A systematic review of strategies to recruit and retain primary care doctors

Background There is a workforce crisis in primary care. Previous research has looked at the reasons underlying recruitment and retention problems, but little research has looked at what works to improve recruitment and retention. The aim of this systematic review is to evaluate interventions and strategies used to recruit and retain primary care doctors internationally. Methods A systematic review was undertaken. MEDLINE, EMBASE, CENTRAL and grey literature were searched from inception to January 2015.Articles assessing interventions aimed at recruiting or retaining doctors in high income countries, applicable to primary care doctors were included. No restrictions on language or year of publication. The first author screened all titles and abstracts and a second author screened 20%. Data extraction was carried out by one author and checked by a second. Meta-analysis was not possible due to heterogeneity. Results 51 studies assessing 42 interventions were retrieved. Interventions were categorised into thirteen groups: financial incentives (n=11), recruiting rural students (n=6), international recruitment (n=4), rural or primary care focused undergraduate placements (n=3), rural or underserved postgraduate training (n=3), well-being or peer support initiatives (n=3), marketing (n=2), mixed interventions (n=5), support for professional development or research (n=5), retainer schemes (n=4), re-entry schemes (n=1), specialised recruiters or case managers (n=2) and delayed partnerships (n=2). Studies were of low methodological quality with no RCTs and only 15 studies with a comparison group. Weak evidence supported the use of postgraduate placements in underserved areas, undergraduate rural placements and recruiting students to medical school from rural areas. There was mixed evidence about financial incentives. A marketing campaign was associated with lower recruitment. Conclusions This is the first systematic review of interventions to improve recruitment and retention of primary care doctors. Although the evidence base for recruiting and care doctors is weak and more high quality research is needed, this review found evidence to support undergraduate and postgraduate placements in underserved areas, and selective recruitment of medical students. Other initiatives covered may have potential to improve recruitment and retention of primary care practitioners, but their effectiveness has not been established

Fair game: exploring the dynamics, perception and environmental impact of ‘surplus’ wild foods in England 10kya-present

This paper brings together zooarchaeological data from Neolithic to Post-medieval sites in England to explore the plasticity of cultural attitudes to the consumption of wild animals. It shows how, through time, game has been considered variously as ‘tabooed’ and ‘edible’, each having implications for patterns of biodiversity and wildlife management. The essential points being made are that deeper-time studies can reveal how human perceptions of ‘surplus foods’ have the potential to both create and remedy problems of environmental sustainability and food security. Perhaps more significantly, this paper argues that understanding the bio-cultural past of edible wild animal species has the potential to transform human attitudes to game in the present. This is important at a time when food security and the production of surplus are pressing national and global concerns

Measuring root system traits of wheat in 2D images to parameterize 3D root architecture models

Background and aimsThe main difficulty in the use of 3D root architecture models is correct parameterization. We evaluated distributions of the root traits inter-branch distance, branching angle and axial root trajectories from contrasting experimental systems to improve model parameterization.MethodsWe analyzed 2D root images of different wheat varieties (Triticum aestivum) from three different sources using automatic root tracking. Model input parameters and common parameter patterns were identified from extracted root system coordinates. Simulation studies were used to (1) link observed axial root trajectories with model input parameters (2) evaluate errors due to the 2D (versus 3D) nature of image sources and (3) investigate the effect of model parameter distributions on root foraging performance.ResultsDistributions of inter-branch distances were approximated with lognormal functions. Branching angles showed mean values <90°. Gravitropism and tortuosity parameters were quantified in relation to downwards reorientation and segment angles of root axes. Root system projection in 2D increased the variance of branching angles. Root foraging performance was very sensitive to parameter distribution and variance.Conclusions2D image analysis can systematically and efficiently analyze root system architectures and parameterize 3D root architecture models. Effects of root system projection (2D from 3D) and deflection (at rhizotron face) on size and distribution of particular parameters are potentially significant

Developmental morphology of cover crop species exhibit contrasting behaviour to changes in soil bulk density, revealed by X-ray computed tomography

Plant roots growing through soil typically encounter considerable structural heterogeneity, and local variations in soil dry bulk density. The way the in situ architecture of root systems of different species respond to such heterogeneity is poorly understood due to challenges in visualising roots growing in soil. The objective of this study was to visualise and quantify the impact of abrupt changes in soil bulk density on the roots of three cover crop species with contrasting inherent root morphologies, viz. tillage radish (Raphanus sativus), vetch (Vicia sativa) and black oat (Avena strigosa). The species were grown in soil columns containing a two-layer compaction treatment featuring a 1.2 g cm-3 (uncompacted) zone overlaying a 1.4 g cm-3 (compacted) zone. Three-dimensional visualisations of the root architecture were generated via X-ray computed tomography, and an automated root-segmentation imaging algorithm. Three classes of behaviour were manifest as a result of roots encountering the compacted interface, directly related to the species. For radish, there was switch from a single tap-root to multiple perpendicular roots which penetrated the compacted zone, whilst for vetch primary roots were diverted more horizontally with limited lateral growth at less acute angles. Black oat roots penetrated the compacted zone with no apparent deviation. Smaller root volume, surface area and lateral growth were consistently observed in the compacted zone in comparison to the uncompacted zone across all species. The rapid transition in soil bulk density had a large effect on root morphology that differed greatly between species, with major implications for how these cover crops will modify and interact with soil structure

Access to general practitioner services amongst underserved Australians: a microsimulation study

<p>Abstract</p> <p>Background</p> <p>One group often identified as having low socioeconomic status, those living in remote or rural areas, are often recognised as bearing an unequal burden of illness in society. This paper aims to examine equity of utilisation of general practitioner services in Australia.</p> <p>Methods</p> <p>Using the 2005 National Health Survey undertaken by the Australian Bureau of Statistics, a microsimulation model was developed to determine the distribution of GP services that would occur if all Australians had equal utilisation of health services relative to need.</p> <p>Results</p> <p>It was estimated that those who are unemployed would experience a 19% increase in GP services. Persons residing in regional areas would receive about 5.7 million additional GP visits per year if they had the same access to care as Australians residing in major cities. This would be a 18% increase. There would be a 20% increase for inner regional residents and a 14% increase for residents of more remote regional areas. Overall there would be a 5% increase in GP visits nationally if those in regional areas had the same access to care as those in major cities.</p> <p>Conclusion</p> <p>Parity is an insufficient goal and disadvantaged persons and underserved areas require greater access to health services than the well served metropolitan areas due to their greater poverty and poorer health status. Currently underserved Australians suffer a double disadvantage: poorer health and poorer access to health services.</p

Mechanistic framework to link root growth models with weather and soil physical properties, including example applications to soybean growth in Brazil

Background and aimsRoot elongation is generally limited by a combination of mechanical impedance and water stress in most arable soils. However, dynamic changes of soil penetration resistance with soil water content are rarely included in models for predicting root growth. Better modelling frameworks are needed to understand root growth interactions between plant genotype, soil management, and climate. Aim of paper is to describe a new model of root elongation in relation to soil physical characteristics like penetration resistance, matric potential, and hypoxia.MethodsA new diagrammatic framework is proposed to illustrate the interaction between root elongation, soil management, and climatic conditions. The new model was written in Matlab®, using the root architecture model RootBox and a model that solves the 1D Richards equations for water flux in soil. Inputs: root architectural parameters for Soybean; soil hydraulic properties; root water uptake function in relation to matric flux potential; root elongation rate as a function of soil physical characteristics. Simulation scenarios: (a) compact soil layer at 16 to 20 cm; (b) test against a field experiment in Brazil during contrasting drought and normal rainfall seasons.Results(a) Soil compaction substantially slowed root growth into and below the compact layer. (b) Simulated root length density was very similar to field measurements, which was influenced greatly by drought. The main factor slowing root elongation in the simulations was evaluated using a stress reduction function.ConclusionThe proposed framework offers a way to explore the interaction between soil physical properties, weather and root growth. It may be applied to most root elongation models, and offers the potential to evaluate likely factors limiting root growth in different soils and tillage regimes

Financial incentives for return of service in underserved areas: a systematic review

<p>Abstract</p> <p>Background</p> <p>In many geographic regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off.</p> <p>Methods</p> <p>We carried out systematic literature searches of PubMed, the Excerpta Medica database, the Cumulative Index to Nursing and Allied Health Literature, and the National Health Services Economic Evaluation Database for studies evaluating outcomes of financial-incentive programs published up to February 2009. To identify articles for review, we combined three search themes (health workers or students, underserved areas, and financial incentives). In the initial search, we identified 10,495 unique articles, 10,302 of which were excluded based on their titles or abstracts. We conducted full-text reviews of the remaining 193 articles and of 26 additional articles identified in reference lists or by colleagues. Forty-three articles were included in the final review. We extracted from these articles information on the financial-incentive programs (name, location, period of operation, objectives, target groups, definition of underserved area, financial incentives and obligation) and information on the individual studies (authors, publication dates, types of study outcomes, study design, sample criteria and sample size, data sources, outcome measures and study findings, conclusions, and methodological limitations). We reviewed program results (descriptions of recruitment, retention, and participant satisfaction), program effects (effectiveness in influencing health workers to provide care, to remain, and to be satisfied with work and personal life in underserved areas), and program impacts (effectiveness in influencing health systems and health outcomes).</p> <p>Results</p> <p>Of the 43 reviewed studies 34 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60–80%). Seven studies compared retention in the <it>same </it>(underserved) area between program participants and non-participants. Six studies found that participants were less likely than non-participants to remain in the same area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Thirteen studies compared provision of care or retention in <it>any </it>underserved area between participants and non-participants. Eleven studies found that participants were more likely to (continue to) practice in any underserved area (nine studies reported the difference to be statistically significant, while two studies did not provide the results of a significance test); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with their work and personal lives in underserved areas.</p> <p>Conclusion</p> <p>Financial-incentive programs for return of service are one of the few health policy interventions intended to improve the distribution of human resources for health on which substantial evidence exists. However, the majority of studies are from the US, and only one study reports findings from a developing country, limiting generalizability. The existing studies show that financial-incentive programs have placed substantial numbers of health workers in underserved areas and that program participants are more likely than non-participants to work in underserved areas in the long run, even though they are less likely to remain at the site of original placement. As none of the existing studies can fully rule out that the observed differences between participants and non-participants are due to selection effects, the evidence to date does not allow the inference that the programs have caused increases in the supply of health workers to underserved areas.</p

Flodoard of Rheims and the Historiography of the Tenth-Century West

Flodoard of Rheims is one of the most important authors of tenth-century Europe, and the only contemporary historian to document the momentous struggles between kings and nobles in Francia in the wake of the demise of the Carolingian Empire. Flodoard’s era stands at the center of major historiographical debates concerning the nature of political and social change and the origins of European institutions. Yet, despite his singularity, his substantial histories have received little attention from scholars examining the profound transformations of the period. Exploring this discrepancy, this article offers an overview of Flodoard’s career and reviews how his histories have been invoked in some of the great scholarly debates about tenth-century Europe. It further proposes to recontextualize Flodoard and to reread his histories from the bottom up in order to gain a subtler understanding of how one contemporary perceived and represented the dramatic events and changes taking place around him