Understanding the field of rural health academic research: a national qualitative, interview-based study

Introduction: Rural areas depend on a specific evidence base that directly informs their unique health systems and population health context. Developing this evidence base and its translation depends on a trained rural health academic workforce. However, to date, there is limited description of this workforce and the field of rural health research. This study aimed to characterise this field to inform how it can be fostered. Methods: Qualitative semi-structured interviews of 50-70 minutes duration were conducted with 17 early career rural health researchers based in Australian rural and remote communities, to explore their professional background, training and research experiences. Results: Six key themes emerged: becoming a rural health researcher; place-based research that has meaning; generalist breadth; trusted partnerships; small, multidisciplinary research teams; and distance and travel. The field mostly attracted researchers already living in rural areas. Researchers were strongly inspired by doing research that effected local change and addressed inequalities. Their research required a generalist skill set, applying diverse academic and local contextual knowledge that was broader than their doctoral training. Research problems were complex, diverse and required novel methods. Research occurred within trusted community partnerships spanning wide geographic catchments, stakeholders and organisations. This involved extensive leadership, travel and time for engagement and research co-production. Responding to the community was related to researchers doing multiple projects of limited funding. The field was also depicted by research occurring in small collegial, multidisciplinary teams focused on 'people' and 'place' although researchers experienced geographic and professional isolation with respect to their field and main university campuses. Researchers were required to operationalise all aspects of research processes with limited help. They took available opportunities to build capacity in the face of limited staff and high community demand. Conclusion: The findings suggest that rural health research is highly rewarding, distinguished by a generalist scope and basis of 'rural' socially accountable research that is done in small, isolated teams of limited resources. Strategies are needed to grow capacity to a level fit to address the level of community demand but these must embrace development of the rural academic entry pathway, the generalist breadth and social accountability of this field, which underpins the perceived value of rural health research for rural communities

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Background Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. Methods An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access –spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. Results 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. Conclusions Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns

Global variability in leaf respiration in relation to climate, plant functional types and leaf traits

• Leaf dark respiration (Rdark) is an important yet poorly quantified component of the global carbon cycle. Given this, we analyzed a new global database of Rdark and associated leaf traits. • Data for 899 species were compiled from 100 sites (from the Arctic to the tropics). Several woody and nonwoody plant functional types (PFTs) were represented. Mixed-effects models were used to disentangle sources of variation in Rdark. • Area-based Rdark at the prevailing average daily growth temperature (T) of each site increased only twofold from the Arctic to the tropics, despite a 20°C increase in growing T (8–28°C). By contrast, Rdark at a standard T (25°C, Rdark25) was threefold higher in the Arctic than in the tropics, and twofold higher at arid than at mesic sites. Species and PFTs at cold sites exhibited higher Rdark25 at a given photosynthetic capacity (Vcmax25) or leaf nitrogen concentration ([N]) than species at warmer sites. Rdark25 values at any given Vcmax25 or [N] were higher in herbs than in woody plants. • The results highlight variation in Rdark among species and across global gradients in T and aridity. In addition to their ecological significance, the results provide a framework for improving representation of Rdark in terrestrial biosphere models (TBMs) and associated land-surface components of Earth system models (ESMs)

Medical school expansion to areas of need improves physician distribution

Commenting on Figueiredo's exploration of national expansion policy, O'Sullivan and Chater further the discussion of what medical schools can contribute to the reduction of healthcare inequalities

Effective dimensions of rural undergraduate training and the value of training policies for encouraging rural work

The implementation of rural undergraduate medical education can be improved by collecting national evidence about the aspects of these programmes that work well and the value of investing in national policies.This study aimed to explore how different durations, degree of remoteness and number of rural undergraduate medical training placements relate to working rurally, and to investigate differences after the introduction of formal national training policies that fund short- and long-term rural training experiences for medical students.A cohort of 6510 Australian-trained doctors who completed the Medicine in Australia: Balancing Employment and Life survey recalled their participation in rural undergraduate medical training. Responses were categorised by duration, remoteness as defined by the Modified Monash Model levels 3-4 and 4-7 compared with 1, and total number of placements. Multivariate regression was used to test associations with working rurally in 2017, and differences between cohorts of students who graduated pre- and post-2000, of which the latter were exposed to formal national training policies.Any rural undergraduate training was associated with working rurally (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.3-1.9) with incrementally stronger associations for longer duration (>1\ua0year: OR 3.0, 95% CI 2.3-4.0), greater remoteness (OR 1.8, 95% CI 1.5-2.1) and three placements (OR 2.4, 95% CI 1.9-3.0) compared with none. Rural background (OR 2.6, 95% CI 2.3-3.0) and general practice (OR 2.6, 95% CI 2.2-2.9) were independently associated with working rurally; being female was negatively associated with rural work (OR 0.7, 95% CI 0.6-0.8). The cohort of doctors who trained in a period when national rural training policies had been implemented included more graduates with a rural background and experience of undergraduate rural training but returned equivalent proportions of rural doctors to pre-policy cohorts, and included proportionally more women and fewer general practitioners.Rural undergraduate training should focus on multiple dimensions of duration, remoteness and number of rural undergraduate training experiences to grow the rural medical workforce. Formal national rural training policies may be an important part of the broader system for rural workforce development, but they rely on the uptake of general practice and the participation of female doctors in rural medicine

Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution

Background: Outreach has been endorsed as an important global strategy to promote universal access to health care but it depends on health workers who are willing to travel. In Australia, rural outreach is commonly provided by specialist doctors who periodically visit the same community over time. However information about the level of participation and the distribution of these services nationally is limited. This paper outlines the proportion of Australian specialist doctors who participate in rural outreach, describes their characteristics and assesses how these characteristics influence remote outreach provision. Methods: We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, collected between June and November 2008. Weighted logistic regression analyses examined the effect of covariates: sex, age, specialist residential location, rural background, practice arrangements and specialist group on rural outreach. A separate logistic regression analysis studied the effect of covariates on remote outreach compared with other rural outreach. Results: Of 4,596 specialist doctors, 19% (n = 909) provided outreach; of which, 16% (n = 149) provided remote outreach. Most (75%) outreach providers were metropolitan specialists. In multivariate analysis, outreach was associated with being male (OR 1.38, 1.12 to 1.69), having a rural residence (both inner regional: OR 2.07, 1.68 to 2.54; and outer regional/remote: OR 3.40, 2.38 to 4.87) and working in private consulting rooms (OR 1.24, 1.01 to 1.53). Remote outreach was associated with increasing 5-year age (OR1.17, 1.05 to 1.31) and residing in an outer regional/remote location (OR 10.84, 5.82 to 20.19). Specialists based in inner regional areas were less likely than metropolitan-based specialists to provide remote outreach (OR 0.35, 0.17 to 0.70). Conclusion: There is a healthy level of interest in rural outreach work, but remote outreach is less common. Whilst most providers are metropolitan-based, rural doctors are more likely to provide outreach services. Remote distribution is influenced differently: inner regional specialists are less likely to provide remote services compared with metropolitan specialists. To benefit from outreach services and ensure adequate remote distribution, we need to promote coordinated delivery of services arising from metropolitan and rural locations according to rural and remote health need

Rural work and specialty choices of international students graduating from Australian medical schools: implications for policy

Almost 500 international students graduate from Australian medical schools annually, with around 70% commencing medical work in Australia. If these Foreign Graduates of Accredited Medical Schools (FGAMS) wish to access Medicare benefits, they must initially work in Distribution Priority Areas (mainly rural). This study describes and compares the geographic and specialty distribution of FGAMS. Participants were 18,093 doctors responding to Medicine in Australia: Balancing Employment and Life national annual surveys, 2012-2017. Multiple logistic regression models explored location and specialty outcomes for three training groups (FGAMS; other Australian-trained (domestic) medical graduates (DMGs); and overseas-trained doctors (OTDs)). Only 19% of FGAMS worked rurally, whereas 29% of Australia's population lives rurally. FGAMS had similar odds of working rurally as DMGs (OR 0.93, 0.77-1.13) and about half the odds of OTDs (OR 0.48, 0.39-0.59). FGAMS were more likely than DMGs to work as general practitioners (GPs) (OR 1.27, 1.03-1.57), but less likely than OTDs (OR 0.74, 0.59-0.92). The distribution of FGAMS, particularly geographically, is sub-optimal for improving Australia's national medical workforce goals of adequate rural and generalist distribution. Opportunities remain for policy makers to expand current policies and develop a more comprehensive set of levers to promote rural and GP distribution from this group

The stability of rural outreach services: a national longitudinal study of specialist doctors

OBJECTIVE: To explore the characteristics of specialists who provide ongoing rural outreach services and whether the nature of their service patterns contributes to ongoing outreach.DESIGN, PARTICIPANTS AND SETTING: Specialist doctors providing rural outreach in a large longitudinal survey of Australian doctors in 2008, together with new entrants to the survey in 2009, were followed up to 2011.MAIN OUTCOME MEASURES: Providing outreach services to the same rural town for at least 3 years.RESULTS: Of 953 specialists who initially provided rural outreach services, follow-up data were available for 848. Overall, 440 specialists (51.9%) provided ongoing outreach services. Multivariate analysis found that participation was associated with being male (odds ratio [OR], 1.82; 95% CI, 1.28-2.60), in mid-career (45-64 years old; OR, 1.44; 95% CI, 1.04-1.99), and working in mixed, mainly private practice (OR, 1.73; 95% CI, 1.18-2.53). Specialists working only privately were less likely to provide ongoing outreach (OR 0.51; 95% CI, 0.32-0.82), whereas metropolitan and rural-based specialists were equally likely to do so. Separate univariate analysis showed travelling further to remote towns had no effect on ongoing service provision. Outreach to smaller towns was associated with improved stability.CONCLUSIONS: Around half of specialists providing rural outreach services continue to visit the same town on an ongoing basis. More targeted outreach service strategies should account for career stage and practice conditions to help sustain access. Financial incentives may increase ongoing service provision by specialists only working privately. There is some indication that outreach services delivered to smaller communities are more stable