Funding for rural health research from the Australian Research Council: A missed opportunity?

Objective:  To determine the number of projects, and level of funding, for rural health research from the Australian Research Council (ARC).
Design:  Analyses of ARC searchable datasets of completed, and new and ongoing projects from 2001 to 2008.
Main outcome measures:  Number of rural health research projects as a proportion of total funding; level of funding for rural health research projects as a proportion of total funding.
Results:  Only 46 of 6498 ARC completed projects were classified as rural health research projects. This represents 0.7% of the total number of projects, and 0.39% of the total funding allocated. Only 25 of 4659 ARC new and ongoing projects were classified as rural health research projects. This represents 0.54% of the total number of projects, and 0.27% of the total funding allocated. None of the 832 completed fellowships were classified as rural health. Only five (0.52%) of the 953 new and ongoing fellowships were classified as rural health.
Conclusions:  The level of under-funding for rural health research could be partially addressed by directing applications towards the ARC, in addition to the National Health and Medical Research Council. With a few exceptions, rural health researchers are not yet competitive in the national funding arena.     

Perceptions of occupational therapists practising in rural Australia: A graduate perspective

Background:  The difficulty in recruiting and retaining health professionals into rural and remote areas of Australia is well recognised. This study explored the perceptions of occupational therapists practising in rural locations regarding the essential skills necessary for rural practice and the ability of undergraduate education to prepare them for rural practice.
Methods:  A qualitative study using a phenomenological approach was conducted using semistructured in-depth interviews. Participants included occupational therapists who were graduates of James Cook University, who were practising in rural areas in Queensland and Victoria, and academic staff.
Results:  This study demonstrates that it is important for universities to develop both a mindset in their graduates for rural practice, as well as developing broader skills in addition to core discipline-specific skills. While subjects developing core occupational therapy skills are at the centre of undergraduate education, the importance of developing a broader understanding of rural health issues and skills in public health, primary health care and health promotion was emphasised.
Conclusion:  The development of specific skills to become competent rural practitioners and to cope with the challenges of rural practice can be strengthened through initiatives at the undergraduate level. Ongoing commitment from all universities across Australia to include rural curriculum content has the potential to improve recruitment and retention of occupational therapists and other health professionals into rural Australia.     

Key considerations in delivering appropriate and accessible health care for rural and remote populations: Discussant overview

Objective:  To provide an overview of papers discussing optimal service delivery models for rural and remote Australia.
Design:  A synthesis of overarching considerations guiding rural and remote health service policies.
Setting:  Small rural and remote communities in Australia.
Participants:  Invited delegates attending the Inaugural Rural and Remote Health Scientific Symposium in Brisbane 2008.
Main outcome measures:  Key issues underpinning health service provision for small rural and remote communities.
Results:  The formulation and implementation of effective health service provision policies must be underpinned by overarching health goals, agreed health service requirements, recognition of how rural and remote health contexts impact upon health service provision and the constraints limiting health service responses.
Conclusion:  Systemic change is required in order to ensure equitable access to health care services in small rural and remote communities.     

Asthma management in rural New South Wales: Perceptions of health care professionals and people with asthma

Objective:  To investigate the perceptions and attitudes towards asthma management of general practitioners, pharmacists and people with asthma in a rural area.
Design:  Qualitative semistructured interviews.
Setting:  Small rural centre in New South Wales.
Participants:  General practitioners, pharmacists and people with asthma in a rural area.
Results:  General practitioners perceived that the patient provided a barrier to the implementation of optimal asthma services. They were aware that other health care professionals had a role in asthma management but were not aware of the details, particularly in relation to that of the pharmacist and would like to improve communication methods. Pharmacists also perceived the patient to be a barrier to the delivery of optimal asthma management services and would like to improve communication with the general practitioner. The impact of the rural environment for the health care professionals included workforce shortages, availability of support services and access to continuing education. People with asthma were satisfied with their asthma management and the service provided by the health care professionals and described the involvement of family members and ambulance officers in their overall asthma management. The rural environment was an issue with regards to distance to the hospital during an emergency.
Conclusions:  General practitioners and pharmacists confirmed their existing roles in asthma management while expressing a desire to improve communication between the two professions to help overcome barriers and optimise the asthma service delivered to the patient. The patient described minimal barriers to optimising asthma management, which might suggest that they might not have great expectations of asthma care.     

Stress and help-seeking for drought-stricken citrus growers in the Riverland of South Australia

Objective:  To explore the psychological impact of a problematic industrial climate for citrus growers, their help-seeking behaviour and perspectives on ways to encourage better use of rural mental health services.
Design:  Thematic analysis of in-depth interviews.
Setting:  The Riverland of South Australia.
Participants:  Sixteen citrus growers (12 male, 4 female) from eight Riverland towns.
Main outcome measures:  Citrus growers' perceived factors relating to psychological stress, coping behaviours, impact of stress on well-being, help-seeking behaviours, barriers to help-seeking and ways to encourage better use of rural mental health services.
Results:  Work-related stresses grouped under broad themes, including 'Uncontrollable events', 'Financial hardship' and 'Pressure', had negative effects on participants' well-being. Furthermore, it was found that significant difficulties arise because many of the stresses which growers endure are not controllable, and that the alleviation of strain with the help of mental health professionals is uncommon because of barriers preventing help-seeking. Five broad themes of barriers to help-seeking were extracted from the data: 'Self-reliance', 'Social image', 'Lack of knowledge', 'Negative perceptions of health professionals' efficacy' and 'Restrictive lifestyle factors'. A specialised model of occupational health for citrus growers was proposed.
Conclusions:  These results highlight the practical need to address the identified issues in delivery and promotion of health services when facilitating help-seeking within this group. The findings also add to our knowledge of occupational health psychology broadly.     

Four years after graduation: Occupational therapists' work destinations and perceptions of preparedness for practice

Objective:  The present study sought to identify the work destinations of graduates and ascertain their perceived preparedness for practice from a regional occupational therapy program, which had been specifically developed to support the health requirements of northern Australians by having an emphasis on rural practice.
Design:  Self-report questionnaires and semistructured in-depth telephone interviews.
Participants:  Graduates ( n =  15) from the first cohort of occupational therapists from James Cook University, Queensland.
Main outcome measure:  The study enabled comparisons to be made between rural and urban based occupational therapists, while the semistructured interviews provided a deeper understanding of participants' experiences regarding their preparation for practice.
Results:  Demographic differences were noted between occupational therapists working in rural and urban settings. Rural therapists were predominantly younger and had worked in slightly more positions than their urban counterparts. The study also offered some insights into the value that therapists placed on the subjects taught during their undergraduate occupational therapy training, and had highlighted the differences in perceptions between therapists with rural experience and those with urban experience regarding the subjects that best prepared them for practice. Generally, rural therapists reported that all subjects included in the curriculum had equipped them well for practice.
Conclusions:  Findings suggest the need to undertake further research to determine the actual nature of rural practice, the personal characteristics of rural graduates and the experiences of students while on rural clinical placements.     

Do rural hospitals lag behind urban hospitals in addressing community health needs? An analysis of recent trends in US community hospitals

Objective:  This study examined whether rural and urban hospitals differ in their level of responsiveness to community health needs.
Design:  This study used a multivariate, longitudinal research design.
Research setting:  A cross-sectional survey was the setting for this study.
Participants:  The participants were rural or urban hospitals in the United States.
Main outcome measures:  The dependent variables were selected from the American Hospital Association hospital survey questions that are related to community health needs. The independent variable was rural or urban location.
Results:  Rural hospitals improved more than urban hospitals in addressing community health needs from 1997 through 2006 for most of the indicators, especially in working with other providers to conduct a community health assessment. However, rural hospitals still lag significantly behind urban hospitals in tracking health information.
Conclusions:  This study suggests that rural hospitals do not lag behind urban hospitals in addressing community health needs. Further research is needed to understand the role of community hospitals in influencing local health delivery system activities regarding the potential community benefits and their impact on improving health of local populations.     

Mental health impact for adolescents living with prolonged drought

Background:  A 2004 study showed adolescents living in rural Australia were aware of the impact of drought on self, family and community, but did not report levels of emotional distress higher than adolescents of similar age and gender in the Australian community. It was proposed that the rural lifestyle had helped adolescents build resilience for managing this environmental adversity.
Objective:  To re sample adolescents from the same rural area and determine if this resilience remained after ongoing drought three years later.
Design:  A mixed methods approach using focus groups and a self-report questionnaire.
Setting:  Government Central Schools within the Riverina region of New South Wales.
Participants:  Male and female adolescents ( n =  111) aged 11–17 years completed the self-report questionnaires, while some adolescents ( n =  61) within this group also participated in focus groups.
Main outcome measure:  The Strengths and Difficulties Questionnaire and a Drought and Community Survey for Children comprised the self-report survey.
Results:  Adolescents reported significantly higher levels of emotional distress than those in the previous study ( t (191)  =  2.80, P <  0.01) and 12% of adolescents scored in the clinical caseness range. Thematic analysis showed consistency with the previous study as well as new themes of grief, loss and the impacts of global climate change.
Conclusions:  Results indicate a reporting of lesser well-being than was reported by a comparable group of young people four years earlier. A preventative intervention with a focus on family and community is recommended to address the mental health of adolescents enduring a chronic environmental adversity such as drought.     

Exploratory study examining barriers to participation in colorectal cancer screening

Objective:  To examine the Stage of Change distribution for bowel cancer screening in a regional Australian community and the factors associated with varying positions on the continuum of change.
Design:  Survey of a convenience sample.
Setting:  Community sample.
Participants:  A total of 59 (31 male, mean age  =  59) service club members from a South Australian regional community.
Main outcome measure:  Self-reported Stage of Change for bowel cancer screening behaviour.
Results:  Attributing greater embarrassment and discomfort to bowel cancer screening was associated with earlier positions on the Stages of Change. Perceiving that bowel cancer screening might have positive value for personal health was associated with more advanced positions on the continuum of change. Those who perceived breast and prostate screening procedures to be embarrassing or to cause discomfort were significantly less likely to be participating in bowel cancer screening. No significant relationships were found between bowel cancer screening Stage of Change and worry about vulnerability; personal, family or wider social network case reports of bowel cancer; and the population-level value attributed to the cancer screening procedures.
Conclusion:  Bowel cancer screening participation rates are currently lower than those associated with breast and prostate screening. Reducing perceptions of embarrassment and discomfort, increasing awareness of potential health benefits and maximising participation in other screening procedures might increase participation in bowel cancer screening.     

The Resilience of the Health Care Safety Net, 1996–2001

Objective .  To determine how the capacity and viability of local health care safety nets changed over the last six years and to draw lessons from these changes.
Data Source .  The first three rounds (May 1996 to March 2001) of Community Tracking Study site visits to 12 communities.
Study Design .  Researchers visited the study communities every two years to interview leaders of local health care systems about changes in the organization, delivery, and financing of health care and the impact of these changes on people. For this analysis, we collected data on safety net capacity and viability through interviews with public and not-for-profit hospitals, community health centers, health departments, government officials, consumer advocates, academics, and others. We asked about the effects of market and policy changes on the safety net and how the safety net responded, as well as the impact of these changes on care for the low-income uninsured.
Principal Findings .  The safety net in three-quarters of the communities was stable or improved by the end of the study period, leading to improved access to primary and preventive care for the low-income uninsured. Policy responses to pressures such as the Balanced Budget Act and Medicaid managed care, along with effective safety net strategies and supportive conditions, helped reinforce the safety net. However, the safety net in three sites deteriorated and access to specialty services remained inadequate across the 12 sites.
Conclusions.  Despite pessimistic predictions and some notable exceptions, the health care safety net grew stronger over the past six years. Given considerable community variation, however, this analysis indicates that policymakers can apply a number of lessons from strong and improving safety nets to strengthen those that are weaker, particularly as the current economy poses new challenges.     

Generational attitudes of rural mental health nurses

Objective:  To determine how attitudes of rural mental health nurses differ across generations.
Design:  Survey.
Setting:  Mental health services in rural New South Wales.
Participants:  Practising mental health nurses.
Main outcome measures:  Survey responses.
Results:  Survey response rate 44%. A total of 89 mental health nurses, clustered in inpatient units and community health centres, responded. Of these nurses, 4 were veterans, 52 baby boomers, 17 Generation X and 5 Generation Y.
Conclusions:  There are significant differences in how mental health nurses from different generations view their work, and in what is expected from managers. Managers need to modify traditional working styles, allowing greater flexibility of employment. They must also accept lower staff retention rates, and facilitate the development of younger staff.     

Loss of income and levels of scholarship support for students on rural clinical placements: A survey of medical, nursing and allied health students

Objective:  To quantify the financial impact of rural clinical placements on medical, nursing and allied health students in rural Australia.
Design:  The Careers in Health Tracking Survey provided data on whether students were employed, usual weekly hours of employment and a range of covariates, such as age, sex, course of study, marital status, dependants and rural or urban origin.
Participants:  A total of 121 students from a range of health professions completed the Careers in Health Tracking Survey while on rural placement at the Northern Rivers University Department of Rural Health.
Outcome measures:  Survey data.
Results:  Forty-one per cent of respondents were working immediately before their clinical placements. Nursing students worked the longest hours by far and were significantly more financially disadvantaged than both medical and allied health students ( P <  0.01). Scholarship support was unevenly distributed, with nursing and allied health students being relatively under-supported in relation to lost earnings.
Conclusion:  Recruitment of students can be an effective strategy to address the rural health workforce shortage throughout Australia. However, there are a number of financial disincentives for students to undertake rural clinical placements. Additional support for some disciplines is needed to provide equitable distribution of scholarship support to offset this financial burden. Establishing an employment scheme for students on rural clinical placements and a scholarship for income replacement where employment is not available would also alleviate income loss.     

Retention of general practitioners in rural Nepal: a qualitative study

Objectives:  To explore the key issues that influence GP retention in rural areas of Nepal.
Design:  A qualitative study using triangulation of data from one postal questionnaire, one hand-delivered questionnaire with semistructured interview and focus group discussions. Data from a small community survey from 13 rural districts also included.
Participants:  Sixty-two Nepali GPs, 25 doctors in General Practice training programs, 11 individuals involved in policy development and rural health care.
Results:  The key issues identified by this study as critical to the retention of Nepali GPs in rural areas were:
•  Career/promotion prospects
•  Status/recognition
•  Financial incentives
•  Working conditions
•  Education for children
•  Continuing medical education
•  Political stability and security
Conclusions:  The strongest theme was that of career development. This must be addressed by the Government of Nepal if there is to be any hope of improving retention of GPs in rural areas. GPs need to have a clear career ladder, with recognition of the value of service in rural areas. There is, however, no one single answer to the complex interacting factors that impact on GP retention in rural Nepal. A multifaceted, holistic response is necessary. From the level of community awareness, a career structure and financial remuneration to adequately set up hospitals, functional teams, family support, continuing professional development and a secure working environment – each area must be addressed for the whole to function.     

Book Reviews

Review article: the development of community care in the 1990s , by Rosamund Bryar
Community Care: Policy and Practice , by Robin Means and Randall Smith. Macmillan, London. 1994, £10.99. 277pp. ISBN 0-333-54932-5
Community Care in Transition , by Lesley Hoyes, by Rachel Lart, by Robin Means, by Marilyn Taylor, by John Lansley MA Lecturer in Social Policy, Department of Sociology, Social Policy and Social Work Studies, University of Liverpool
The Development of Community Care by the Independent Sector , by Diana Leat Policy Studies Institute, London. 1993, £7.95,73pp. ISBN 0-85374-577-3
The Myth of Community Care: An Alternative Neighbourhood Model of Care by Steve Baldwin. Chapman and Hall, London. 1993, £9.95, 176pp. ISBN 0-412-47830-7., by Steve Baldwin, by Michael Cahill BA (Hons) Dip Soc Admin D Phil Principal Lecturer in Social Policy, Department of Community Studies, University of Brighton
Sewing the Seams for a Seamless Service: a Review of Development in Interprofessional Education and Training , by Jenny Weinstein Central Council for the Education and Training of Social Workers, London. 1994, £5.00 41 pp. ISBN 1-8571 9-082-3, by Terri Whittaker BA Hons PhD CQSW Lecturer in Community Care, Department of Sociology, Social Policy and Social Work Studies, University of Liverpool
Disability is not Measles: New Research Paradigms in Disability , by Marcia H Roux and Michael Bach. L'lnstitut Roeher Institute, Ontario, Canada. 1994. 287pp. ISBN 1-895070-34-1
The New Social Policy , by Michael Cahill. Blackwell, Oxford. 1994, £10.99,203pp. ISBN 0-631-17862-7. by David Hughes PhD BA MA Senior Lecturer, Department of Nursing, Midwifery and Health Care, University of Wales, Swansea
A Doctor Looks at Health Economics , by Ken Wright M Phil BSc Deputy Director, Centre for Health Economics, University of York, Sir Douglas Black, Office of Health Economics, London, 1994,34 pp. £5.00.     

Riverina men's study: An exploration of rural men's attitudes to health and body image

Aim:  To determine the attitudes of rural men to matters of health and body image.
Methods:  Focus group discussions were used to examine the attitudes of a sample of Australian rural men to matters of health and body image in the context of their eating and exercise behaviours. Forty-two rural men, aged 25–64 years, took part in four focus groups, one exclusively for farmers, in south-western New South Wales (NSW).
Results:  Results from these focus groups reveal that many of the masculine myths surrounding male behaviour in relation to health and ideas on body image persist among rural men in south-western NSW. Talking about health is not considered a male past-time; visiting health professionals is still seen as a last resort; being a 'big bloke' is perceived to be advantageous and heavy drinking is still considered an Australian male domain, especially among the younger men in the groups.
Conclusion:  The present study provides a deeper understanding of rural men's attitudes to body image issues and lifestyle behaviours, which is critical to helping change health outcomes for this hard-to-reach group.