grey literature were also searched. Searches identified 970 potentially eligible articles published between 1988 and 2015. Studies and manuscripts of any type were included if they described telehealth services (store-and-forward or real-time videoconferencing) to provide clinical service or education and training related to health care in rural or remote locations of Australia. Data were extracted according to pre-defined criteria and checked for completeness and accuracy by a second reviewer. Any disagreements were resolved with discussion with a third researcher. All articles were appraised for quality and levels of evidence. Data were collated and grouped into categories including clinical speciality, disciplines involved, geographical location and the role of the service. Data relating to the success or sustainability of services were grouped thematically. RESULTS: Inclusion criteria were met by 116 articles that described 72 discrete telehealth services. Telehealth services in rural and remote Australia are described and we have identified six key factors associated with the success and sustainability of services: vision, ownership, adaptability, economics, efficiency and equipment. CONCLUSIONS: Telehealth has the potential to address many of the key challenges to providing health in Australia, with its substantial land area and widely dispersed population. This review collates information regarding the telehealth services in Australia and describes models of care and characteristics of successful and sustainable services. We identified a wide variety of telehealth services being provided in rural and remote areas of Australia. There is great potential to increase this number by scaling up and replicating successful services. This review provides information for policy makers, governments and public and private health services that wish to integrate telehealth into routine practice and for telehealth providers to enhance the sustainability of their service.

Towards understanding the availability of physiotherapy services in rural Australia.

INTRODUCTION: A recent exploration of factors affecting rural physiotherapy service provision revealed considerable variation in services available between communities of the study. Multiple factors combined to influence local service provision, including macro level policy and funding decisions, service priorities and fiscal constraints of regional health services and capacity and capabilities at the physiotherapy service level. The aim of this article is to describe the variation in local service provision, the factors influencing service provision and the impact on availability of physiotherapy services. METHODS: A priority-sequence mixed methods design structured the collection and integration of qualitative and quantitative data. The investigation area, a large part of one Australian state, was selected for the number of physiotherapy services and feasibility of conducting site visits. Stratified purposive sampling permitted exploration of rural physiotherapy with subgroups of interest, including physiotherapists, their colleagues, managers, and other key decision makers. Participant recruitment commenced with public sector physiotherapists and progressed to include private practitioners, team colleagues and managers. Surveys were mailed to key physiotherapy contacts in each public sector service in the area for distribution to physiotherapists, their colleagues and managers within their facility. Private physiotherapist principals working in the same communities were invited by the researcher to complete the physiotherapy survey. The survey collected demographic data, rural experience, work setting and number of colleagues, services provided, perspectives on factors influencing service provision and decisions about service provision. Semi-structured interviews were conducted with consenting physiotherapists and other key decision makers identified by local physiotherapists. Quantitative survey data were recorded in spreadsheets and analysed using descriptive statistics. Interviews were recorded and transcribed verbatim, with transcripts provided to participants for review. Open-ended survey questions and interview transcripts were analysed thematically. RESULTS: Surveys were received from 11/25 (44%) of facilities in the investigation area, with a response rate of 29.4% (16/54) from public sector physiotherapists. A further 18 surveys were received: five from principals of private physiotherapy practices and 13 from colleagues and managers. Nineteen interviews were conducted: with 14 physiotherapists (nine public, five private), four other decision makers and one colleague. Three decision makers declined an interview. The variation in physiotherapy service availability between the 11 communities of this study prompted the researchers to consider how such variation could be reflected. The influential factors that emerged from participant comments included rurality and population, size and funding model of public hospitals, the number of public sector physiotherapists and private practices, and the availability of specialised paediatric and rehabilitation services. The factors described by participants were used to develop a conceptual framework or index of rural physiotherapy availability. CONCLUSIONS: It is important to make explicit the link between workforce maldistribution, the resultant rural workforce shortages and the implications for local service availability. This study sought to do so by investigating physiotherapy service provision within the rural communities of the investigation area. In doing so, varying levels of availability emerged within local communities. A conceptual framework combining key influencing factors is offered as a way to reflect the availability of physiotherapy services.

James Cook University's decentralised medical training model: an important part of the rural workforce pipeline in northern Australia.

INTRODUCTION: There has been much recent investment to improve the recruitment and retention of medical graduates in rural Australia. This paper describes the different outcomes of the strategies used at the James Cook University (JCU) medical school to improve the recruitment and retention of medical graduates in northern Australian towns: the decentralised model of four rural clinical schools, selecting students with a rural home town, enrolling students under the Bonded Medical Placements (BMP) scheme, and providing rurally orientated scholarships. METHODS: Home town at application to medical school, clinical school location, scholarship, BMP and postgraduate practice location data for JCU medical graduates were retrieved from an ongoing longitudinal cohort study. Multivariate logistic regression analysis was used to identify independent predictors of intern practice location from 2006 to 2013, and current (2014) practice location for postgraduate year 4-9 graduates for each of the four rural clinical school sites of Townsville, Cairns, Darwin and Mackay. RESULTS: The strongest predictor of JCU Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates undertaking their internship in Townsville, Cairns, Mackay or Darwin hospitals was attending the JCU clinical school in that location (p<0.001, prevalence odds ratios (POR)=7.1; p<0.001, POR=11.5; p<0.001, POR=19.4; p<0.001, POR=85.7; respectively). Attending the JCU clinical school in the main town was also a strong predictor of JCU MBBS graduates currently practising (2014) in the Townsville, Cairns and Mackay health service districts (p<0.001, POR=2.9; p<0.001, POR=3.8; p=0.033, POR=3.6; respectively). CONCLUSIONS: While this study supports the effectiveness of improving the rural medical workforce via the targeted selection of students with a rural background, the JCU medical school's decentralised medical education program also appears to be significantly associated with rural recruitment and retention, including in districts of workforce shortage and/or geographically remote locations. These findings support other evidence that decentralised medical training can assist recruitment to underserved regions, and have implications for other jurisdictions looking to invest in a decentralised training model.

Community assets and capabilities to recruit and retain GPs: the Community Apgar Questionnaire in rural Victoria.

INTRODUCTION: Rural communities continue to experience significant challenges recruiting and retaining physicians. The Community Apgar Questionnaire (CAQ) was developed in Idaho in the USA to comprehensively assess the characteristics associated with successful recruitment and retention of rural physicians. The CAQ has been utilised and validated across the USA; however, its value in rural Australia has not been examined. The objective of this study was to use the CAQ in rural Australia to examine its utility and develop a greater understanding of the community factors that impact general practitioner (GP) recruitment and retention. METHOD: The project conducted structured face-to-face interviews with hospital chief executive officers (CEOs) and directors of clinical services (DCSs) from 14 of the 21 (76%) health services that agreed to participate in rural north-eastern Victoria, Australia. The interviews were undertaken to complete the CAQ, which contains 50 questions centred on factors that influence physician recruitment and retention. Once completed, CAQs were scored by assigning quantitative values to a community's strengths and challenges including the level of importance placed on each factor. As such, the most important factors in physician recruitment, whether they are advantages or challenges for that community, were then weighed for their relative importance. Scores were then combined to create a CAQ score. To ensure reliability and validity of the results, three additional CAQs were purposefully administered to key general practices within the region. RESULTS: The 14 rural communities exhibited cumulative CAQ scores ranging from a high of 387 to a low score of 61. This suggests the tool was sensitive enough to differentiate between communities that were high and low performers in terms of physician recruitment. The groups of factors that had the greatest impact on recruitment and retention were ranked highest to lowest and included medical support, hospital/community support, economic, scope of practice and geographic factors. Overall, the highest individual factors to impact recruitment and retention were perception of quality, hospital leadership, nursing workforce and transfer arrangements. Conversely, the lowest factors and challenges to recruitment and retention were family related, specifically spousal satisfaction and access to schools. CONCLUSIONS: Hume, in rural Victoria, was the first international site to implement the CAQ to differentially diagnose a community's relative strengths and challenges in recruiting and retaining GPs, while supporting health facilities to prioritise achievable goals to improve long-term retention strategies. It provided each community with a tailored gap analysis, while confidentially sharing best practices of other health facilities. Within Hume, open communication and trust between GPs and health facility leadership and nursing staff ensures that GPs can feel valued and supported. Possible solutions for GP recruitment and retention must consider the social, employment and educational opportunities that are available for spouses and children. Participation in the program was useful as it helped health facilities ascertain how they were performing while highlighting areas for improvement.

Twenty-five years on: outcomes of a longitudinal evaluation of the NSW Rural Resident Medical Officer Cadetship Program.

INTRODUCTION: The New South Wales Rural Resident Medical Officer Cadetship Program began in 1988 as a strategy to increase the numbers of junior doctors in rural hospitals. This article outlines the results of an evaluation undertaken in 2014. Specifically, it will look at where former cadets who entered the program between 1989 and 2010 were working in 2014, what training programs they chose and their attitudes toward the program. METHOD: Data were collected using a semi-structured questionnaire sent to all the former cadets who entered the program from 1989 until 2010. This included self-administered questions relating to background (where the majority of the students' primary schooling was undertaken), vocational training, current role, current work location and attitudes towards the cadetship. Responses were received from 142 of the 211 cadets in the study (67%). RESULTS: Of the 142 former cadets who responded to the questionnaire, 90 had completed a vocational training program and were working as fully qualified medical practitioners. A further 44 were trainees, six were non-specialist hospital doctors and two were no longer practising. Overall, the most popular vocational training programs among fully qualified doctors and trainees combined were general practice, anaesthetics/intensive care and emergency medicine. Over half of the cadets included in the analysis (n=74, 53%) were working in rural areas (Australian Standard Geographical Classification Remoteness Areas 2-5) in 2014 and practice location was significantly (p<0.001) influenced by career choice. Of the cadets working in rural locations, the majority (58%) were working as general practitioners while 38% had chosen other specialties and 4% were working as hospital non-specialists. An equal proportion of cadets came from urban and rural backgrounds while a small proportion grew up overseas. The cadets with rural backgrounds were more likely to choose general practice than those from urban backgrounds. A similar analysis of cadets comparing geographic background and practice location showed cadets of rural background were more likely to be working in a rural location than cadets of urban background. CONCLUSIONS: The cadetship is an effective link between medical school and rural practice. The success of the program relies in part on the mentoring, networking and other educational opportunities available to cadets, which serve to foster their interest and provide a structured pathway to long-term rural practice. It has been demonstrated that targeted incentive based scholarship schemes with a return-of-service component can be beneficial, particularly where they include ongoing support and reinforcement throughout the transition from undergraduate to postgraduate training.

The answers are out there! Developing an inclusive approach to collaboration.

Professional isolation is a recurring issue in the delivery of rural and remote health care. However, collaboration is now more feasible with developments in technology and connectivity. At an international scale, collaboration offers clear opportunities for good ideas and great work to be shared across distances and boundaries that previously precluded this. This article reflects a presentation given to the Rethinking Remote conference in Inverness (Scotland) in May 2016. A number of factors with regard to infrastructure and engagement are considered, along with ways in which the opportunities of collaboration between individuals and large centres can be optimised. Social media and increased connectivity pave the way for easier access to great practice across international sites that share similar challenges.