Rural GPs Research Articles

Development of a rural strategy for an urban-based medical program: a pragmatic reality.

Health disparities between rural and urban areas in Aotearoa New Zealand are exacerbated by rural workforce issues. Traditionally, undergraduate medical programs are urban-based, and reconfiguring the curriculum to meet the needs of rural communities is challenging. The aim of this project is explore how urban-located universities might develop and implement a rural strategy. Evaluation of a rural strategy may lead to the strategy's ongoing improvements designed to increase the rural workforce. This is a qualitative study involving semi-structured interviews with purposively selected key stakeholders. Enquiry included the systematic identification of processes required to develop a rural strategy, including possible facilitators and challenges to be addressed. Qualitative analysis of de-identified data was conducted using a thematic approach. Fourteen stakeholders were interviewed: four rural GPs, two rural hospital doctors, four administrators involved in placing students, and four senior medical academics with involvement in the regional and rural programs. Five overarching themes were identified: (1) developing rural pathways into medical school, (2) improving and expanding rural exposures, (3) developing rural GP pathways, (4) implementing interprofessional education and (5) having a social mission. These findings align with the literature relating to developing rural strategies for universities. However, this study also suggested that rural health interprofessional programs may have a role. A key finding was that the social mission of a university may not be visible to rural stakeholders. Reorientating an urban-located university to having a rural strategy requires moving past having policy around social accountability to operationalising it.

Aeromedical retrievals as a measure of potentially preventable hospitalisations and cost comparison with provision of GP-led primary health care in a remote Aboriginal community.

Kowanyama is a very remote Aboriginal community on the Cape York Peninsula of Far North Queensland, Australia. It is among the five most disadvantaged communities in Australia, with a very high burden of disease. It has access to 2.5 days each week of fly-in, fly-out, GP-led primary health care for a population of 1200. All patients requiring higher level care undergo aeromedical retrieval to a bigger centre. A retrospective clinical audit of charts was undertaken assessing aeromedical retrievals from Kowanyama for the year 2019 to assess whether GP access might correlate with retrievals or hospital admissions for potentially preventable conditions and whether it could be cost-effective and improve outcomes to provide the benchmarked staffing of GPs. Using a tool made by the authors for this audit, the management and reason for evacuation were assessed against Queensland Health's Primary Clinical Care Manual guidelines, whether the presence of a rural generalist GP would have prevented the need for retrieval, and assessed against accepted Australian (and Canadian) criteria for potentially preventable hospital admissions. Each retrieval was then assessed as 'preventable' or 'not preventable'. The cost of providing benchmark levels of GPs in community was compared with the cost of potentially preventable retrievals. In 2019, there were 89 retrievals of 73 patients. Thirty-nine percent (35) of all retrievals occurred when a doctor was on site. Of preventable retrievals, 33% (18) occurred with a doctor on site and 67% (36) occurred with no doctor on site. All retrievals with a doctor on site resulted in an admission. All immediate discharges (10% (9)) or deaths (1% (1)) were for retrievals without a doctor on site. Sixty-one percent (54) of all retrievals were potentially preventable, with the two most common conditions being pneumonia - non vaccine preventable (18% (9)) and bacterial/unspecified (14% (7)). Thirty-two percent (20) of patients accounted for 52% (46) of retrievals and of these 63% (29) were potentially preventable (compared to 61% overall). For preventable condition retrievals, the mean number of visits to the clinic compared to non-preventable condition retrievals was higher for registered nurse or Aboriginal Health Worker visits (1.24 v 0.93) and lower for doctor visits (0.22 v 0.37). The conservatively calculated costs of retrievals matched the maximum cost of providing benchmark numbers (2.6 full-time equivalents) of rural generalist doctors in a rotating model for the audited community. Greater access to GP-led primary health care may lead to fewer retrievals/hospital admissions for potentially preventable conditions. It is likely that some preventable condition retrievals might be avoided if full coverage with benchmarked numbers of rural generalist GPs in a GP-led primary health team was provided in remote communities. This may be cost-effective and improve patient outcomes, and should be further explored.

Physicians' experiences working in emergency medicine in a rural area in Northern Sweden: a qualitative study.

Working in emergency medicine in rural areas may entail challenges due to absence of medical backup, difficulties in logistics, lack of healthcare system coordination, and, potentially, feelings of loneliness. The aim of this study was to elucidate the experiences of physicians working in an emergency medical setting in a rural area in Northern Sweden. A qualitative study was performed based on semi-structured interviews. Six physicians were interviewed. The interviews were transcribed and analysed using the systematic text condensation method. Rural physicians described thriving in the rural environment. Four main themes were identified as important to their wellbeing and job satisfaction. They described close relations to the nearest referral centre, where they felt connected to the personnel in the centre. The participants described this as a crucial factor aiding their everyday work in emergency medicine. The rural physicians underlined educational and professional development individually, in teams training sessions, and through the locally created rural residency program for rural GPs as important. They expressed an adaptability to the rural environment and described having a problem-solving attitude. Additionally they found a functional transport system crucial as part of their workflow. Overall, the rural physicians thrived in the rural environment where interpersonal relations and creative initiatives along with a customised rural residency program prepared the physicians to work in rural areas. Despite the long distances between hospitals and health clinics, the physicians rarely felt alone in the field and the general well-functioning transport system with possibility for improvisations aided them in medical emergencies.

Nurse practitioner led model of after-hours emergency care in an Australian rural urgent care Centre: health service stakeholder perceptions

BackgroundThe challenges of providing and accessing quality health care in rural regions have long been identified. Innovative solutions are not only required but are also vital if effective, timely and equitable access to sustainable health care in rural communities is to be realised. Despite trial implementation of some alternative models of health care delivery, not all have been evaluated and their impacts are not well understood. The aim of this study was to explore the views of staff and stakeholders of a rural health service in relation to the implementation of an after-hours nurse practitioner model of health care delivery in its Urgent Care Centre.MethodsThis qualitative study included semi-structured individual and group interviews with professional stakeholders of a rural health service in Victoria, Australia and included hospital managers and hospital staff who worked directly or indirectly with the after-hours NPs in addition to local GPs, GP practice nurses, and paramedics. Thematic analysis was used to generate key themes from the data.ResultsFour themes emerged from the data analysis: transition to change; acceptance of the after-hours nurse practitioner role; workforce sustainability; and rural context.ConclusionsThis study suggests that the nurse practitioner-led model is valued by rural health practitioners and could reduce the burden of excessive after-hour on-call duties for rural GPs while improving access to quality health care for community members. As pressure on rural urgent care centres further intensifies with the presence of the COVID-19 pandemic, serious consideration of the nurse practitioner-led model is recommended as a desirable and effective alternative.

Urban or Rural GP? In the Czech Republic It Is not just Distances That Matter

This article proposes a combined mixed methods approach to categorising GP practices. It looks not only at location but also at differences in the nature of the work that rural GPs perform. A data analysis was conducted of the largest health insurance company in the Czech Republic (5.9 million patients, 60% of the population, 100% coverage within the Czech Republic). We performed two data analyses, one for 2014-2015 and one for 2016, and divided GP practices into urban, intermediate, and rural groups (taking into account the OECD methodology). We compared groups in terms of the total annual cost in CZK per adult registered insurance holders. The total volume of data indicated the financial costs of €1.52 billion and €2.57 billion respectively. Both analysis showed differences between all groups of practises which confirmed the assumption that the work of the GP is influenced by regionality. A multidisciplinary hospital is the main factor that fundamentally affects the way a GP's work in that area. The proposed principle of categorising general practices combines geographical and cost characteristics. This requires knowledge of the cost data of healthcare payer and on the basic demographic knowledge of the area. We suggest this principe may be transferrable and particularly suitable for categorising general practice.

Incorporation of human papillomavirus self-sampling into the revised National Cervical Screening Program: a qualitative study of GP experiences and attitudes in rural New South Wales.

Human papillomavirus self-sampling is part of the revised Australian National Cervical Screening Program for eligible under- or never-screened women. Although research demonstrates self-sampling as an acceptable method from the perspective of women, little is known about GP experiences and perspectives of this new screening alternative. This study sought to explore the experiences and perspectives of rural GPs towards the revised National Cervical Screening Program and the new self-sampling option. Semistructured qualitative interviews were completed with 12 GPs in central west New South Wales. The study found that GPs had limited experience facilitating self-sampling. The limited provision of education, difficulty accessing testing kits, poor availability of accredited laboratories and unclear rebate guidelines hindered their capacity to offer self-sampling. GPs reported uncertainty around patient eligibility and the quality of self-collected samples. GPs explained that self-sampling could increase cervical screening participation among some women, but because it is only available to complete in a general practice, it would not benefit those who are disengaged from health services. Despite GPs' limited experience with facilitating self-sampling to date, they were optimistic about potential increases in cervical screening rates. Clearer articulation of specific program details and the evidence underpinning the program changes would reduce clinician uncertainty regarding the practicalities of how to incorporate patient-collected sampling into their daily practice, as well as the quality of patient-collected samples compared with clinician-collected samples. GPs must also be supported at a systems level to ensure there are processes in place to enable easy access to kits, laboratories, Medicare rebates and relevant support.

Impact of geography on Scottish cancer diagnoses in primary care: Results from a national cancer diagnosis audit

BackgroundA recent meta-analysis of global research found cancer patients living in rural locations are 5% less likely to survive than their urban counterparts, a survival disadvantage that has never been satisfactorily explained. Aims[1] To describe and compare primary-care involvement in the diagnosis of cancer between rural and urban patients in Scotland. [2] To compare the length of key diagnostic pathway intervals between rural and urban cancer patients in Scotland. MethodsParticipating GPs in the Scottish National Cancer Audit of cancer diagnosis (2017) collected data from primary-care medical records on the diagnostic pathway of patients diagnosed in 2014. Residential postcodes designated the patients as rural or urban dwellers. Key cancer diagnostic pathway intervals (primary, diagnostic, secondary, and treatment) were compared using binary logistic regression. Descriptive analysis included comparison of patient characteristics, and routes to diagnosis. Results73 Scottish general practices provided data on 1,905 cancer diagnoses. Rural patients did not have higher odds of prolonged diagnostic intervals compared to urban patients but were significantly more likely to have had a cancer alarm feature at presentation and three or more primary-care consultations prior to referral. Rural GPs were significantly more likely to perceive an avoidable delay in their patient’s diagnostic pathway. ConclusionThere was no evidence that rural patients were more likely to be subject to prolonged cancer diagnostic delays than urban patients. Rural patients may experience primary care differently in the lead-up to a cancer diagnosis. The effect on outcome is probably negligible, but further research is required to confirm this.

Regional differences in reasons for consultation and general practitioners\u2019 spectrum of services in northern Germany \u2013 results of a cross-sectional observational study

BackgroundAmong other factors, the patients’ consultation reasons and GPs’ spectrum of services determine the process and outcome of the medical treatment. So far, however, there has been little information on differences in reasons for consultation and GPs’ services between urban and rural areas. Our study’s goal was thus to investigate these factors in relation to the regional location of GPs’ practices.MethodsWe conducted a cross-sectional observational study based on standardised GP interviews in a quota sampling design. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban area, environs, rural area) and stratified proportionally to the population size. Differences in the number of reasons for consultation and services were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the German federal states and administrative districts. Differences in individual consultation reasons and services were identified by logistic regression via stepwise forward and backward selection.ResultsPrimary care practices in 34 of the 37 selected administrative districts (91.9%) were represented in the dataset. In total, 211 GPs were personally interviewed. On average, GPs saw 344 patients per month with a slightly higher number of patients in rural areas. They reported 59.1 ± 15.4 different reasons for consultation and 30.3 ± 3.9 different services. There was no statistically significant regional variation in the number of different consultation reasons, but there was a broader service spectrum by rural GPs (ß = − 1.42; 95% confidence interval − 2.75/− 0.08; p = 0.038) which was statistically explained by a higher level of medical training. Additionally, there were differences in the frequency of individual consultation reasons and services between rural and urban areas.ConclusionGPs in rural areas performed more frequently services usually provided by medical specialists in urban areas. This might be caused by a low availability of specialists in rural areas. The association between medical training and service spectrum might imply that GPs compensate the specific needs of their patients by completing advanced medical training before or after setting up a medical practice.Trial registrationThe study was registered in ClinicalTrials.gov (NCT02558322).

‘It’s so rich, you know, what they could be experiencing’: rural places for general practitioner learning

ABSTRACTGlobally there is an urban/rural divide in relation to health and healthcare access. A key strategy for addressing general practitioner shortages in rural areas is GP vocational training in rural places, as this may aid in developing practitioners’ scope, values and community orientation, and increase propensity for rural practice. This creates a need for deeper understanding of the nature and quality of this training. Rural GPs are well-positioned to reflect on vocational learning in ‘place’. We aimed to explore rural GPs’ perceptions and experiences of GP vocational learning in relation to rural places. Semi-structured interviews were conducted with 25 GPs based in smaller rural communities in Tasmania. Inductive and theoretical thematic analysis was undertaken. Rural places provide learning opportunities for GP registrars, which shape the relationships between GPs and registrars and their communities. Rural GPs are committed to developing the next generation and improving access to primary care for their communities. Rural places provide unique learning environments for general practice, including rich learning, relationships and community commitment.

Impact of participation in continuing medical education small group learning (CME-SGL) on the stress, morale, and professional isolation of rurally-based GPs: a qualitative study in Ireland.

BackgroundThe pressures of general practice contribute to high levels of stress, low morale, and burnout in some GPs. In addition, rurally-based doctors may experience significant professional isolation. Participation in continuing medical education (CME) appears to reduce stress, and may improve the retention of rural GPs.AimAs part of a larger study devised to examine the effectiveness of regular participation in CME small group learning (SGL) on rurally-based Irish GPs, this study explored whether CME-SGL had any impact on GP stress, morale, and professional isolation.Design & settingThis was a qualitative study involving four CME-SGL groups based in rural Ireland.MethodSemi-structured focus group interviews were conducted in established CME-SGL groups in four different rural geographical locations. Interviews were audiorecorded, transcribed verbatim, and analysed thematically.ResultsAll members of these CME-SGL groups (n = 43) consented to interview. These GPs reported that regular meetings with an established group of trusted colleagues who are ‘in the same boat’ provided a ‘safe space’ for discussion of, and reflection on, both clinical concerns and personal worries. This interaction in a supportive, non-threatening atmosphere helped to relieve stress, lift morale, and boost self-confidence. The social aspect of CME-SGL sustained these rural GPs, and served to alleviate their sense of professional isolation.ConclusionDelivery of CME through locally-based SGL provides as an important means of supporting GPs working in rural areas. The non-educational benefits of CME-SGL, as described by these Irish GPs, are of relevance for rural doctors in other countries.

Advance care planning in rural New South Wales from the perspective of general practice registrars and recently fellowed general practitioners.

This study examined advance care planning as delivered by general practice registrars and recently fellowed GPs in New South Wales rural settings. The facilitators and barriers to advance care planning uptake in these areas were investigated, as well as the state of general practice training on advance care planning. Qualitative descriptive methodology, involving semi-structured face-to-face and telephone interviews. Primary care. General practice registrars and recently fellowed GPs in New South Wales rural settings. Definition of rural using the Australian Standard Geographical Classification - Remoteness Area. Thirteen participants were included in the study. Thematic analysis of interview transcripts elucidated key issues emerging from participants' accounts. Key barriers included doctor-dependent uptake, demands on doctor's time and the limited relevant resources available. Facilitators recognised were patient control in end-of-life care and long-standing relationships between GPs and their patients. Uptake among patients was low, and minimal training on advance care planning reported. The lack of training opportunities in advance care planning during vocational training, especially when combined with the essential role played by rural GPs in initiating advance care planning and providing end-of-life care, appears to be a major problem that might contribute to poor uptake among patients in rural areas. This study demonstrated, however, the significant benefits that advance care planning could bring in patients living in rural communities if delivered effectively. Given that rural GPs face a number of barriers to providing routine health care, these results highlight an important need to provide GPs and rural communities with support, education, incentive, better administrative tools, options and greater awareness of advance care planning.

Outreach specialists' use of video consultations in rural Victoria: a cross-sectional survey.

In Australia, about one in five medical specialist doctors travel away from their main practice to provide regular outreach services in rural communities. A consistent policy question is whether video consultations (VC) are used as part of rural outreach service provision and the degree to which they partly or wholly substitute outreach visits. This study aimed to explore how commonly specialists providing rural outreach services also use VC to provide clinical service at the outreach site, the aspects of outreach clinical services they consider suitable for VC delivery, whether VC use reduces outreach travel frequency and, if used, has the potential to improve the sustainability of outreach. The study involved 390 specialists in Victoria being invited to participate in an online survey between December 2016 and March 2017. Invited specialists were those travelling to provide rural outreach services in areas of need, already subsidised by the Australian government's outreach policy. Analysis included basic frequency counts and proportions and Pearson χ2 tests for associations. Qualitative free text responses were analysed and grouped thematically. Of 65 respondents, who were travelling to provide rural outreach services on average 11 times per year, 57% (95% confidence interval (CI) 44-69%) used VC to provide aspects of clinical services to the outreach site. They used VC for a median of 12 sessions per year, mainly for one patient per session. VC was used for non-complicated health care, to support rural GPs, undertake clinical reviews or see urgent new patients expediently. Key restrictions were the inability to conduct physical examinations and complex assessments. VC reduced the frequency of outreach travel for 50% of those using it (95%CI 29-63%) although 43% (95%CI 27-61%) reported that providing outreach clinical services via VC took more time than providing face-to-face consultations. Use was not associated with increased intention to continue rural outreach services for 5 or more years (56% v 62%; p=0.70) Conclusion: More than half of specialist doctors complemented their rural outreach services with VC. However, VC was used infrequently, mainly for one patient per session, for restricted clinical scenarios. Although VC use reduced outreach travel frequency for half of providers, 43% responded that VC takes more time than face-to-face clinical service provision. In conclusion, VC is a potentially useful adjunct to outreach service models, but it is unlikely to replace the utility of face-to-face rural specialist services, particularly for complex care, and may not influence outreach service sustainability in the manner in which it is currently used.

Does locally delivered small group continuing medical education (CME) meet the learning needs of rural general practitioners?

ABSTRACTThe World Health Organisation policy of improving retention of rural health care practitioners recommended that continuing medical education (CME) programmes addressing their needs should be accessible and delivered where they live and work. This cross-sectional study involved a self-administered anonymous questionnaire completed by GPs attending CME small groups (CME-SGL) in Ireland. All GPs attending CME-SGL in a one-month period were invited to complete the questionnaire which examined demographic details, distance to travel to educational meetings/nearest regional hospital, barriers to accessing continuing education, whether CME-SGL met their educational needs, morale and professional isolation.A total of 1,686 responses were collected, of which 332 (19.6%) were from rural GPs. Of these, 289 (87%) reported that their educational needs were fully or mostly met by attending CME-SGL. Compared to urban doctors, rural GPs had further to travel to CME-SGL meetings, were further from the nearest regional hospital, and reported increased barriers to accessing continuing education. Rural GPs reported lower morale and greater levels of professional isolation. Despite considerable barriers to accessing continuing education, rural GPs reported that CME-SGL meets their educational needs. Future research should focus on the potential positive impact this may have on professional isolation and morale.

Physical activity counselling and referrals by general practitioners for prostate cancer survivors in Australia.

Physical activity is an important component of standard care to ensure quality of life for prostate cancer survivors. This paper describes the frequency of physical activity management (physical activity counselling or referrals) by GPs for prostate cancer survivors. A secondary aim is to explore GP characteristics that may influence physical activity recommendations, such as GP or patient age, GP gender and GP geographical location. Analysis was conducted using the longitudinal survey data from the Bettering the Care and Evaluation of Health (BEACH) study. Consultations where prostate cancer was managed, but not classified as a new problem or associated with palliative care, were included. GPs provided physical activity recommendations at 2.0% (n = 58/2882) of prostate cancer survivorship management contacts. The physical activity management provided was physical activity counselling on 39 occasions and a physical activity referral on 19 occasions. All physical activity referrals were made to physiotherapy. After controlling for potential confounding factors, results showed that younger GPs used physical activity management at four-fold the rate of older GPs, and that GPs in major cities used physical activity management at twice the rate of rural GPs. No patient characteristics influenced physical activity management. Australian GPs rarely incorporate physical activity management as part of their management of prostate cancer. Strategies are needed to increase the frequency with which GPs recommend physical activity for prostate cancer survivors.

General practitioners' perception of being a doctor in urban vs. rural regions in Germany - A focus group study.

BackgroundInadequate recruitment numbers for GPs in rural regions give cause for concern. Working in rural regions is less attractive among medical students because of strong associations concerning a higher workload, restriction of privacy and demands exceeding their competences. We aimed to explore perceptions of GPs working in urban versus rural regions to contrast these prejudices.MethodsWe conducted nine focus groups with GPs [female = 21, male = 44] from urban and rural regions, using a semi-structured guideline. Transcripts were content analyzed using deductive and inductive categories.ResultsUrban GPs perceived themselves as a provider of medical services and rural GPs as being a medical companion. Compared to urban GPs, GPs from non-urban regions portray themselves more strongly as a family physician that accompanies patients ‘from the cradle to the grave’ and is responsible for the treatment of any medical issue. They emphasized their close relationship with their patients. Rural GPs establish a close relationship with their patients and considered this as beneficial for the treatment relationship. This aspect seems to play a subordinate role for urban GPs.ConclusionsGPs enjoy their work and the role they play in their patients’ lives. Being a rural GP was described very positively. Greater emphasis should be made on positive aspects of being a GP in rural regions, e.g. by university lectures given by rural GPs, campaigns emphasizing the positive aspects of working as a GP [in rural regions], promotion of work placements or incentives for working in rural general practices.

General practitioners\u2019 experiences and perceptions of mild moderate depression management and factors influencing effective service delivery in rural Australian communities: a qualitative study

BackgroundRural communities in Australia face significant disadvantages relating to geographical isolation and limited access to mental health services. Documenting general practitioners’ (GP) experiences and perception of mental health services in rural Australia may be useful to gain insight into rural GP management of mild to moderate depression.AimsTo explore GPs’ experience and views on which factors influence access to mental health services for mild to moderate depression.MethodThis qualitative study was conducted in 2014 in the Northern Rivers, NSW, Australia. Data were obtained from semi-structured in-depth face-to-face interviews with ten GPs, and analyses were performed using a general inductive method of thematic analysis.ResultsMost GPs believed that the current services for managing mild-moderate depression were adequate, however they also identified the need for better access and more services that were free for patients. GPs had a positive perception of management of depression in a rural setting, identifying advantages including better doctor-patient relationships, continuity of care and the proximity of services. However, GPs also identified several barriers to access to mental health services in a rural setting, including long waiting-times, inadequate patient rapport with referred professionals, cost of treatment, transportation, geographical location, stigma, and lack of education about available mental health services. As a result, GPs frequently self-managed patients in addition to referring them to other community mental health service providers where possible.ConclusionOverall, GPs appeared relatively satisfied with the resources available in their communities but also identified numerous barriers to access and room for improvement. Rural GPs often self-managed patients in addition to referring patients to other mental health services providers. This should be taken into account when designing mental health policies, developing new services or re-designing current services in rural communities.

Australia's rural medical workforce: Supply from its medical schools against career stage, gender and rural-origin.

The aim of this study was to explore the association between career stage and rural medical workforce supply among Australian-trained medical graduates. Descriptive analysis using the national Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal study. Australian-trained GPs and other specialists who participated in the MABEL study, 2008-2013. Proportions of GPs and specialists working in rural locations, according to career stage (establishing, early, mid and late), gender and childhood-origin type (rural versus metropolitan). Logistic regression models revealed that establishing- and early-career GPs had significantly higher likelihood (OR 1.67 and 1.38, respectively) of working rurally, but establishing and early-career doctors were significantly less likely (OR 0.34 and 0.43, respectively) to choose general practice, contributing proportionally fewer rural GPs overall (OR 0.77 and 0.75, respectively) compared to late-career doctors. For specialists, there were no significant associations between career cohorts and rural practice. Overall, there was a significantly lower likelihood (OR 0.83) of establishing-career doctors practising rurally. Women were similarly likely to be rural GPs but less likely to be rural specialists, while rural-origin was consistently associated with higher odds of rural practice. The supply of Australia's rural medical workforce from its medical schools continues to be challenging, with these data highlighting both their source and associations with doctors at different career stages. Despite large investments through rural medical training and rural workforce recruitment and retention policies, these data confirm continued reliance on internationally trained medical graduates for large proportions of rural supply is likely.

Service providers’ experiences of using a telehealth network 12 months after digitisation of a large Australian rural mental health service

BackgroundDespite evidence of benefits of telehealth networks in increasing access to, or providing, previously unavailable mental health services, care providers still prefer traditional approaches. For psychiatric assessment, digital technology can offer improvements over analog systems for the technical and, subsequently, the social quality of provider-client interaction. This is in turn expected to support greater provider uptake and enhanced patient benefits. ObjectiveWithin the framework of Innovation Diffusion Theory, to study service providers’ experiences of an existing regional telehealth network for mental health care practice twelve months after digitisation in order to identify the benefits of digital telehealth over an analog system for mental health care purposes in rural Australia. MethodsQualitative interviews and focus groups were conducted with over 40 service providers from June to September 2013 in South Australia, ranging from the metropolitan central operations to health providers located up to 600km away in rural and remote areas of the same state. Participants included rural mental health teams, directors of nursing at rural hospitals, metropolitan-based psychiatrists and registrars, the metropolitan-based mental health team dedicated to rural provider support, rural GPs, administrative staff, and the executive group of the state rural health department. Fieldwork was conducted 12 months after the analog system was digitised. The interview and focus group data were analysed using thematic analysis, focusing on three key areas of innovation diffusion theory: relative advantage, technical complexity and technical compatibility. ResultsFive themes with 11 sub-themes were identified: (1) “Existing Uses”, with three sub-themes: current mental health use, use by GPs, and use for staff support; (2) “Relative Advantage”, with four sub-themes: improved technical quality, improved clinical practice, time and cost benefits for providers, and improved patient care; (3) “Technical Complexity”; (4) “Technical Compatibility” with two sub-themes: technical-clinical and technical-administrative; and (5) “Broader Organisational Culture”, with two sub-themes: organizational policy support and ‘digital telehealth' culture. ConclusionsThe digitised telehealth network was generally well received by providers and adopted into clinical practice. Compared with the previous analog system, staff found advantages in better visual and audio quality, more technical stability with less “drop-out”, less time delay to conversations and less confusion for clients. Despite these advantages, providers identified a range of challenges to starting or continuing use and they recommended improvements to increase uptake among mental health service providers and other providers (including GPs), and to clinical uses other than mental health. To further increase uptake and impact of telehealth-mediated mental health care in rural and remote areas, even with a high quality digital system, future research must design innovative care models, consider time and cost incentives for providers to use telehealth, and must focus not only on technical training but also how to best integrate technology with clinical practice and must develop an organization-wide digital telehealth culture.

Determinants of rural Australian primary health care worker retention: A synthesis of key evidence and implications for policymaking.

To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking. A comprehensive search of Medline, PsychINFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention. Rural and remote Australian primary health care workers. Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural). A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of training, vocational training, practitioner age group and cognitive behavioural coaching. These findings suggest that retention strategies should be multifaceted and 'bundled', addressing the combination of modifiable factors most important for specific groups of Australian rural and remote primary health care workers, and compensating health professionals for hardships they face that are linked to less modifiable factors. The short retention of many Australian rural and remote Allied Health Professionals and GPs, particularly in small, outer regional and remote communities, requires ongoing policy support. The important retention patterns highlighted in this review provide policymakers with direction about where to best target retention initiatives, as well as an indication of what they can do to improve retention.

Integrated and consumer-directed care: a necessary paradigm shift for rural chronic ill health.

Chronic ill health has recently emerged as the most important health issue on a global scale. Rural communities are disproportionally affected by chronic ill health. Many health systems are centred on the management of acute conditions and are often poorly equipped to deal with chronic ill health. Cardiovascular disease (CVD) is one of the most prominent chronic ill health conditions and the principal cause of mortality worldwide. In this paper, CVD is used as an example to demonstrate the disparity between rural and urban experience of chronic ill health, access to medical care and clinical outcomes. Advances have been made to address chronic ill health through improving self-management strategies, health literacy and access to medical services. However, given the higher incidence of chronic health conditions and poorer clinical outcomes in rural communities, it is imperative that integrated health care emphasises greater collaboration between services. It is also vital that rural GPs are better supported to work with their patients, and that they use consumer-directed approaches to empower patients to direct and coordinate their own care.