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Thirty years ago the first edition of the Australian Journal of Rural Health (AJRH) was published. Following reviews published in 2002 and 2012, it is again time to review what progress has been made in bringing about improved health outcomes for residents of rural and remote Australia over the past decade. Compounded by the Covid‐19 crisis that has affected the health and health care system throughout Australia, this review notes the significant lack of progress over the past decade in ameliorating ongoing problems of poor access to primary health care and associated avoidable hospitalisations, persistent poor health of Indigenous Australians, and the greater prevalence of a range of health risk factors. Following the findings of the recent New South Wales enquiry into rural health, this review highlights what is needed to implement the many recommendations that have emerged from the wealth of evidence‐based research published in journals such as the AJRH to improve health outcomes and increase the parity and equity in health between metropolitan and non‐metropolitan Australians. [ABSTRACT FROM AUTHOR]

Introduction: Australians in rural and remote areas experience poorer health status compared with many metropolitan residents, due partly to inequitable access to primary health care (PHC) services. Building on recent research that identified PHC services which all Australians should be able to access regardless of where they live, this paper aims to define the population thresholds governing which PHC services would be best provided by a resident health worker, and to outline attendant implementation issues. Methods: A Delphi method comprising panellists with expertise in rural, remote and/or Indigenous PHC was used. Five population thresholds reflecting Australia's diverse rural and remote geography were devised. Panellists participated in two electronic surveys. Using a Likert scale, they were asked at what population threshold each PHC service should be provided by a resident health worker. A follow-up focus group identified important underlying principles which guided the consensus process. Results: Response rates were high. The population thresholds for core PHC services provided by a resident worker were less in remote communities compared with rural communities. For example, the population threshold for 'care of the sick and injured,' was ≤ 100 for remote compared with 101-500 for rural communities. For 'mental health', 'maternal/ child health', 'sexual health' and 'public health' services in remote communities the population threshold was 101-500, compared to 501-1000 for rural communities. Principles underpinning implementation included the fundamental importance of equity; consideration of social determinants of health; flexibility, effective expenditure of resources, tailoring services to ensure consumer acceptability, prioritising services according to need, and providing services as close to home as possible. Conclusion: This research can assist policy makers and service planners to determine the population thresholds at which PHC services should be delivered by a resident health worker, to allocate resources and provide services more equitably, and inform consumers about PHC services they can reasonably expect to access in their community. This framework assists in developing a systematic approach to strategies seeking to address existing rural-urban health workforce maldistribution, including the training of generalists as opposed to specialists, and providing necessary infrastructure in communities most in need. [ABSTRACT FROM AUTHOR]

Background: Australians living in rural and remote areas experience poorer access to primary health care (PHC) and poorer health outcomes compared to metropolitan populations. Current health reform in Australia aims to ensure all Australians, regardless of where they live, have access to essential PHC services. However, at a national level policy makers and health planners lack an evidence-based set of core PHC services to assist in implementing this goal. Methods: A Delphi method was used to reach consensus on an evidence-based list of core PHC services to which all Australians should have access and their necessary support functions. Experts in rural and remote and/or Indigenous PHC, including policy-makers, academics, clinicians and consumers, were invited to consider a list of core services derived from the literature. Results: Thirty nine experts agreed to participate. After three survey rounds there was a strong consensus (≥80% agreement) on core PHC services namely; ‘care of the sick and injured’ , ‘mental health’ , ‘maternal/child health’ , ‘allied health’ , ‘sexual/reproductive health’ , ‘rehabilitation’ , ‘oral/dental health’ and ‘public health/illness prevention’; and on the PHC support functions of; ‘management/governance/leadership’ , ‘coordination’, ‘health infrastructure’, ‘quality systems’ , ‘data systems’ , ‘professional development’ and ‘community participation’. Themes emerging from qualitative data included challenges in providing equitable PHC in rural and remote areas, the importance of service coordination and diverse strategies to overcome access barriers. Conclusion: This study identifies a basket of PHC services that consumers in rural and remote communities can expect to access. It provides rigorously derived evidence that will contribute to a more systematic approach to PHC service planning and availability and will assist policy makers in the allocation of scarce resources necessary to improve the health outcomes of residents of rural and remote areas. [ABSTRACT FROM AUTHOR]

The Australian Journal of Rural Health is currently celebrating its 20th anniversary. Following a review of the first decade of rural health published by the authors in 2002, this article outlines and reviews the range of policies that have impacted upon rural health in Australia since then. During the past decade there has been a raft of new policies and programs designed to bring about improved rural health outcomes, and some progress has been made. However, a number of significant barriers to overcoming the rural-urban health differential remain. Special consideration will continue to be needed to rural affairs generally and to health system reform and rural health in particular. [ABSTRACT FROM AUTHOR]

To measure variations in patterns of turnover and retention, determinants of turnover, and costs of recruitment of allied health professionals in rural areas. Data were collected on health service characteristics, recruitment costs and de-identified individual-level employment entry and exit data for dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, social workers and speech pathologists employed between 1 January 2004 and 31 December 2009. Health services providing allied health services within Western Victoria were stratified by geographical location and town size. Eighteen health services were sampled, 11 participated. Annual turnover rates, stability rates, median length of stay in current position, survival probabilities, turnover hazards and median costs of recruitment were calculated. Analysis of commencement and exit data from 901 allied health professionals indicated that differences in crude workforce patterns according to geographical location emerge 12 to 24 months after commencement of employment, although the results were not statistically significant. Proportional hazards modelling indicated profession and employee age and grade upon commencement were significant determinants of turnover risk. Costs of replacing allied health workers are high. An opportunity for implementing comprehensive retention strategies exists in the first year of employment in rural and remote settings. Benchmarks to guide workforce retention strategies should take account of differences in patterns of allied health turnover and retention according to geographical location. Monitoring allied health workforce turnover and retention through analysis of routinely collected data to calculate selected indicators provides a stronger evidence base to underpin workforce planning by health services and regional authorities. [ABSTRACT FROM AUTHOR]

Consumer input is vitally important when planning health care services and monitoring health system performance. Australia's rural residents suffer poorer health status and health outcomes than do metropolitan residents; this, along with medical and health workforce shortages, makes this planning and monitoring especially relevant. In rural and remote regions people are geographically dispersed across diverse communities, often making it difficult to access and recruit consumers. This paper provides a framework to address the major issues associated with how best to canvass representative rural consumer views relating to health care services and quality assurance. The review provides a critical appraisal of the advantages and disadvantages of the main methodologies employed in rural health studies. Many of the problems associated with gaining representative rural consumer perspectives in relation to health can be overcome by planning the research process, adopting the appropriate survey tool and engaging potential participants. [ABSTRACT FROM AUTHOR]

The rural and remote primary medical workforce continues to struggle to meet community needs. This paper looks at the strengths and weaknesses of the various datasets used to measure workforce. The analysis concludes that no current data set adequately describes workforce from a community need perspective. In particular, activity based data sets based on claims data do not capture issues such as service mix or the importance of issues outside activity collections, such as time on call. The paper calls for a new approach to workforce measurement based on a community needs model. [ABSTRACT FROM AUTHOR]

The aim of this study was to identify the factors that influence foreign doctors’ community integration and examine how these affect their intention to stay in the rural community. Qualitative study using life-history perspective. Rural communities throughout Victoria. Fifty-seven overseas-trained doctors (OTDs) working throughout rural Victoria, Australia. Key factors of community integration influencing OTDs’ decision to stay in or leave a rural community. Maintaining cultural and religious values, as well as relationships to their respective ethnic communities is important to OTDs. While they do not expect excessive support from the community they appreciated the cultures of welcoming or ‘embracing differences’. Supportive communication and supervisory support positively influence OTDs’ appreciation of what the rural community can offer them and how they might overcome any difficulties that they face with their rural practice and life. As well as ensuring that OTDs’ professional needs are met, the importance of a supportive environment within the clinic and community awareness of the OTDs’ needs should not be underestimated as influences on an OTD's retention in a rural community. [ABSTRACT FROM AUTHOR]

The absence of an agreed definition of ‘rural’ limits the utility of existing research into a possible relationship between rurality of residence and mental health. The present study investigates the bipolar dimension accessibility/remoteness as a possible correlate of mental health. A continuous area of non-metropolitan Australia was selected to provide a range of scores on the Accessibility/Remoteness Index of Australia (ARIA). A questionnaire measuring demographics, the five-factor model of personality and three aspects of mental health (distress, disability and wellbeing) was mailed to 20 000 adults selected randomly from electoral rolls. Responses were received from 7615 individuals (response rate = 40.5%; 57.1% female). ARIA was not associated with either distress or disability measures, but a small negative association was found between accessibility and two measures of wellbeing. Individuals residing in locales with better access to services and opportunities for interaction reported higher levels of satisfaction with life (SWL) and positive affect (PA). Adjusting statistically for a range of demographic and personality correlates did not alter the effect of ARIA on SWL. The effect on PA remained significant after adjusting for demographics, but not once personality correlates entered the model. By sampling across a single proposed parameter of rurality, a novel profile of correlations was identified. In accord with existing data, accessibility was not associated with distress or disability. In contrast, accessibility was positively associated with the wellbeing aspect of mental health. Further attention to the measurement of rural place and the exploration of accessibility as a parameter with mental health relevance, is warranted. [ABSTRACT FROM AUTHOR]

Priorities in the delivery of health care to Australian country people with developmental disability were explored through focus groups and interviews of key stakeholder groups from four rural/regional towns. Data were analysed for themes, which converged on lack of access to primary health care providers who lacked knowledge about and had poor attitudes towards developmental disability, discriminatory practices, the burden on support people, and communication difficulties between GPs and people with developmental disability. Potential strategies to address the apparent dissatisfaction with primary health care and GP concerns about working with this group were also evident in the data. In particular, open communication between stakeholders as a mechanism for collaborative problem solving and a strategy to avoid burn out for both support people and GPs is recommended. Facilitation of such communication can best occur through undergraduate training and participation of disability workers in activities of organisations that support GPs. [Copyright &y& Elsevier]

This paper argues that lack of adequate research is a barrier to the long-term improvement of the mental health and well-being of rural Australians. Following from national mental health policy, potential research avenues in four broad domains (prevention and early intervention, pathways to care, outcome of illness and aetiology) are defined. These four broad domains are interdependent and research into them can be brought together into a simple framework or model. This model could be used to guide research into rurality and mental health. The proposed model uses the inclusive concept of place to capture the potential complexities of the rural locale as a variable in mental health and disorder. The model's predictor variables include both risk and resilience factors, and the outcome variables extend beyond morbidity to positive psychological wellness. It is proposed that this provisional model, and the strategic research that it directs, will act as a useful counterpoint to the more immediate evaluation and resourcing needs that confront rural mental health. [ABSTRACT FROM AUTHOR]

In this paper the need for further investigation into the mental health of rural Australians will be discussed. It will be argued that while research to date has yielded valuable information, the volume and scope of existing studies has been inadequate to address the needs of the diverse and dynamic communities in non-metropolitan Australia. The diversity that exists within rural Australia is examined and the potential effects of this diversity on mental health status are highlighted. Then a number of issues that are relevant to people living in non-metropolitan areas that underscores the need for further study into rural mental health are identified. Finally, some specific areas that require further examination are outlined and some guiding principles for future mental health research are proposed. [ABSTRACT FROM AUTHOR]

The burden of mental health problems and disorders is high and rising both in Australia and globally. In response, the Commonwealth Government has moved to implement a national mental health strategy as the basis for a coordinated national approach to underpin initiatives designed to promote mental wellbeing and address mental ill health. This article outlines the nature and extent of mental health problems, provides an overview of changes in mental health policy and service delivery in Australia over the past decade, highlights issues in these areas of particular relevance for rural and remote Australia and calls for the development of a National Rural Mental Health Strategy. [ABSTRACT FROM AUTHOR]

Arguably the policies and programs designed to bring about improvements in the health status of rural and remote residents have been limited by the absence of systematic statistical data about health status and its relationship with place of residence. The Australian Institute of Health and Welfare addresses this problem in the recent report Health in rural and remote Australia. The report compares the health status, health risk factors and preventative measures, and health resources for rural, remote and urban areas. The data highlights that people in rural and remote areas of Australia have poorer health status than their metropolitan counterparts on several counts. While further work is required, the report provides a useful and important basis for identifying and monitoring the pattern of health status and resource availablility in rural and remote Australia. [ABSTRACT FROM AUTHOR]

Rural and remote Australia is characterised by considerable geographical and social diversity. There is no ‘natural’ classification of what constitutes ‘rural’ or ‘remote’, and precise definition of what is meant by the term ‘rural’ has proved to be an elusive goal. Nonetheless, it is recognised that the differentiation of rural areas has important implications for healthcare planning and the research that underpins it. Whether it be the development of resource allocation formulae that determine the provision, location and type of rural health services, measuring service utilisation rates as an indicator of need for services or health outcome measures, the way in which populations and communities are delimited as urban, rural and remote will always influence and sometimes may even determine the assessment. The time is ripe for the development of an agreed classification for the investigation of rural health issues. [ABSTRACT FROM AUTHOR]

The concept of health service sustainability, endorsed by the Australian Health Ministers as a key dimension of the National Performance Framework, is particularly important in rural and remote communities. To date, however, few Australian studies have demonstrated how the real drivers of sustainability inter-relate or are translated into sustainable rural and remote health services. This article highlights the need for a systemic approach in which the integrated nature of sustainability components are recognised and evaluated in terms of access to rural and remote health services, quality of care and cost of provision. [ABSTRACT FROM AUTHOR]

Abstract: A key policy issue in many countries is the maldistribution of doctors across geographic areas, which has important effects on equity of access and health care costs. Many government programs and incentive schemes have been established to encourage doctors to practise in rural areas. However, there is little robust evidence of the effectiveness of such incentive schemes. The aim of this study is to examine the preferences of general practitioners (GPs) for rural location using a discrete choice experiment. This is used to estimate the probabilities of moving to a rural area, and the size of financial incentives GPs would require to move there. GPs were asked to choose between two job options or to stay at their current job as part of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. 3727 GPs completed the experiment. Sixty five per cent of GPs chose to stay where they were in all choices presented to them. Moving to an inland town with less than 5000 population and reasonable levels of other job characteristics would require incentives equivalent to 64% of current average annual personal earnings ($116,000). Moving to a town with a population between 5000 and 20,000 people would require incentives of at least 37% of current annual earnings, around $68,000. The size of incentives depends not only on the area but also on the characteristics of the job. The least attractive rural job package would require incentives of at least 130% of annual earnings, around $237,000. It is important to begin to tailor incentive packages to the characteristics of jobs and of rural areas. [Copyright &y& Elsevier]

Many governments have implemented incentive programs to improve the retention of doctors in rural areas despite a lack of evidence of their effectiveness. This study examines rural general practitioners' (GPs') preferences for different types of retention incentive policies using a discrete choice experiment (DCE). In 2009, the DCE was administered to a group of 1720 rural GPs as part of the “Medicine in Australia: Balancing Employment and Life (MABEL)” study. We estimate both a mixed logit model and a generalized multinomial logit model to account for different types of unobserved differences in GPs' preferences. Our results indicate that increased level of locum relief incentive, retention payments and rural skills loading leads to an increase in the probability of attracting GPs to stay in rural practice. The locum relief incentive is ranked as the most effective, followed by the retention payments and rural skills loading payments. These findings are important in helping to tailor retention policies to those that are most effective. [ABSTRACT FROM AUTHOR]

Significant demographic, social and economic change has come to characterise much of rural Australia, with some authors arguing there are now two sharply differentiated zones, one of growth and one of decline. This restructuring process, which has been similar to other western nations, has had a profound impact upon rural places—socially, economically and physically. Findings from research investigating the relationship between health, place and income inequality suggest that rural ‘desertification’, which is characterised by decline of the agricultural sector, net population loss and the deterioration of demographic structures, may negatively influence mental health outcomes in these areas. By contrast, the growth in rural areas, which is associated with expanding employment opportunities and the movement of capital and people, may confer positive benefits to mental health. The aim of this study was to investigate differences in mental health and well-being between rural communities experiencing growth and decline as measured by net population change. Utilising a survey methodology, questionnaires were distributed to 20,000 people randomly sampled from the electoral role in rural Australia. We selected four sub-regions from the sample area that were characteristic of areas experiencing population growth and decline in Australia and analysed the results of respondents from these four regions (n=1334). The analysis provided support for our hypothesis that living in a declining area is associated with poorer mental health status; however, the factors that underpin growth and decline may also be important in influencing mental health. Discussed are the mechanisms by which demographic and social change influence mental health. The findings of this study highlight the diversity of health outcomes in rural areas and suggest that aspects of place in declining rural areas may present risk factors for mental health. [Copyright &y& Elsevier]