IS AUSTRALIAN RURAL PRACTICE CHANGING? FINDINGS FROM THE NATIONAL RURAL GENERAL PRACTICE STUDY

ABSTRACT: The National Rural General Practice Study (NRGPS) was the first comprehensive national study covering rural and remote general practitioners throughout Australia. It was undertaken in 1996–1997 and drew on data from existing sources such as the Australian Bureau of Statistics and the Australian Institute of Health and Welfare, together with a postal survey of general practitioners in rural and remote areas. There was a 75% response rate to the survey, which covered professional issues, personal and social issues, personal background, patient issues, recruitment and retention programs and changing health services. Overall, the study findings confirmed those of previous individual State-based studies in the early 1990s and showed that there had been some changes since those previous studies. In particular, access to continuing medical education has improved, the rural medical workforce appears to be ageing, the proportion of women rural doctors is increasing and the projected length of stay in rural practice is decreasing. Whereas in the early 1990s the projection for rural doctor numbers was continuing decline, the NRGPS projected overall numbers in rural practice as staying approximately the same over the next 5 years. In the light of these trends, the challenge is to implement targeted initiatives that improve the recruitment and retention of rural and remote general practitioners.     

ARE RURAL PEOPLE GETTING HEARTSMART?

Objective: This study evaluates the impact of a cardiac rehabilitation program (HeartSmart) in a rural area on the quality of life, dietary behaviour, weight loss and physical activity participation of patients with cardiovascular disease (CVD) or at high risk of CVD. Design: The evaluation of the program consisted of a single group pre and post‐test design with follow‐up at 3, 6 and 12 months after program completion, complemented with a cross‐sectional survey of non‐participants as a pseudo comparison group. Setting: The HeartSmart program is a hospital‐based cardiac rehabilitation program in Bunbury, a regional centre of Western Australia. Subjects: A total of 203 participants and 159 non‐participants. Interventions: The program consisted of 7 weeks of education and exercise sessions. Results: The program had a high rate of completion (92%). Evaluation results suggested that HeartSmart participants demonstrated significant improvements in quality of life, compliance with medication, dietary behaviour, weight loss and physical activity participation. The largest changes were mostly observed between pre and post‐program stages, with sustained behaviour change at 6 months after the completion of the program. Further evidence of the HeartSmart benefits was provided through significantly better health‐related behaviour, confidence to diet and exercise, dietary fat intake, cardiac knowledge and quality of life scores among HeartSmart participants compared with non‐participants. Conclusions: While this program has achieved its objectives, there are a few issues that need to be considered by similar programs: the post‐program stage of patient follow‐up by general practitioners; the geographical disadvantage of those living outside regional centres to access the service; enhancing the primary prevention aspect of the program; adapting the program to the needs of Aboriginal clients; facilitating evaluations by resourcing and training program staff in computer skills.     

RURAL PRACTICE EVALUATION: HOW DO RURAL PHYSICIANS EVALUATE THEIR WORKING CONDITIONS?

ABSTRACT: Evaluating the quality of rural doctors' working conditions is essential for retaining physicians in rural areas. We carried out a trial to investigate those aspects of working conditions that are important to rural physicians and with which aspects they are satisfied or dissatisfied. Questionnaires were mailed to 204 doctors who were working in rural clinics in Japan. The professional conditions of rural clinic practices were classified into 17 items. The doctors were then asked to evaluate the importance of and degree of satisfaction with each item. Among the 17 items, the clinic's equipment, the municipal government's attitude and the base hospital were evaluated to be more important than the overall average. With regard to satisfaction, the distance to major cities, the municipal government's attitude and locum availability were rated significantly lower than that overall. There were some items where there was a discrepancy between the importance and the degree of satisfaction. Identifying these discrepancies may contribute to creating an environment that will raise the level of rural physicians' satisfaction.     

WHITHER RURAL HEALTH? REVIEWING A DECADE OF PROGRESS IN RURAL HEALTH

ABSTRACT: The problems associated with rural and remote health have been widely recognised by health workers, rural communities and health professions for some time. Yet it has only been in the past decade that any concerted effort has been made to address rural health issues. Today the state of health in rural Australia remains less than optimal. The tenth anniversary of the Australian Journal of Rural Health provides the opportunity to reflect on what progress has been achieved over the past decade, to recognise those factors that have contributed most to the implementation of policies designed to address the health needs of rural and remote Australians, and to discuss outstanding impediments and barriers to resolving rural health issues.     

WHO SHALL NURSE THE SICK?

Commissioner Robertson asserts that with two months'' schooling intelligent women can become capable nurses. He brings out an important by-product to the work in public health education of the women who study. They prove to be a force in caring for their own families as well as others. The Chicago Training School has graduated four thousand pupils.     

RURAL DOCTORS AND RURAL BACKGROUNDS: HOW STRONG IS THE EVIDENCE? A SYSTEMATIC REVIEW

Objective: We sought to summarise the evidence for an association between rural background and rural practice by systematically reviewing the national and international published reports. Design: A systematic review. Setting: A search of the national and international published reports from 1973 to October 2001. Subject: The search criteria included observational studies of a case‐control or cohort design making a clear and quantitative comparison between current rural and urban doctors, this resulted in the identification of 141 studies for potential inclusion. Results: We systematically reviewed 12 studies. Rural background was associated with rural practice in 10 of the 12 studies, in which it was reported, with most odds ratios (OR) approximately 2–2.5. Rural schooling was associated with rural practice in all 5 studies that reported on it, with most OR approximately 2.0. Having a rural partner was associated with rural practice in 3 of the 4 studies reporting on it, with OR approximately 3.0. Rural undergraduate training was associated with rural practice in 4 of 5 studies, with most OR approximately 2.0. Rural postgraduate training was associated with rural practice in 1 of 2 studies, with rural doctors reporting rural training about 2.5 times more often. Conclusions: There is consistent evidence that the likelihood of working in rural practice is approximately twice greater among doctors with a rural background. There is a smaller body of evidence in support of the other rural factors studied, and the strength of association is similar to that for rural background. What is already known on this subject?: It is widely perceived that doctors with a rural background are more likely to return to work in rural areas and major policy initiatives in Australia rely on this assumption. It is recognised that other factors such as location of primary and secondary education, rural medical training and spouse or partner background may also be influential. In order to determine the strength of the evidence for an association between rural background and rural practice we did a systematic review of the published reports. What does this study add?: This systematic review provides good evidence that doctors with a rural background are about twice as likely to work as rural doctors, compared with those with an urban background. Rural background seems to be an important factor that can be employed in policy and practice, however, the problem of increasing the number of rural doctors is multifactorial and so is the solution.     

BRIGHT STARS IN THE SKY?

ABSTRACT: Actions to improve the health of people in rural and remote areas are supported by people's ability as individuals and as a community to take part actively in the design, management and evaluation of their own health services. To do this successfully, people need information about their health, resources to support their actions and political support or legitimacy. This article focuses on the third requirement. At the beginning of 2000, there seems to be strong political interest in improving the status of rural communities and rural services overall, including rural health and health services. The constellation of events that contribute to this encouraging state of affairs includes the Regional Australia Summit that was held in October 1999, the existence of a strategic framework for rural health that was agreed on by all health jurisdictions ( Healthy Horizons ), improved clarity about the relative state of health and health service utilisation in rural and remote areas, and the Prime Minister's recent commitment to improve rural services. The next major national opportunity to convert these positive signs into action comes with the Federal Budget in May 2000, the content of which will be closely watched by people concerned about improving health in country areas.     

PREVENTIVE SOCIAL HEALTH PROGRAMS: ARE THEY AUSTRALIA’S ANSWER TO RISING HEALTH CARE COSTS IN RURAL COMMUNITIES?

ABSTRACT: Although we have good evidence to support the notion that early intervention, prevention and community education programs can mitigate the impact of preventable disease, expanded primary health care is also being promoted by Australian governments as a panacea for reducing growth in demand generally. While preventive programs do reduce acute demand, they may not do so to the extent that resources, currently allocated to the acute sector, can be substituted to provide the additional primary care services necessary to reduce acute demand permanently. These developments have particular relevance for rural and isolated communities where access to acute services is already very limited. What appears to be occurring, in rural South Australia at least, is that traditional acute services are being reduced and replaced with lower level care and social intervention programs. This is well and good, but eventually the acute care being provided in rural health units now will still need to be provided by other units elsewhere and probably at much higher cost to the system and to consumers. Where rural communities have previously managed much of their own acute service demand, they may now be forced to send patients to more distant centres for care but at much greater social and economic cost to individuals and the system.     

GP-BASED EMERGENCY RESPONSE IN RURAL AREAS: IS THERE A NEED?

Rural general practitioners (GPs) traditionally provide the initial care for the very ill and severely traumatised in small and medium-sized rural hospitals. It has been said that these patients would be better managed in a level 1 trauma centre. The present paper will test this hypothesis and shows that the benefits of the expertise available in the large centres may be outweighed by the loss of life in the prehospital phase, most of which occurs before the arrival of the ambulance. General practitioner involvement would enhance the current early retrieval system. Very ill and severe trauma should be assessed and stabilised in the most appropriate local facility. Routine by-passing of local emergency medical services should be avoided. A national standard for training rural GPs in emergency management skills is needed. Emergency facilities and equipment must be maintained and improved throughout rural Australia. These facilities and their staff must be accredited so that the ambulance service can more appropriately determine its transport priorities.     

RURAL ORIGIN MEDICAL STUDENTS: HOW DO THEY COPE WITH THE MEDICAL SCHOOL ENVIRONMENT?

Australia suffers from a well documented shortage of rural medical practitioners. In an attempt to increase recruitment, it has emerged that rural origin medical students are more than twice as likely as their urban colleagues to become rural practitioners. This has led to a wide range of programs aimed at increasing the number of rural students who apply for and gain entry into medical school. But how do rural students cope with the medical school environment? This paper was based on the results of a survey of senior medical students and looked at how rural students’ fare with the medical school environment compared to their urban counterparts. It was concluded that government initiatives currently supporting rural medical students must be continued into the future and continuously evaluated to ensure that rural students have a positive learning experience in preparation for future rural practice.