Evidence‐Based Practice in Rural and Remote Clinical Practice: Where is the Evidence?

Objective: To critically review the evidence regarding barriers to implementing research findings in rural and remote settings, and the ways those barriers have been addressed. Design: A systematic review that included searching several electronic databases, Internet sites and reference lists of relevant articles, assessment of methodological quality of the studies, and data extraction and analysis where possible. Eligibility for the review was not limited by study design. Settings/Participants: Studies that reported on: (1) barriers to the implementation of evidence by health professionals in rural and remote areas, or (2) interventions for implementing evidence‐based practice or an element of evidence‐based practice in rural and remote areas. Results: There were no experimental data available on the implementation of research findings in rural and remote clinical settings. The small amounts of empirical research undertaken (surveys) showed that some of the problems experienced by general practitioners were exacerbated by rural and remote location, particularly with relation to isolation, lack of time and locum cover, and poor information technology infrastructure. Conclusion: There is a paucity of empirical literature on implementing evidence‐based practice in rural and remote settings. This is in contrast to the large amount of literature available on implementing evidence in other clinical settings. A clear finding from the literature was that getting evidence into practice needs to be context‐specific and yet very little research has been conducted into the rural and remote context. Research is needed into how evidence can be implemented in contextually specific ways in rural and remote areas. What is already known: There is a substantial body of literature about the barriers to implementing research findings into clinical practice and how to address these barriers. This literature includes many systematic reviews and even overviews of systematic reviews. One of the consistent findings of the literature is that the implementation of research findings needs to be context‐specific to have any chance of making lasting and worthwhile changes to practice. There is little work, however, on the context of rural and remote clinical practice. What this study adds: This study aimed to review the literature on the implementation of evidence based practice in rural and remote settings. No experimental studies were found and the limited empirical evidence from surveys found that the rural and remote context exacerbated some of the problems experienced by health professionals in other settings, particularly those related to lack of time, inability to get locum cover and poor and unreliable information technology infrastructure. More research is required to isolate the aspects of rural and remote practice that influence the uptake of research findings.     

Employee psychological distress and treated prevalence by indices of rurality

Objective: Although there is population data on the prevalence and treated prevalence of mental disorders by urban‐rural indices, there is a lacuna of information pertaining to employees. This paper examines the prevalence and treated prevalence of psychological distress in employees by urban‐rural indicators. Methods: Cross‐sectional employee Health and Performance at Work Questionnaire responses (n=78,726 from 58 large companies) are interrogated by indices of remoteness (Accessibility/Remoteness Index of Australia), psychological distress (Kessler 6) and treatment‐seeking behaviours for mental health problems. Results: The overall prevalence of moderate or high psychological distress in employees was 35.2%. The prevalence varied only slightly (maximum to minimum difference of 4.6%) by rural/remote indices. Overall treatment‐seeking behaviour for psychological distress was low (22.5%). The percentage of employees seeking treatment for high levels of psychological distress was the lowest in very remote regions (15.1%). Conclusion: Very remote employees are less likely to access mental health treatments and may be an employee subgroup that would benefit from specific employer health interventions aimed to increase treatment‐seeking behaviours. Implications: Employees in very remote Australia could benefit from specific interventions aimed to increase mental health awareness/literacy.     

Royal Flying Doctor Service 'field days': a move towards more comprehensive primary health care

Objective: To examine the Royal Flying Doctor Service (RFDS) field day program as a means of strengthening community capacity within a primary health care context in remote communities of north Queensland. Design: Qualitative explanatory study using in‐depth face‐to‐face and phone interviews with field day participants, field day coordinators and RFDS staff and a focus group with RFDS staff. Setting: Rural and remote communities of north Queensland that participate in RFDS field days. Results: Field days were found to be contributing to building capacity for health in the remote communities that have been involved in field days. Participants reported increased linkages and partnerships; increased participation; improved problem‐solving capacity and increased knowledge transfer associated with the conduct of RFDS field days. Conclusion: RFDS field days represent a viable framework for building community capacity for health in remote communities within a primary health care context.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

Charting the future course of rural health and remote health in Australia: Why we need theory

Objective: This paper argues that rural and remote health is in need of theoretical development. Design: Based on the authors’ discussions, reflections and critical analyses of literature, this paper proposes key reasons why rural and remote health warrants the development of theoretical frameworks. Results: The paper cites five reasons why theory is needed: (i) theory provides an approach for how a topic is studied; (ii) theory articulates key assumptions in knowledge development; (iii) theory systematises knowledge, enabling it to be transferable; (iv) theory provides predictability; and (v) theory enables comprehensive understanding. Conclusion: This paper concludes with a call for theoretical development in both rural and remote health to expand its knowledge and be more relevant to improving health care for rural Australians.     

Towards a health career for rural and remote students: cultural and structural barriers influencing choices

Objective: To promote tertiary health careers to rural and remote young people. Design: Qualitative research using large and small group discussions and semistructured interviews. Setting: Fifteen secondary schools in rural and remote Western Australia including five senior secondary schools and 10 district high schools. Subjects: One hundred and twenty students from eight year 10 groups, 35 students from three year 11 groups, 54 students from five year 12 groups, 52 parents, 10 grandparents, 76 teachers and four Aboriginal and Islander Education Officers (AIEO). Results: Students prefer information about the range of health careers to be delivered interactively. Choices to follow a health career at tertiary level were constrained by structural and cultural issues including geographical isolation, financial cost, stereotyping of health professions, insufficient information about the diversity of health careers, obligation to family, community and place and a devalued rural culture. Conclusions: The under representation of rural and remote students in health related university courses needs to be addressed by long‐term strategies taking into account both structural and cultural barriers when making career choices. Health policies should include the provision of financial support for rural and remote students and promote a broad range of health careers as challenging and rewarding life choices that offer much needed services to rural communities. What this paper adds: In 1997, only 19.2% of Australian university students came from rural and remote areas, a figure dramatically below the equity reference point of 28.8% of the population living in rural areas derived from the 1996 census data. 1 In 2001, the figure remained steady with 19.1% of rural students attending university. 2 These data highlight the need for developing higher education opportunities for all Australians regardless of where they live. However, despite ongoing concern about attracting rural and remote students to health careers, limited success has been achieved to date. Barriers to students choosing health careers at tertiary level include lack of information about the range of health careers available, the cost of tertiary education for families, social dislocation and a perceived lack of support structure for students at university. These are underpinned by cultural assumptions about gender, occupational roles in rural communities and professed lack of academic ability. Strategies to overcome barriers must be situated within a broad socio‐cultural context to understand the complexity of issues underpinning students’ choices.      

Children's participation in health research: from objects to agents?

Background In the UK, there is a growing recognition of the need to include children's accounts in research on paediatric health care. This paper seeks to examine ways in which children have been included in health‐related studies to identify strengths and weaknesses. Methods Key empirical based studies were identified via comprehensive searches of academic literature databases to exemplify research practices related to three ways of engaging with children in health‐related research. These three approaches are summarized as research on children, with children and by children. Results Research on children engages with adult ‘authorities’, such as parents and medical professionals. This approach allows some access to children including those understood as hard‐to‐reach: for example, pre‐speech infants, or children with complex developmental disabilities. Research with children includes children as respondents to engage directly with their own understandings. This may be achieved alongside adult representatives, or by focusing only on the children themselves. Research by children encourages children to participate in the research process itself. This may occur across any, or indeed, every stage from design to dissemination to enable children to set the agenda themselves. Each of the three approaches has strengths and weaknesses, and involves some form of adult‐mediation. Conclusion Inclusion of children's perspectives can be achieved, at varying levels, in each approach (on, with and by) examined here. Although claims to authority around including children's perspectives may appear to hold more credence when children have directly participated in the research, there may be times when this is neither possible nor appropriate. Researchers are challenged to be open and reflexive about ways in which children are engaged with, incorporated in and represented across the many stages of research. Whichever approach is taken, ethical issues and notions of equity remain problematic. This point holds particular resonance for ways in which ethics around children may be considered in National Health Service ethics governance processes.     

Expanding the role of paramedics in northern Queensland: An evaluation of population health training

Objective: To describe the experience of the paramedics doing the population health component of the Graduate Certificate in Rural and Remote Paramedic Practice. Design: Analysis of paramedics' reported opinions about the course and its impact. Setting: Primary care. Participants: Data were obtained from de‐identified surveys submitted by the paramedics at the beginning and the end of the population health component of the course. Results: All paramedics felt that after the course they were more committed to undertaking population health activities in their work and were better prepared to do so. As a result of undertaking the course, 73% of students have already changed their practice. Seventy‐five per cent agreed that doing the course would increase the likelihood of staying in rural and remote areas and all agreed that doing the course resulted in increased job satisfaction. The majority (87%) of the students rated the course as excellent or very good and all of them said that they would recommend the course to others. Conclusions: These results suggest that rural and remote paramedics have the opportunity and desire to incorporate more health promotion and prevention into their practice and that this course has provided them with the skills and knowledge to do so. The curriculum is based on National Health Priority Areas focusing in particular on lifestyle change to prevent and manage chronic disease. This means that in rural and remote areas, all health professionals can use a common framework to work together to enhance primary health care and chronic disease management as a multidisciplinary team.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

Is a global rural and remote health research agenda desirable or is context supreme?

Objective: This paper proposes that there is value in international comparison of rural and remote health‐care service delivery models because of practical reasons – to find ideas, models and lessons to address ‘local’ delivery challenges; and for theoretical reasons – to derive a conceptual framework for international comparison. Methods: Literature review and commentary. Findings: There are significant challenges to international comparative research that have been highlighted generically; for example, equivalence of terminology, datasets and indicators. Context supremacy has been raised as a reason why models and research findings might not be transferable. This paper proposes that there is insufficient knowledge about how rural contexts in relation to health service delivery are similar or different internationally. Investigating contexts in different countries and identifying the dimensions on which service delivery might differ is an important stimulus for study. The paper suggests, for discussion, dimensions on which rural service delivery might differ between countries and regions, including physical geographical factors, social interaction with rurality, policies of service provision and the politics and operation of health care. Conclusions: The paper asks whether, given the need to develop models suitable for rural areas and for theory on rural health to extend, international comparative research is an imperative or an indulgence.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

An exploration into the wellbeing of the families living in the ‘suburbs in the bush’*

Objective: To examine the wellbeing of families of male mine‐workers living in remote mining towns in Australia. Methods: Through an extensive review of available (but limited) social science literature on mining towns this paper explores and identifies the key social issues and problems of mining towns. Social science and health‐related research are used to argue that there are several factors that may negatively affect the relationship and psychological wellbeing of family members. Results: Atypical work schedules of the mining jobs could negatively affect the long‐term health of the workers, and could constrain their qualitative participation in domestic roles. Limited availability of resources, services and flexi‐time jobs in mining towns marginalise female partners to domestic chores. Higher level of alcohol consumption by workers and their preferred spending of leisure time with workmates symbolise patriarchal culture in mining towns that further marginalises women and could strain marital relationships. These factors could affect the social and emotional health of the children. Conclusion: Interdisciplinary studies are needed to gain realistic understanding of the dynamics of long‐term impacts of long work hours/compressed work weeks, socio‐cultural, motivational and environmental factors on the wellbeing of the workers and their families living in mining towns. Family counsellors and mental health professionals working in remote mining towns must take into consideration the likely negative impacts of work and community on individuals and families.     

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

Objective

To determine the percentage of research projects funded by the National Health and Medical Research Council in the period 2000–2014 that aimed specifically to deliver health benefits to Australians living in rural and remote areas and to estimate the proportion of total funding this represented in 2005–2014.

Design

This is a retrospective analysis of publicly available datasets.

Setting

National Health and Medical Research Council Rural and Remote Health Research 2000–2014.

Outcome measures

‘Australian Rural Health Research’ was defined as: research that focussed on rural or remote Australia; that related to the National Health and Medical Research Council's research categories other than Basic Science; and aimed specifically to improve the health of Australians living in rural and remote areas. Grants meeting the inclusion criteria were grouped according to the National Health and Medical Research Council's categories and potential benefit. Funding totals were aggregated and compared to the total funding and Indigenous funding for the period 2005–2014.

Results

Of the 16 651 National Health and Medical Research Council‐funded projects, 185 (1.1%) that commenced funding during the period 2000–2014 were defined as ‘Australian Rural Health Research’. The funding for Australian Rural Health Research increased from 1.0% of the total in 2005 to 2.4% in 2014. A summary of the funding according to the National Health and Medical Research Council's research categories and potential benefit is presented.

Conclusion

Addressing the health inequality experienced by rural and remote Australians is a stated aim of the Australian Government. While National Health and Medical Research Council funding for rural health research has increased over the past decade, at 2.4% by value, it appears very low given the extent of the health status and health service deficits faced by the 30% who live in rural Australia.     

Role of multi-purpose service programs providing residential aged care in rural Australia: a discussion paper

Objective: To determine if multi‐purpose service (MPS) Programs deliver improved residential aged care as opposed to traditional rural hospitals. Design: A variation on comparative–experimentalist: type 4. In this design 2 groups providing different service models of rural health services are compared. Setting: Six MPS Programs and three traditional hospitals in rural New South Wales. Subjects: Key stakeholders – area representatives, health service managers, MPS managers, doctors, staff, MPS or hospital committee members and consumer groups including residents. Main outcome measure: To analyse the ability of MPS Programs to deliver quality residential aged care as opposed to using traditional hospitals for such services. Results: Multi‐purpose service programs provided better residential environments and greater flexibility of service provision. There were few apparent differences between the two service models in regard to organisational culture and training. Conclusions: The findings of this evaluation suggest that in the provision of residential aged care in rural communities, MPS Programs demonstrated better standards of care than traditional hospital based services. What is already known on the subject: The development of multi‐purpose service programs to replace the older traditional rural hospitals is a relatively new practice in Australia. With the introduction of MPS programs there has been little evaluative research to demonstrate their effectiveness in health service delivery and the provision of residential aged care. Multi‐purpose service programs aim to integrate and coordinate acute, aged and community rural health services under one structure and so it is imperative that evaluative studies such as this one takes place. What does this study add?: The findings of this study demonstrate that the MPS model provides a better solution than hospitals to the problem of providing residential aged care in rural communities. With Australia looking to further develop MPS Programs in rural areas, it is hoped quality aged care services will be enhanced allowing older adults to remain in the communities of their choice.     

Mental health of farmers in Southern Queensland: Issues and support

Objective: To inform the development of an initiative designed to support the mental well‐being of farmers in Queensland. Design: Interactive focus groups. Setting: Rural and remote Queensland. Participants: Health professionals, farmers and representatives of organisations and agencies working with farmers. Main outcome measures: Determination of factors contributing to the declining mental health of rural landholders. Content material for inclusion into mental health first aid programs held for field officers. Results: Key areas identified to contribute to the decline in mental health of farmers were: increasing isolation in its varying forms, the ongoing drought, increased government regulations and widening of the schism between urban and rural Australians. The issues that affect farmers are recognised to have a ‘knock‐on’ effect on the people who interact with them. In particular, rural support organisations are concerned for the well‐being of their staff, prompting some to begin to put protocols in place to address their staff need for mental health support. Additional mental health training of field officers that involves awareness, recognition, communication skills, understanding and empathy was recognised by participants to be beneficial. Conclusion: Training of field officers was considered to be of benefit to the support of farmers. An understanding of the various and diverse issues that rural landholders face should be a fundamental component of that training.     

Psychological distress of rural parents: Family influence and the role of isolation

Objective: Research regarding psychological distress has often underestimated the importance of contextual social factors. This research aims to investigate patterns of psychological distress within the family system (parent dyads) across rural and remote communities and the influence of remoteness on such distress. Design: Self‐report survey data from the Australian Rural Mental Health Study was used to examine the distress levels of cohabitating parental figures in rural and remote Australia. Setting: The survey was conducted across rural and remote communities within New South Wales. Participants: The sample consisted of 129 adult couples (mean age = 42.66 years, SD = 8.11), 43 from Inner Regional areas, 48 from Outer Regional areas, 24 from Remote areas and 14 from Very Remote areas. Main outcome measure: Distress levels (Kessler‐10). Results: A significant association was detected between the levels of psychological distress among parents within a household. The strength of this relationship increased with increasing remoteness of residence. Conclusions: Identifying the influence of spousal factors on mental health in rural and remote areas allows health services in such regions to be aware of the needs of rural couples and families. These results support the need to consider partner/spouse mental health in clinical assessment and support the importance of household factors especially in remote communities.     

Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence‐based policy

Background: Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care. Objective: This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia. Design: A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria. Results: While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required. Conclusions: This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre‐ and post‐intervention comparisons.     

Short‐stay rural and remote placements in dental education,an effective model for rural exposure: A review of eight‐year experience in Western Australia

Objectives: The increase in demand for dental care over the next 10 years is expected to outstrip the supply of dental visits in Australia, resulting in an ongoing shortage of dental practitioners. As trends in medicine have shown, the greatest effect will be felt in rural and remote regions, where an undersupply of dentists already exists. It is clearly evident that it is important to provide strategies that will increase the recruitment and retention of practitioners in rural and remote areas. Previous research suggested an increased likelihood for health graduates to choose rural practice if they have a rural background, or were exposed to rural practice during their education. Short‐stay (three to four weeks) placements for final‐year dental students has been part of dental education in Western Australia for near on a decade. Methods: This paper reflects on the experiences gained from managing this placement program. Conclusions: Short‐stay placements are a quality learning initiative but need a high level of planning and a clear vision to be effective. Implications: The key factors in ensuring sustainable, student centred learning is driven through a small core group of staff who have strong direct links with rural and remote communities, students and support providers. The integration of service, education and research goals have played a critical role in sustaining placements. The philosophy underpinning the rural placements needs to be clearly articulated and applied effectively in each step of their implementation and a highly focused customer‐service driven implementation is required to make short‐stay rural and remote placements effective.