Rural Health Service Delivery Research Articles

A Qualitative Study of Rural and Remote Australian General Practitioners’ Involvement in High-Acuity Patients

This study aimed to understand the experiences, barriers, and facilitators of rural general practitioners' involvement with high-acuity patients. Semi-structured interviews with rural general practitioners in South Australia who had experience delivering high-acuity care were audio-recorded, transcribed verbatim, and analyzed through content and thematic approaches incorporating Potter and Brough's capacity-building framework. Eighteen interviews were conducted. Barriers identified include the inability to avoid high-acuity work in rural and remote areas, pressure to handle complex presentations, lack of appropriate resources, lack of mental health support for clinicians, and impacts on social life. Enablers included a commitment to community, comradery in rural medicine, training, and experience. We concluded that general practitioners are a vital pillar of rural health service delivery and are inevitably involved in disaster and emergency response. While the involvement of rural general practitioners with high-acuity patients is complex, this study suggested that with the appropriate system, structure and role supports, rural general practitioners could be better empowered to manage high-acuity caseloads locally.

Staffing rural emergency departments in Ontario: The who, what and where.

The emergency department (ED) in rural communities is essential for providing care to patients with urgent medical issues and those unable to access primary care. Recent physician staffing shortages have put many EDs at risk of temporary closure. Our goal was to describe the demographics and practices of the rural physicians providing emergency medicine services across Ontario in order to inform health human resource planning. The ICES Physician database (IPDB) and Ontario Health Insurance Plan (OHIP) billing database from 2017 were used in this retrospective cohort study. Rural physician data were analysed for demographic, practice region and certification information. Sentinel billing codes (i.e., a billing code unique to a particular clinical service) were used to define 18 unique physician services. A total of 1192 physicians from the IPDB met inclusion as rural generalist physicians out of a total of 14,443 family physicians in Ontario. From this physician population, a total of 620 physicians practised emergency medicine which accounted for 33% of their days worked on average. The majority of physicians practising emergency medicine were between the ages of 30 and 49 and in their first decade of practice. The most common services in addition to emergency medicine were clinic, hospital medicine, palliative care and mental health. This study provides insight into the practice patterns of rural physicians and the basis for better targeted physician workforce-forecasting models. A new approach to education and training pathways, recruitment and retention initiatives and rural health service delivery models is needed to ensure better health outcomes for our rural population.

The transformation of a student-led health clinic in rural Australia from a face-to-face service to a telehealth model: Evaluation of student and client experiences during a COVID 19 driven transition

Introduction: The COVID-19 pandemic has necessitated the rapid transition of many face-to-face health services to alternate modes of service delivery. The objective of this study was to explore the benefits, challenges and perceived quality of a telehealth service delivery model from the perspective of clients and students. Further, students’ perceptions relating to the quality of the educational experience were also explored. Methods: The study was set in a student-led interprofessional health and wellness clinic in rural Queensland, Australia. A qualitative case study design was used, including semi-structured student interviews and client open-response survey data. Participants were nursing and allied health students who completed a student-led interprofessional clinic placement and adults with low to rising risk of chronic disease who attended the clinic for telehealth delivered services. Results: Themes identified following analysis included: new or adapted skills needed for success; challenges, limitations and the need for resources, training and support; quality interprofessional education experiences can be achieved in telehealth; coming away with a new set of skills; the important role of the client for success; and benefits and disadvantages of telehealth for clients. Conclusions: The findings support that telehealth-based service-learning models are a feasible way to deliver health and wellness services from the perspective of students and clients and provide students with important skills for rural health service delivery.

Evidence-based practice and rural health service delivery: knowledge and barriers to adoption among clinical nurses in Ghana

ABSTRACT Evidence-based practice (EBP) has gained appreciable recognition in health service delivery. Knowledge about EBP in developing countries, however, appears to be limited, despite practitioners’ understanding of the concept having a high propensity to influence adoption and implementation. This article presents findings from research conducted to investigate clinicians’ knowledge and barriers to EBP adoption in Ghana. Criterion purposive sampling was used to recruit 13 clinicians from Wa West District Hospital and health centres across the district to conduct qualitative interviews. Thematic analysis found clinicians have a paucity of knowledge about EBP as all clinicians considered sources of knowledge to include the Standard Nursing Guide and books. Findings uncovered clinicians paid very little attention to published scientific research and saw clients’ experiences as valuable sources of knowledge. Clinicians attributed limited knowledge of EBP to limited familiarity with the concept and poor technology regime. Practical and policy implications of findings are discussed.

Using digital and social media for health promotion: A social marketing approach for addressing co-morbid physical and mental health.

This study examines consumer engagement with a social marketing digital media strategy designed to support the implementation of Equally Well-a program to improve the physical health of people living with mental illness. A four-stage strategic analysis and intervention mix were used as the theoretical framework to assess stakeholder needs and to evaluate the effectiveness of the intervention. Online and digital media. Mental health consumers, carers, clinicians and service managers. A digital media, social marketing intervention to support those seeking to improve the physical health of people living with mental illness. The strategy was developed using a co-design methodology and provided links to self-care resources, access to service providers, clinical tools for health professionals and links to existing successful rural programs. The main outcome measures were the number of people from each category accessing the media, making connections and downloading resources. The program has resulted in more than 24500 website hits per annum, 3500 tweets and 14.5million Twitter impressions with good bounce and download rates. The analysis suggested the materials were mostly used by clinicians and service managers using desktop computers. Using a co-design approach, the study demonstrated the potential of a social marketing digital media strategy as a health promotion methodology. The paper has provided a framework for implementing and evaluating the effectiveness of digital social media campaigns that can help consumers, carers, clinicians and service planners address the challenges of rural health service delivery and the tyranny of distance.

Prevalence of asthma and allergic disorders in regional, rural, and indigenous children aged 6–8 years in Tasmania

Objective: Asthma and allergic diseases are poorly described in rural areas. The objective of this study was, therefore, to determine the prevalence of wheezing, asthma, and other allergic disorders among children living in regional and rural Tasmania. Methodology: Data from a cross-sectional survey using standardized questionnaires of asthma, allergic conditions and food allergies were collected from 39 primary schools across North West Tasmania. We enrolled 1075 children between 6 and 8 years. The main outcomes were prevalences of wheezing, asthma, and other allergic disorders further stratified by sex and indigenous status. Results: Baseline characteristics were as follows: median age 8.1 years (IQR: 7.6, 8.7) with equal sex distribution, most (80.1%) attended public schools and 11.0% identified as indigenous. We report prevalences of current wheezing (22.7%), allergic rhinoconjunctivitis (16.3%) and atopic eczema (16.6%), with higher prevalences among boys (except eczema). Food allergies were reported in 8.6% and food-related anaphylaxis in 1.6% of the sample. Indigenous children had significantly higher prevalence of current wheezing (indigenous 31.1% versus non-indigenous 21.6%; p = 0.02). Further, children with current wheezing and no asthma diagnosis, had similar prevalence of other atopic diseases (hayfever 31.4%, eczema 44.0%, and food reaction 23.2%) compared with diagnosed asthmatics, although likely shared the illness. Conclusions: Childhood asthma is more prevalent in regional Tasmania compared with national estimates, especially among indigenous children. This appears not to be driven by an allergic response. Also, a significant proportion of children are likely to have undiagnosed asthma which has implications for rural health service delivery.

Building Rural Surgical Networks: An Evidence-Based Approach to Service Delivery and Evaluation

Formalized rural health service delivery networks are emerging as an over-arching response to the attrition of rural surgical and maternity services in Canada. In effective networks, there is strong collaborative leadership, form follows function, core network elements are identified and site-specific variations are accommodated to meet the surgical needs of the population in each geographic catchment. The network catchment must reflect the natural alliances that already exist among health professionals, policy makers, health administrators, academic institutions and communities. Although each key stakeholder plays a key role in determining success, value is added through the synergistic interplay of all participants.

From expert generalists to ambiguity masters: using ambiguity tolerance theory to redefine the practice of rural nurses.

To redefine the practice of rural nurses and describe a model that conceptualises the capabilities and characteristics required in the rural environment. The way in which the practice of rural nurses has been conceptualised is problematic. Definitions of rural nursing have been identified primarily through the functional context of rural health service delivery. The expert generalist term has provided a foundation theory for rural nurses with understandings informed by the scope of practice needed to meet service delivery requirements. However, authors exploring intrinsic characteristics of rural nurses have challenged this definition, as it does not adequately address the deeper, intangible complexities of practice required in the rural context. Despite this discourse, an alternative way to articulate the distinctive nature of rural nursing practice has eluded authors in Australia and internationally. A theoretical paper based on primary research. The development of the model was informed by the findings of a study that explored the nursing practice of managing telephone presentations in rural health services in Victoria, Australia. The study involved policy review from State and Federal governments, nursing and medical professional bodies, and five rural health services; semi-structured interviews with eight Directors of Nursing, seven registered nurses and focus group interviews with eight registered nurses. An ambiguity tolerance model drawn from corporate global entrepreneurship theory was adapted to explain the findings of the study. The adapted model presents capabilities and characteristics used by nurses to successfully manage the ambiguity of providing care in the rural context. Redefining the practice of rural nurses, through an adapted theory of ambiguity tolerance, highlights nursing characteristics and capabilities required in the rural context. This perspective offers new ways of thinking about the work of rural nurses, rural nurse policy, education, recruitment, retention and clinical governance. A greater understanding of rural nurse practice will assist in achieving positive care outcomes in an environment with competing stakeholder needs, and limited resources and options for care.

Feasibility of a rural palliative supportive service

Healthcare models for the delivery of palliative care to rural populations encounter common challenges: service gaps, the cost of the service in relation to the population, sustainability, and difficulty in demonstrating improvements in outcomes. Although it is widely agreed that a community capacity-building approach to rural palliative care is essential, how that approach can be achieved, evaluated and sustained remains in question. The purpose of this community-based research project is to test the feasibility and identify potential outcomes of implementing a rural palliative supportive service (RPaSS) for older adults living with life-limiting chronic illness and their family caregiver in the community. This paper reports on the feasibility aspects of the study. RPaSS is being conducted in two co-located rural communities with populations of approximately 10 000 and no specialized palliative services. Participants living with life-limiting chronic illness and their family caregivers are visited bi-weekly in the home by a nurse coordinator who facilitates symptom management, teaching, referrals, psychosocial and spiritual support, advance care planning, community support for practical tasks, and telephone-based support for individuals who must commute outside of the rural community for care. Mixed-method collection strategies are used to collect data on visit patterns; healthcare utilization; family caregiver needs; and participant needs, functional performance and quality of life. A community-based advisory committee worked with the investigative team over a 1-year period to plan RPaSS, negotiating the best fit between research methods and the needs of the community. Recruitment took longer than anticipated with service capacity being reached at 8 months. Estimated service capacity of one nurse coordinator, based on bi-weekly visits, is 25 participants and their family caregivers. A total of 393 in-person visits and 53 telephone visits were conducted between January 2013 and May 2014. Scheduled in-person visit duration showed a mean of 67 minutes. During this same time period only 19 scheduled visits were declined, and there was no study attrition except through death, indicating a high degree of acceptability of the intervention. The primary needs that were addressed during these visits have been related to chronic disease management, and the attending physical symptoms were addressed through teaching and support. The use of structured quality of life and family caregiver needs assessments has been useful in facilitating communication, although some participants experienced the nature of the questions as too personal in the early stages of the relationship with the nurse coordinator. Findings from this study illustrate the feasibility of providing home-based services for rural older adults living with life-limiting chronic illness. The RPaSS model has the potential to smooth transitions and enhance quality of life along the disease trajectory and across locations of care by providing a consistent source of support and education. This type of continuity has the potential to foster the patient- and family-centered approach to care that is the ideal of a palliative approach. Further, the use of a rural community capacity-building approach may contribute to sustainability, which is a particularly important part of rural health service delivery.

What factors influence physiotherapy service provision in rural communities? A pilot study.

To obtain stakeholder perspectives on factors influencing rural physiotherapy service provision and insights into decision making about service provision. Purposive sampling, open-ended survey questions and semi-structured interviews were used in this exploratory, qualitative study. A rural centre and its regional referral centre formed the pilot sites. Nine participant perspectives were obtained on rural physiotherapy services. Stakeholder perspectives on factors influencing rural physiotherapy service provision and service level decision making. Workforce capacity and capability, decision maker's knowledge of the role and scope of physiotherapy, consideration of physiotherapy within resource allocation decisions and proof of practice emerged as key issues. The latter three were particularly reflected in public sector participant comments. Business models and market size were identified factors in influencing private practice. Influencing factors described by participants both align and extend our understanding of issues described in the rural physiotherapy literature. Participant insights add depth and meaning to quantitative data by revealing impacts on local service provision. Available funding and facility priorities were key determinants of public sector physiotherapy service provision, with market size and business model appearing more influential in private practice. The level of self direction or choice about which services to provide, emerged as a point of difference between public and private providers. Decisions by public sector physiotherapists about service provision appear constrained by existing capacity and workload. Further research into service level decision making might provide valuable insights into rural health service delivery.

Developed-developing country partnerships: benefits to developed countries?

Developing countries can generate effective solutions for today’s global health challenges. This paper reviews relevant literature to construct the case for international cooperation, and in particular, developed-developing country partnerships. Standard database and web-based searches were conducted for publications in English between 1990 and 2010. Studies containing full or partial data relating to international cooperation between developed and developing countries were retained for further analysis. Of 227 articles retained through initial screening, 65 were included in the final analysis. The results were two-fold: some articles pointed to intangible benefits accrued by developed country partners, but the majority of information pointed to developing country innovations that can potentially inform health systems in developed countries. This information spanned all six WHO health system components. Ten key health areas where developed countries have the most to learn from the developing world were identified and include, rural health service delivery; skills substitution; decentralisation of management; creative problem-solving; education in communicable disease control; innovation in mobile phone use; low technology simulation training; local product manufacture; health financing; and social entrepreneurship. While there are no guarantees that innovations from developing country experiences can effectively transfer to developed countries, combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is virgin and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardized method for reporting partnership benefits is needed—this is perhaps the single most immediate need in planning for, and realizing, the full potential of international cooperation between developed and developing countries.

Ambiguous and arbitrary: the role of telephone interactions in rural health service delivery

Anecdotal evidence and a limited body of research suggests that telephone interactions between health care consumers and health professionals form an important part of unscheduled health care provision. However, very little is known about these interactions, particularly in the rural context. In rural Australia, there is a need to explore a range of models of service delivery. Telephone-based unscheduled care is one area that demands consideration. By defining unscheduled health care and delineating telephone-based unscheduled health care from other telehealth services, the concepts of formal and informal telephone-based unscheduled health care provision are explored. This article raises previously unasked questions about the role of telephone-based unscheduled health care in the rural context. As a dimension of health care that is poorly understood, the need for further conceptualisation, research and policy development in this area is highlighted.

Impact of rurality on environmental determinants and hazards

The original of this paper was prepared as invited pre-reading for the Inaugural Rural Health Symposium held in Brisbane in July 2008 under the theme "The impact of 'rurality'", sub-theme (a) Environmental determinants. The natural environment shapes human activity, both economically and socially. It also directly and indirectly influences health and well-being. People in rural and remote areas are more directly exposed to the natural environment than their urban counterparts. The built environment is largely a product of economic activity; thus, the built environment in rural areas tends to reflect the predominant primary industry/ies. The rural built environment presents many potential hazards and risks to health and well-being, particularly for those involved in the primary industries, which are either not present in urban areas, or are present on smaller or more contained scales. The natural and built environments also influence individuals' attitudes and behaviours, both positively and negatively. The environmental determinants of rural health, therefore, can be considered in terms of the natural environment, the built environment and individuals' responses to environmental influences. This paper raises some of the common environmental determinants of rural health and well-being and briefly touches on what these mean for rural health service delivery.

Improving access to dementia care: Development and evaluation of a rural and remote memory clinic

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

Publicly Funded, Pegylated Interferon-Alpha Treatment in British Columbia: Disparities in Treatment Patterns for People with Hepatitis C

An estimated 60,000 British Columbians are chronically infected with the hepatitis C virus (HCV); 10% to 20% will develop cirrhosis after 20 years and 5% to 10% of these will develop hepatocellular carcinoma. Although treatment may prevent cirrhosis and liver cancer, and improve quality of life, availability is limited. Individuals with HCV genotypes 1, 4, 5 and 6 who underwent baseline HCV-RNA tests between January 1, 2003 and December 31, 2005, and were eligible for publicly funded treatment through PharmaCare were linked to British Columbia's reportable disease database. Patterns in treatment were examined, including age at treatment, sex, location, time to treatment from HCV diagnosis and seasonality of treatment. When corrected for HCV prevalence, men were more likely to receive treatment than women (RR 1.16, 95% CI 1.02 to 1.31). Patients aged 35 to 54 years and 55 years or older were 3.45 times (95% CI 2.80 to 4.26 times) and 4.49 times (95% CI 3.55 to 5.69 times), respectively, more likely to initiate treatment than 15- to 34-year-olds. Differences were noted between health authorities. Patients in rural health service delivery areas (HSDAs) were 1.25 times (95% CI 1.10 to 1.42 times) more likely to receive treatment than those in urban HSDAs. Patients had an average lapse of four years between HCV diagnosis and receiving treatment. The highest proportion of patients initiated therapy between January and March (36.5%), with the lowest between October and December (less than 14%). This data linkage enabled us to identify populations less likely to receive publicly funded treatment. Rural HSDAs have higher rates of therapy initiation; this pattern merits further research but may be a result of integrated prevention and care projects in rural areas. Policy changes to the current PharmaCare funding co-payment schedules could reduce seasonal variability of treatment initiations throughout the year.

Developing a Competitive Advantage: Considerations from Australia for the Recruitment and Retention of Rural and Remote Primary Health Workers

Globally, health workforce shortages in rural and remote areas significantly affect the capability of health systems, both public and private, to deliver their services. Regional and national governments and academic and professional bodies have been active in attempting to address the situation. This paper overviews the extensive human resources literature on recruitment and retention. Findings are contrasted with recent Australian and international research literature investigating health workforce issues. The context of rural health service delivery, workforce issues and recruitment and retention strategies implemented are discussed. Recruitment and retention issues for the rural and remote health workforce would be well understood if human resources knowledge was applied to the problem. However, few retention strategies were identified other than for general practitioners and no analyses of their effectiveness could be found. Health employers need to use the body of knowledge developed in the business sector to implement recruitment and retention strategies consistently, evaluate them and report the findings. "Silos" created by a sector or discipline-specific approach can be broken down by seeking knowledge from a number of disciplines. Health research can then focus on developing models of health care that address professional and community needs.

Use of Secure e-Mail and Telephone: Psychiatric Consultations to Accelerate Rural Health Service Delivery

Telemedicine is one strategy to improve the accessibility and quality of specialty healthcare to rural settings. After nearly 10 years of video evaluation of patients in rural primary care, telephone and e-mail physician-to-physician consultations were initiated to supplement video and hasten treatment initiation. This paper proposes a model of using telephone and e-mail consultations before or in place of video consultations, because the latter are not always available or timely. Two cases are presented in depth to delineate clinical, consultation, and health services issues. Early use of telephone appears to accelerate the telepsychiatric consultation and resulted in clinical improvement for patients. Primary care providers (PCPs) appeared satisfied with the process of these consultations. The average duration of consultation was about 10 minutes for each party. Telephone and e-mail consultation appear satisfactory to providers and inexpensive, but need to be further evaluated in terms of clinical, health service, and cost outcomes.

SEAM - improving the quality of palliative care in regional Toowoomba, Australia: lessons learned

The proliferation of professional palliative care services in recent years has increased access for people with palliative care needs; however, gaps in services continue to exist, particularly in rural and remote areas of Australia. In order to address one gap in rural health service delivery, the Support, Education, Assessment, and Monitoring (SEAM) Service for regional and rural people in Toowoomba, Queensland, Australia, was introduced. This new model of service delivery aimed to provide palliative services to patients and their families who live in the regional city of Toowoomba and its rural catchment area. It also aimed to facilitate education, support and networking among health-care professionals, particularly general practitioners and nurses employed in general practice (practice nurses). The evaluation involved twenty face-to-face interviews with a variety of health professionals who had contact with the SEAM service from June 2003 to June 2004. Qualitative data analysis of the transcribed interviews provided the basis for the evaluation. The emergent themes regarding the SEAM service included: satisfaction and benefit of the SEAM service; knowledge of and contact with the SEAM service; the SEAM role; and expansion of the role. The data indicate that the majority of health professionals who had contact with the SEAM service were satisfied with the service and found it to be of benefit to them and their clients. Participants commented on the extensive networking and support work established by the SEAM nurse with other health service providers. Difficulties experienced with the SEAM service included poor utilisation by GPs and, therefore, clients in need of palliative support. This was predominately due to lack of knowledge of the service as well as limited understanding of the SEAM nurse role. The SEAM service has resulted in increased links between health professionals providing palliative care to rural clients. The most successful strategy was the use of multidisciplinary case conferencing which not only built links among health professionals caring for individual clients, but also resulted in improved care for those clients. As a result of better integration and communication, palliative care services to rural people have been improved. However, with regard to the delivery of direct patient care, or in the support of GPs for the management of palliative care patients, it was apparent that the service did not meet its objectives. The lack of use by GPs and patients appears to be related to a lack of awareness of the existence of the service. A positive outcome of this poor utilisation is, however, that the model has allowed the identification of factors that work as barriers to GPs and client/family utilisation of rural palliative care services.

Telemedicine services in the Republic of Ireland: An evolving policy context

The Republic of Ireland is characterised by few urban conurbations and a high rural population, including significant numbers of island dwellers. Information communication technologies (ICT), including telemedicine, present opportunities to address rural health-service delivery issues. As in other countries, the recent National Health Information Strategy is regarded as pivotal to the modernisation of the Irish healthcare system. There is, however, a dearth of research about telemedicine in Ireland. This paper reports, to the best of our knowledge, the first systematic review of telemedicine in the two regional healthboards in the Republic of Ireland. Details of 11 telemedicine services, all initiated by local policy, will be presented. Results of an interview study with service providers about their experiences of the practices and processes involved in telemedicine service delivery are also provided. The focus of our analysis is two-fold. We assess the resonance of these Irish data with the international literature with particular reference to a recently developed model for the normalisation of telemedicine. For the first time, this model which was developed in the United Kingdom is applied to a fresh set of empirical data in a different healthcare context. We then discuss a number of health information policy issues for Ireland and elsewhere arising from our analysis.

Ranching in the West: Is it Hazardous to Your Health?

Conditions in the West and ranching culture, including the rural geography, the cowboy mystique, the social fabric of the rural lifestyle, and the of agriculture can negatively impact the delivery of rural health services and the attitude of ranchers and farmers toward seeking help for personal problems. This paper outlines how these conditions may create a behavioral hazard to ranchers, farmers and individuals in the West. Also highlighted are strategies that exist to improve the availability and acceptance of rural behavioral health services. Language: en