From 'problem-describing' to 'problem-solving': challenging the 'deficit' view of remote and rural health

Objective: Rural and remote health research has highlighted the many problems experienced in the bush. While attention to problems has raised awareness of the needs of rural and remote health, embedding a deficit perspective in research has stereotyped rural and remote health as poor environments to work in and as inherently problematic. The objectives of this paper are to challenge this thinking and suggest that a more balanced approach, acknowledging strengths, is beneficial. Design: This discussion identifies why the deficit approach is problematic, proposes a strengths‐based approach and identifies some key strengths of rural and remote health. Results: This study suggests alternative ways of thinking about rural and remote practice, including the rewards of rural and remote practice, that rural and remote communities can act as change agents, that these disciplines actively address the social determinants of health, that rural and remote areas have many innovative primary health care services and activities and that rural and remote contexts provide opportunities for evaluation and research. It is proposed that rural and remote health can be viewed as problem‐solving, thus dynamic and improving rather than as inherently problematic. Conclusion: Critical of a deficit approach to rural and remote health, this paper provides alternatives ways of thinking about these disciplines and recommends a problem‐solving perspective of rural and remote health.     

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.     

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.     

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.     

Evaluating the impact of sustainable comprehensive primary health care on rural health

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia. Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria. Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria. Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.     

Using cohort studies to investigate rural and remote mental health

This paper, presented at the 2010 rural health researchers' National Scientific Symposium on Rural and Remote Health, provides an overview of large Australian population mental health cohort studies which have a focus on climate-related and environmental adversity, social factors and mental health. These studies highlight the value of exploiting multiple exceptional datasets to better understand the drivers of rural health, including how to use population-level research to improve health resources in non-metropolitan areas. We show how the key characteristics of rural and remote mental health might be explored by exploiting the following cohort studies: Household, Income and Labour Dynamics in Australia Survey; Australian Rural Mental Health Study; Hunter Community Study; and Extending Treatments, Education and Networks in Depression study. Existing cohort studies that focus on significant rural and regional characteristics can be creatively analysed to better understand geographic variation in mental health. They have the potential to move understanding beyond simple prevalence to building knowledge about the trajectories of psychological distress and determinants of mental disorders and outcomes over time.     

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.     

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.      

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.     

偏远及农村地区卫生人力留用计划成本分析技术框架

背景：通过加强卫生人力留用以提高偏远和农村地区卫生人力的可及性,对于人口健康至关重要。然而,此类干预措施有关成本方面的信息往往零散、不全面、甚至缺失。政策措施的成本分析对于政策的选择、规划、实施和评估至关重要,但是由于缺少成本分析的系统方法,为卫生政策制定和决策带来了严峻的挑战。方法：本文提出了提高偏远及农村地区卫生人力可及性政策干预措施的成本分析实施框架,旨在为卫生政策决策者提供帮助。同时,该框架也强调了确定财政的主要来源和财政资金可持续性的重要性。文章对加强边远农村地区卫生人力留用相关政策措施的成本分析进行了文献综述,为此类干预措施的成本分析提供了指导框架,并进一步调查分析了成本分析在整个卫生人力规划与管理中的角色与重要意义。结果：尽管对于人力留用相关政策措施效益的争论得到越来越多的关注,但如何对此类政策措施进行成本分析,目前仍缺乏相关的知识与证据。为了解决这个问题,文章提出了实施成本分析框架的关键要素,并对此进行讨论分析。结论：这些关键要素能够帮助决策者对政策措施有更加深入的了解,明晰与理解财政来源和运行机制,同时确保财政资金的可持续性。     

Innovative rural and remote primary health care models: What do we know and what are the research priorities?

This paper examines the literature pertaining to 'innovative' primary health care models in rural and remote areas in order to identify areas where knowledge is lacking and describes future research priorities. Although a number of reviews have identified successful primary health care models and synthesised principles that help to understand why they are successful, there is generally a dearth of rigorously collected information regarding rural and remote health service delivery. The evidence base that supports the superiority of any one model or models in a given context is thin because of the lack of systematic, policy-informing evaluation of primary care innovations. The paper identifies the need for more rigorous health services evaluation information, including examination of optimal financing systems, the optimal range and mix of providers, and supports for team practice, appropriate community participation mechanisms, improved health information systems and relevant performance indicators.     

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.     

Improving mental health capacity in rural communities: mental health first aid delivery in drought-affected rural New South Wales

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought‐affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems. Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front‐line workers from agricultural‐related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families. Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence‐based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help. Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.     

Health inequalities,fundamental causes and power: towards the practice of good theory

Reducing health inequalities remains a challenge for policy makers across the world. Beginning from Lewin’s famous dictum that “there is nothing as practical as a good theory”, this paper begins from an appreciative discussion of ‘fundamental cause theory’, emphasizing the elegance of its theoretical encapsulation of the challenge, the relevance of its critical focus for action, and its potential to support the practical mobilisation of knowledge in generating change. Moreover, it is argued that recent developments in the theory, provide an opportunity for further theoretical development focused more clearly on the concept of power (Dickie et al. 2015). A critical focus on power as the essential element in maintaining, increasing or reducing social and economic inequalities – including health inequalities – can both enhance the coherence of the theory, and also enhance the capacity to challenge the roots of health inequalities at different levels and scales. This paper provides an initial contribution by proposing a framework to help to identify the most important sources, forms and positions of power, as well as the social spaces in which they operate. Subsequent work could usefully test, elaborate and adapt this framework, or indeed ultimately replace it with something better, to help focus actions to reduce inequalities.     

Rural maternity care and health policy: parents' experiences

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty‐three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re‐evaluated in order to improve rural Australians' access to vital health services such as maternity care.     

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.     

Understanding rural and remote health: a framework for analysis in Australia

People living in rural and remote areas face challenges in accessing appropriate health services, many of which struggle to recruit and retain staff. While researchers have documented these issues in Australia and internationally, rural health remains reactive to current problems and lacks comprehensive understanding. This paper presents a conceptual framework that can be used to better understand specific rural and remote health situations. The framework consists of six key concepts: geographic isolation, the rural locale, local health responses, broader health systems, social structures and power. Viewed through Giddens' theory of structuration, the framework suggests that rural health is understood as spatial and social relations among local residents as well as the actions of local health professionals/consumers that are both enabled and constrained by broader health systems and social structures. The framework provides a range of stakeholders with a guide to understanding rural and remote health.     

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.     

Successes in sexual health communications development,programmatic implementation and evaluation in the Torres Strait region 2006 to 2012

Objective: To evaluate the Indigenous sexual health promotion program in the Torres Strait 2006–2012 that culminated in an education‐entertainment radio drama, Kasa Por Yarn (KPY). Methods: A mixed methods approach applied to unpublished program documents and program‐derived peer‐reviewed publications was utilised. Results: Early initiatives established a strong partnership with Torres Strait Islander stakeholders. Significant community engagement throughout ensured a positive process. Telephone survey data (n=100, TSI, 15–24 years) found: 95% had heard of KPY and 80% listened to 2 or more episodes (reach); 86% recalled storylines/characters (recall); and 54% talked about KPY to family/friends (resonance). There was improvement in sexual health knowledge scores (p<0.00) in the 15–19‐year‐old Torres Strait Islander population between 2007 and 2012. The 2012 15–24‐year‐old population exposed to KPY had higher sexual health knowledge scores compared with those unexposed (p=0.02). Conclusions: This is an uncommon comprehensive evaluation of population‐based sexual health communications strategies delivered over years in a remote Australian setting. The findings are encouraging but demonstrate that positive shifts take time and are incremental. Implications: In addition to clinical strategies, strategic and sustained investment in sexual health promotion expertise that leads community partnership and program development is required to reduce youth risk and prevent HIV/AIDS in remote populations.