Rural and remote health最新文献

Introduction: Rural Canadians have poorer health indices than their urban counterparts and struggle with worse access to care due to an undersupply of physicians. Research has identified personal factors, such as being raised in a rural environment, and traits, such as lower harm avoidance, among those drawn to rural practice. As well, the impact of aspects of medical training, such as rural rotations, have been recognized in creating rural practice intentions, but the role of specific clinical competencies here has yet to be determined. Emergency medicine is often one of the most challenging components of rural practice and thought by some to have its competencies poorly developed in family practice training. We hypothesized a model for rural practice affinity in which a strong sense of general self-efficacy would be independently mediated by the development of emergency medicine competence and rural practice self-efficacy, leading to stronger intentions to embark on a rural practice career.

Methods: This model was tested using the data from a survey of all family medicine residents nearing graduation from 14 of the 17 Canadian medical schools. Demographics and data on factors known to influence a rural career choice were collected and accounted for when determining the strength of the hypothesized relationships. Both existing and specifically designed survey tools were used to assess model components. A partial correlation matrix between the variables of interest (general self-efficacy, emergency medicine competency, rural practice self-efficacy, and rural practice intentions) - controlling for the effects of relationships, financial aspects, personal aspects, and social desirability - was created and subjected to a structural equation model.

Results: Our initial rural practice affinity model resulted in a poor fit of the model to the data. However, the addition of a pathway from emergency medicine competence to rural practice self-efficacy improved the model to one showing significant paths as hypothesized as well as excellent measures of fit.

Discussion: The importance of general self-efficacy is recognized and is itself mediated by the more specific rural practice self-efficacy to rural practice intentions, consistent with the literature. Emergency medicine competency has a central role in both mediating general self-efficacy to rural practice intentions, while also being mediated itself by rural practice self-efficacy to rural practice intentions. This provides new understanding in the development of rural practice self-efficacy. The link of emergency medicine competency to both rural practice self-efficacy and rural practice intentions suggests that this is a curricular area that deserves greater focus and consideration of how to ensure that residents are meeting emergency medicine requirements and receiving robust training in this area. This is especi

Context: Necrotising fasciitis is a rapidly progressing, life-threatening soft tissue infection that carries a high morbidity and mortality, especially in susceptible populations.

Issue: During the La Niña spring-summer-autumn of 2021-2022, five male patients aged between 59 and 86 were admitted into the Hervey Bay Hospital (Queensland, Australia) intensive care unit (ICU) with necrotising fasciitis and multi-organ failure. All five patients had been in saltwater rivers within the local Fraser Coast area and either hunting for Scylla serrata (commonly known as green mud crabs), or descaling barnacles from their vessels. Following rapid and extensive surgical intervention and aggressive antibiotic and supportive treatment, all five patients were either discharged home or are currently in rehabilitation.

Lessons learned: With a strong possibility of future floods due to climate change and the cyclic return of the La Niña in the future, this article highlights a potential public health issue. This case series demonstrates the importance of increased vigilance for necrotising fasciitis by frontline healthcare staff after flooding events. Identification and escalation of a potential public health warning about the need for vigilance by people experiencing even the smallest of injury by green mud crabs or barnacles post-flood event may need to be considered.

Introduction: The lack of a stable general practice workforce in rural and remote Australia has been a topic of much discussion as there are fewer GPs working in many rural areas, where mortality and morbidity are higher than in urban areas. Doctors who have been trained in rural and remote areas are more likely to continue working there, but in many practices supervision is not available onsite. Good supervision ensures patient safety, an educational alliance between the supervisor and trainee, and adequate clinical and professional support by the supervisor and the onsite team. This project involved the evaluation of the pilot of the newly developed guidelines for the remote supervision of GP trainees (registrars) within the Royal Australian College of General Practitioners (RACGP) Australian General Practice Training program: Remote supervision: Guidelines for safe and effective general practice training utilising remote supervision.

Methods: The aim of the evaluation was to assess the appropriateness, effectiveness and efficiency of the remote supervision guidelines and placement processes such as the selection process, risk management plan, face-to-face orientation period, development of the onsite team, communication strategies and increased payment. The guidelines were implemented as a pilot in two practice localities in 2022. The remote supervisors, remotely supervised registrars, practice managers and training organisation stakeholders were interviewed at three time points during the placement: before the placement, after the orientation period and at the conclusion of the placement. Their responses were analysed and organised into themes.

Results: Overall, the results were positive, with suggestions for improvement and challenges identified. There was an identified need to ensure that guidelines are flexible and able to be tailored to the context of the registrar, the supervisor and the placement. Both registrars in the pilot continued to work in the remotely supervised practices at the end of their training and the three supervisors were keen to supervise remotely again.

Discussion: The RACGP remote supervision guidelines were developed as an evidence-based practical means of supervising registrars in rural and remote locations where there is no onsite supervisor. The guidelines were updated where necessary and have now been published and implemented nationally.

Conclusion: The pilot and evaluation of the RACGP remote supervision guidelines demonstrate that they are safe and fit for purpose. These guidelines form one of the training strategies to support the dwindling rural and remote general practice workforce.

Introduction: The centralisation of birthing care, driven by the closure of 225 of Australia's rural birthing centres over the past 20 years, has resulted in a 47% increase in births before arrivals at hospitals. This shift positions paramedics as critical primary health providers for out-of-hospital births and obstetric emergencies. Despite the infrequency of such emergencies for paramedics, they demand proficient clinical management due to their severity and potential complications. Confidence is vital for paramedics in managing high-risk obstetric emergencies effectively. However, there is limited research on paramedics' confidence levels and the factors influencing them, particularly in Australia following the introduction of paramedic registration and mandatory obstetric training in 2018. This scoping review seeks to explore paramedics' confidence in managing prehospital obstetric emergencies, identify influencing factors and examine the implications of confidence on both patient and paramedic welfare.

Methods: Following Joanna Briggs Institute methodology, a comprehensive literature search across three databases yielded 125 results. Screening of titles and abstracts by two authors, followed by full-text screening of 18 remaining articles, was conducted. Conflicts were resolved by the primary author, and three additional relevant articles were retrieved manually. Thirteen studies met the inclusion criteria and were analysed to inform the review.

Results: The findings consistently highlighted feelings of low confidence, insecurity, vulnerability and heightened stress among paramedics when confronted with prehospital obstetric emergencies. These were largely attributed to infrequent and inadequate education and training, leading to skills decay and difficulties in distinguishing normal from complicated obstetric events. Rurality due to various logistical, geographical and resourcing factors was found to exacerbate paramedic insecurity attending and managing obstetric emergencies. The decline in confidence not only affects clinical proficiency but also poses risks to patient safety and contributes to paramedic stress and poor mental health outcomes.

Conclusion: Proportional confidence emerges as a crucial factor in medical education, facilitating enhanced clinical competence and better mental health outcomes for patients, clinicians and teams. This is of increased importance in rural areas where logistical barriers to ensuring appropriate care are prevalent. Further research is needed to ascertain the optimal frequency and type of training/education required to bolster paramedic confidence in managing obstetric emergencies effectively.

Introduction: Persons with disabilities living in rural areas were disproportionately affected during the COVID-19 pandemic. This population, with a higher propensity for poor health and higher need for health services, bore the brunt of adverse effects of emergency regulations that cancelled or restricted access to rehabilitation. South African legislative and policy frameworks support the availability and promotion of disability and rehabilitation services as priority healthcare programs for all. Rehabilitation services in the country were, however, underresourced prior to the pandemic, and halted during lockdowns because of their non-essential status in the healthcare system. Within this context, this study explored the experiences of rehabilitation practitioners in the Eastern Cape Province of South Africa during the COVID-19 pandemic.

Methods: Forming part of a mixed study on inclusiveness of pandemic responses to people with disabilities, we reviewed government responses across different African countries, analysed the South African government responses to the pandemic and conducted interviews with rehabilitation practitioners in the rural Eastern Cape Province of South Africa. This article reports on the qualitative interviews, while the reviews and survey findings were published elsewhere. Rehabilitation practitioners were recruited from a provincial rehabilitation forum for practitioners who work in the public health facilities in the province. A combination of online and telephone individual interviews were conducted with participants, as well as three asynchronous interviews using Google Forms and WhatsApp. Transcriptions of interviews were analysed inductively and thematically through coding and categorisation.

Results: Eight practitioners participated in the study (a response rate of 8.4%). This included six physiotherapists and two occupational therapists. Three themes developed from data reported by the participants: reconfiguring rehabilitation services, experienced impact on rehabilitation service delivery and exacerbation of pre-pandemic rehabilitation shortfalls.

Discussion: The low priority of rehabilitation services as part of health services exacerbated pre-pandemic barriers for persons with disabilities. The cessation of such services rendered rehabilitation wholly inaccessible to persons with disabilities in the province, with detrimental effects on their function, health and wellbeing. Practitioners suggested that integrated collaborative health and rehabilitation service delivery enabled the continuation of some service aspects to some persons with disabilities. Initiatives and adaptations to services were driven by practitioners, although often in the absence of clear directives from the Department of Health. Some alternative methods of delivery (eg telerehabilitation) that were deployed elsewhere, were not as accessible and viable

Introduction: A maldistributed primary care workforce and disparities in health outcomes are ongoing concerns for rural populations across the globe. Nurse practitioners (NPs) are a promising solution for mitigating rural healthcare inequities by reducing provider shortages and improving access to essential primary care services. The NP workforce is the fastest growing sector of primary care providers in the US. NPs are more likely than their physician colleagues to spend careers in rural and underserved settings practicing in isolation from other providers, with higher rates of turnover. An indistinct understanding of rural NPs' early career experiences highlights the need for a critical synthesis of the literature and key future recommendations. This integrative review aimed to analyze and synthesize various types of empirical reports and theoretical articles about new NPs' experiences in rural primary healthcare practice; identify current literature gaps; and discuss implications for education, policy, and further research.

Methods: Whittemore and Knafl's integrative method was used to inform the selection, review, and analysis of the literature. Search keywords were based on the Population, Effect of Interest, Measure, Study Design, Setting framework: (1) population (primary care NPs), (2) effect of interest (early career phase in a rural context), (3) measure (NP perspectives about their experiences), (4) study design (empirical, theoretical), and (5) setting (rural US and countries with a similar healthcare system and NP workforce, such as Australia, Canada, Ireland, Netherlands, and New Zealand). Four key databases (PubMed, Embase, Web of Science and CINAHL) were searched, followed by manual searching of reference lists to identify relevant empirical and theoretical literature; no time delimitation was applied in the search. A total of 174 sources were scanned. Data were iteratively compared, and significant patterns were extracted and organized into thematic clusters.

Results: The literature search yielded five studies that met the eligibility criteria: three phenomenological studies, one descriptive qualitative study, and one descriptive quantitative study. Three themes emerged: the trajectory of early career practice for rural NPs, commitment and persistence of new rural NPs, and adaptive and maladaptive early career factors for rural NPs.

Conclusion: This review included articles published in the US, although emergent themes may contribute to global knowledge about early career experiences in rural settings where advanced practice nurses are used. This review reinforced that NPs as a distinct professional population are underrepresented in rural workforce research, particularly during their early career phases. Scholarly literature about new rural NPs emphasized clinical preparedness and competence, workplace recruitment incentives, transition-to-p

Introduction: Metabolic adaptations can differ significantly among Arctic residents with different ethnicities, lifestyles and adherences to traditional diets. The objective of this study was to examine the status of saturated fatty acids (SFAs) and triglycerides and the variability of BMI among Russian Arctic residents according to ethnicity and lifestyle.

Methods: The study involved adult females and males living in the territories of the Russian Arctic. The participants were divided into three groups: Indigenous reindeer herders leading a nomadic lifestyle (NIP), Indigenous people leading a sedentary lifestyle (SIP) and the Caucasian population (CP). The content of SFAs (C6-C24) and metabolic characteristics was determined using gas chromatographic and spectrophotometric methods. The study also included a quantitative comparison of the consumption of certain categories of food products. To analyze data, we used the descriptive analyses by non-parametric methods, as well as multiple linear regression analysis.

Results: The study found that the Caucasian females had higher triglyceride levels (p<0.001), higher total content of long-chain SFAs (LCSFAs) (C13-C18) (p=0.002) and that the SIP females had reduced content of very-long-chain fatty acids (C20-C24) (p=0.039). These changes were not statistically significant for the males, partly due to the almost identical levels of triglycerides C16:0 and C18:0 in the NIP and the CP. The content of medium-chain SFAs (MCSFAs) (C6-C12) was higher in the SIP (p<0.001 for females; p=0.002 for males). The Indigenous males tended to have a lower BMI compared to the Caucasian males, resulting in a lower prevalence of overweight or obesity: 49.3% in the NIP (p=0.006) and 57.4% in the SIP versus 69.3% in the CP. In female participants, these frequencies did not differ, being 64%, 65.4% and 66% respectively. The NIP and SIP groups had higher consumption of traditional foods, carbohydrate-rich foods, meat products and vegetable oils, the latter of which was positively associated with SFA content.

Conclusion: The study revealed the dependence of the studied parameters of lipid metabolism on ethnicity (Indigenous v Caucasian) and lifestyle (nomadic v sedentary). The population metabolic variability was expressed as the increase in the levels of LCSFAs and triglycerides in the CP, reflecting, most likely, an imbalance in the processes of their accumulation and consumption with a predominantly western type of nutrition. Indigenous populations, despite changes in diet towards an increased consumption of carbohydrate-rich products, have preserved an adaptive metabolism with the predominant use of lipids as energy resources. Higher levels of MCSFAs in the SIP, who are less adherent to a traditional diet compared to the NIP, may be compensatory, with a growing role of such fatty acids in energy consumption and thermogenesis.

Introduction: Migraine is an episodic, debilitating form of headache. Guidelines exist for the management of acute migraine, concluding that opioids should be avoided, unless as a last resort. Australian research shows a poor consistency in ED prescribing patterns with no published rural hospital data. Treatment of acute migraine often involves multiple medications used in succession. The overprescription of opioids is reported and often accompanied by an underuse of triptans. Previous studies do not differentiate prescriber intervention over time. It is unclear if opioid medications are routinely selected as first-line therapy in rural Australian EDs. The aim of this research is to complete an evaluation of migraine management in a rural Australian ED and compare trends to pre-existing data.

Methods: This study is a retrospective cohort analysis of clinician-diagnosed migraine patients presenting to a single Australian ED between 1 January 2017 and 31 December 2021. Cases with migraine were defined by a primary G439 diagnosis (International Classification of Diseases 10th Revision). Patients with alternative diagnoses and those who did not wait were excluded. Cases underwent a non-blinded chart review extracting demographic and clinical data. Diagnoses were not evaluated against the international headache society criteria. ED interventions were recorded as first-, second-, third- or fourth-line based on the ordering time by the prescribing doctor. Medications were classified as being compliant or non-complaint with current standards of care. Trends were compared to previous studies.

Results: A total of 341 patients were diagnosed with migraine, 72.4% female, median 35 years. A total of 6.5% arrived by ambulance, 76.8% had a prior history of migraine, 6.5% were admitted, 36.4% underwent blood investigations and 12.0% neuroimaging. A total of 7.6% of patients received opioids as first-line therapy, 44.3% failed self-medication and 21.7% of patients with migraine history trialled opioids prior to presentation. Regarding prescriptions, 795 were written, 18.1% were non-compliant with guidelines. Seventy percent of patients received dopamine and 5-HT3 antagonists, 43.1% non-steroidal anti-inflammatory drugs (NSAIDs), 27.0% serotonin receptor agonists and 27.0% opioids. There was a statistically significant prescribing difference for aspirin, used in 16.4% of those with a migraine history and 5.1% without (p=0.01). A total of 13.8% reported allergies/contraindications to guideline therapies.

Conclusion: Prescribing for acute migraine in Australia is highly variable by context. This single-site study has similarities and differences with prior research. Rates of opioid prescribing were lower, possibly due to the known sparing effect of serotonin receptor agonist usage. Similar rates of NSAID and intravenous hydration prescription occurred. Patterns of intervention o