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Background Incorporating supportive care into routine cancer care is an increasing priority for the multi-disciplinary team with growing evidence of its importance to patient-centred care. How to design and deliver a process which is appropriate for patients, clinicians and health services in rural areas needs further investigation. Objective To (i) examine the patient and clinician acceptability and feasibility of incorporating a supportive care screening and referral process into routine cancer care in a rural setting, and (ii) explore any potential influences of patient variables on the acceptability of the process. Methods A total of 154 cancer patients and 36 cancer clinicians across two rural areas of Victoria, Australia participated. During treatment visits, patients and clinicians participated in a supportive care process involving screening, discussion of problems, and provision of information and referrals. Structured questionnaires with open and closed questions were used to measure patient and clinician acceptability and feasibility. Results Patients and clinicians found the supportive care process highly acceptable. Screening identified relevant patient problems (90%) and problems that may not have otherwise been identified (83%). The patient-clinician discussion helped patients realize help was available (87%) and enhanced clinician-patient rapport (72%). Patients received useful referrals to services (76%). Feasibility issues included timing of screening for newly diagnosed patients, privacy in discussing problems, clinician time and availability of referral options. No patient demographic or disease factors influenced acceptability or feasibility. Conclusions Patients and clinicians reported high acceptability for the supportive care process, although mechanisms for incorporating the process into health care need to be further developed. [ABSTRACT FROM AUTHOR]

Objective: This study examined rural women's satisfaction with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Differences in satisfaction were investigated between treatment groups (mastectomy and breast conservation surgery) and demographic variables (age, marital status, education level, employment status and place of residence). Practice was compared with clinical practice guidelines. Design: The study was designed as a cross-sectional survey. Setting: The study was set in Eastern regional Victoria, Australia. Participants: Seventy women diagnosed with early breast cancer participated in the study. Main outcome measures: The main outcome measures used by the study were satisfaction in three areas of practice: (i) telling a woman she has breast cancer; (ii) providing information and involving the woman in the decision-making; and (iii) preparing the woman for specific management. Results: No differences in satisfaction were found between treatment groups and demographic variables. Overall, women in this study were highly satisfied (>93%) with the interaction and communication with their surgeon. Women reported that the surgeon created a supportive environment for discussion, that they were provided with adequate information and referrals, and that they were actively involved in the decision-making. Practice could have been improved for women who were alone at diagnosis as women without a partner made a quicker decision about treatment. Conclusion: Rural women in Victoria Australia were largely satisfied with the interaction and communication with their surgeon during diagnosis and treatment planning for early breast cancer. Current practice was predominately in line with clinical practice guidelines. [ABSTRACT FROM AUTHOR]

Background: The two step floating catchment area (2SFCA) method has emerged in the last decade as a key measure of spatial accessibility, particularly in its application to primary health care access. Many recent 'improvements' to the original 2SFCA method have been developed, which generally either account for distance-decay within a catchment or enable the usage of variable catchment sizes. This paper evaluates the effectiveness of various proposed methods within these two improvement groups. Moreover, its assessment focuses on how well these improvements operate within and between rural and metropolitan populations over large geographical regions. Results: Demonstrating these improvements to the whole state of Victoria, Australia, this paper presents the first comparison between continuous and zonal (step) decay functions and specifically their effect within both rural and metropolitan populations. Especially in metropolitan populations, the application of either type of distance-decay function is shown to be problematic by itself. Its inclusion necessitates the addition of a variable catchment size function which can enable the 2SFCA method to dynamically define more appropriate catchments which align with actual health service supply and utilisation. Conclusion: This study assesses recent 'improvements' to the 2SFCA when applied over large geographic regions of both large and small populations. Its findings demonstrate the necessary combination of both a distance-decay function and variable catchment size function in order for the 2SFCA to appropriately measure healthcare access across all geographical regions. [ABSTRACT FROM AUTHOR]

Abstract: Quantifying spatial accessibility in relation to the provision of rural health services has proven difficult. This article critically appraises the two-step floating catchment area (2SFCA) method, a recent solution for measuring primary care service accessibility across rural areas of Victoria, Australia. The 2SFCA method is demonstrated to have two fundamental shortcomings – specifically the use of only one catchment size for all populations, and secondly the assumption that proximity is undifferentiated within a catchment (especially problematic when the catchment is large). Despite its advantages over simple population-to-provider ratios, the 2SFCA method needs to be used with caution. [Copyright &y& Elsevier]

Context: There is growing evidence supporting a shift towards 'grow your own' approaches to recruiting, training and retaining health professionals from and for rural communities. To achieve this, there is a need for sound methodologies by which universities can describe their area of geographic focus in a precise way that can be utilised to recruit students from their region and evaluate workforce outcomes for partner communities. In Australia, Deakin University operates a Rural Health Multidisciplinary Training (RHMT) program funded Rural Clinical School and University Department of Rural Health, with the purpose of producing a graduate health workforce through the provision of rural clinical placements in western and south-western Victoria. The desire to establish a dedicated Rural Training Stream within Deakin's Doctor of Medicine course acted as a catalyst for us to describe our 'rural footprint' in a way that could be used to prioritise local student recruitment as well as evaluate graduate workforce outcomes specifically for this region., Issue: In Australia, selection of rural students has relied on the Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) or Modified Monash Model (MMM) to assign rural background status to medical course applicants, based on a standard definition provided by the RHMT program. Applicants meeting rural background criteria may be preferentially admitted to any medical school according to admission quotas or dedicated rural streams across the country. Until recently, evaluations of graduate workforce outcomes have also used these rurality classifications, but often without reference to particular geographic areas. Growing international evidence supports the importance of place-based connection and training, with medical graduates more likely to work in a region that they are from or in which they have trained. For universities to align rural student recruitment more strategically with training in specific geographic areas, there is a need to develop precise geographical definitions of areas of rural focus that can be applied during admissions processes., Lessons Learned: As we strived to describe our rural activity area precisely, we modelled the application of several geographical and other frameworks, including the MMM, ASGS-RA, Primary Healthcare Networks (PHN), Local Government Areas (LGAs), postcodes and Statistical Areas. It became evident that there was no single geographical or rural framework that (1) accurately described our area of activity, (2) accurately described our desired workforce focus, (3) was practical to apply during the admissions process. We ultimately settled on a bespoke approach using a combination of the PHN and MMM to achieve the specificity required. This report provides an example of how a rural activity footprint can be accurately described and successfully employed to prioritise students from a geographical area for course admission. Lessons learned about the strengths and limitations of available geographical measures are shared. Applications of a precise footprint definition are described including student recruitment, evaluation of workforce outcomes for a geographic region, benefits to stakeholder relationships and an opportunity for more nuanced RHMT reporting.

Background: Improved medical care access for rural populations continues to be a major concern. There remains little published evidence about postgraduate rural pathways of junior doctors, which may have strong implications for a long-term skilled rural workforce. This exploratory study describes and compares preferences for, and uptake of, rural internships by new domestic and international graduates of Victorian medical schools during a period of rural internship position expansion., Methods: We used administrative data of all new Victorian medical graduates' location preference and accepted location of internship positions for 2013-16. Associations between preferred internship location and accepted internship position were explored including by rurality and year. Moreover, data were stratified between 'domestic graduates' (Australian and New Zealand citizens or permanent residents) and 'international graduates' (temporary residents who graduated from an Australian university)., Results: Across 2013-16, there were 4562 applicants who filled 3130 internship positions (46% oversubscribed). Domestic graduates filled most (69.7%, 457/656) rural internship positions, but significantly less than metropolitan positions (92.2%, p < 0.001). Only 20.1% (551/2737) included a rural location in their top five preferences, less than for international graduates (34.4%, p < 0.001). A greater proportion of rural compared with metropolitan interns accepted a position not in their top five preferences (36.1% versus 7.4%, p < 0.001). The proportion nominating a rural location in their preference list increased across 2013-2016., Conclusions: The preferences for, and uptake of, rural internship positions by domestic graduates is sub-optimal for growing a rural workforce from local graduates. Current actions that have increased the number of rural positions are unlikely to be sufficient as a stand-alone intervention, thus regional areas must rely on international graduates. Strategies are needed to increase the attractiveness of rural internships for domestic students so that more graduates from rural undergraduate medical training are retained rurally. Further research could explore whether the uptake of rural internships is facilitated by aligning these positions with protected opportunities to continue vocational training in regionally-based or metropolitan fellowships. Increased understanding is needed of the factors impacting work location decisions of junior doctors, particularly those with some rural career intent.

Introduction: Access to medical services for rural communities is poorer than for metropolitan communities in many parts of the world. One of the strategies to improve rural medical workforce has been rural clinical placements for undergraduate medical students. This study explores the workforce outcomes of one model of such placements - the longitudinal integrated clerkship (LIC) - delivered in year 4, the penultimate year of the medical course, as part of the rural programs delivered by a medical school in Victoria, Australia. The LIC involved student supervision under a parallel consulting model with experienced rural generalist doctors for a whole year in small community rural general practices., Methods: This study aimed to compare the work locations (regional or more rural), following registration as a medical practitioner, of medical students who had completed 1 year of the LIC, with, first, students who had other types of rural training of comparable duration elsewhere, and second, students who had no rural training. Study participants commenced their medical degree after 2004 and had graduated between 2008 and 2016 and thus were in postgraduate year 1-9 in 2017 when evaluated. Information about the student training location(s), and duration, type and timing of training, was prospectively collected from university administrative systems. The outcome of interest was the main work location in 2017, obtained from the Australian Health Practitioner Regulation Agency's public website., Results: Students who had undertaken the year 4 LIC along with additional rural training in years 3 and/or 5 were more likely than all other groups to be working in smaller regional or rural towns, where workforce need is greatest (relative risk ratio (RRR) 5.62, 95% confidence interval (CI) 2.81-11.20, compared with those having metropolitan training only). Non-LIC training of similar duration in rural areas was also significantly associated, but more weakly, with smaller regional work location (RRR 2.99, 95%CI 1.87-4.77). Students whose only rural training was the year 4 LIC were not significantly associated with smaller regional work location (RRR 1.72, 95%CI 0.59-5.04). Overall, after accounting for both LIC and non-LIC rural training exposure, rural work after graduation was also consistently positively associated with rural background, being an international student and having a return of service obligation under a bonded program as a student., Conclusion: This study demonstrates the value of rural LICs, coupled with additional rural training, in contributing to improving Australia's medical workforce distribution. Whilst other evidence has already demonstrated positive educational outcomes for doctors who participate in rural LIC placements, this is the first known study of work location outcomes. The study provides evidence that expanding this model of rural undergraduate education may lead to a better geographically distributed medical workforce.

Introduction: In Australia, about one in five medical specialist doctors travel away from their main practice to provide regular outreach services in rural communities. A consistent policy question is whether video consultations (VC) are used as part of rural outreach service provision and the degree to which they partly or wholly substitute outreach visits. This study aimed to explore how commonly specialists providing rural outreach services also use VC to provide clinical service at the outreach site, the aspects of outreach clinical services they consider suitable for VC delivery, whether VC use reduces outreach travel frequency and, if used, has the potential to improve the sustainability of outreach., Methods: The study involved 390 specialists in Victoria being invited to participate in an online survey between December 2016 and March 2017. Invited specialists were those travelling to provide rural outreach services in areas of need, already subsidised by the Australian government's outreach policy. Analysis included basic frequency counts and proportions and Pearson χ2 tests for associations. Qualitative free text responses were analysed and grouped thematically., Results: Of 65 respondents, who were travelling to provide rural outreach services on average 11 times per year, 57% (95% confidence interval (CI) 44-69%) used VC to provide aspects of clinical services to the outreach site. They used VC for a median of 12 sessions per year, mainly for one patient per session. VC was used for non-complicated health care, to support rural GPs, undertake clinical reviews or see urgent new patients expediently. Key restrictions were the inability to conduct physical examinations and complex assessments. VC reduced the frequency of outreach travel for 50% of those using it (95%CI 29-63%) although 43% (95%CI 27-61%) reported that providing outreach clinical services via VC took more time than providing face-to-face consultations. Use was not associated with increased intention to continue rural outreach services for 5 or more years (56% v 62%; p=0.70) Conclusion: More than half of specialist doctors complemented their rural outreach services with VC. However, VC was used infrequently, mainly for one patient per session, for restricted clinical scenarios. Although VC use reduced outreach travel frequency for half of providers, 43% responded that VC takes more time than face-to-face clinical service provision. In conclusion, VC is a potentially useful adjunct to outreach service models, but it is unlikely to replace the utility of face-to-face rural specialist services, particularly for complex care, and may not influence outreach service sustainability in the manner in which it is currently used.

Background: Limited evidence exists about the extent to which doctors are returning to rural region(s) where they had previously trained. This study aims to investigate the rate at which medical students who have trained for 12 months or more in a rural region return to practice in that same region in their early medical career. A secondary aim is to investigate whether there is an independent or additional association with the effect of longer duration of rural exposure in a region (18-24 months) and for those completing both schooling and training in the same rural region., Methods: The outcome was rural region of work, based on postcode of work location in 2017 for graduates spanning 1-9 years post-graduation, for one large medical program in Victoria, Australia. Region of rural training, combined with region of secondary schooling and duration of rural training, was explored for its association with region of practice. A multinomial logistic regression model, accounting for other covariates, measured the strength of association with practising in the same rural region as where they had trained., Results: Overall, 357/2451 (15%) graduates were working rurally, with 90/357 (25%) working in the same rural region as where they did rural training. Similarly, 41/170 (24%) were working in the same region as where they completed schooling. Longer duration (18-24 vs 12 months) of rural training (relative risk ratio, RRR, 3.37, 1.89-5.98) and completing both schooling and training in the same rural region (RRR: 4.47, 2.14-9.36) were associated with returning to practice in the same rural region after training., Conclusions: Medical graduates practising rurally in their early career (1-9 years post-graduation) are likely to have previous connections to the region, through either their basic medical training, their secondary schooling, or both. Social accountability of medical schools and rural medical workforce outcomes could be improved by policies that enable preferential selection and training of prospective medical students from rural regions that need more doctors, and further enhanced by longer duration of within-region training.

Background: Poor access to doctors at times of need remains a significant impediment to achieving good health for many rural residents. The two-step floating catchment area (2SFCA) method has emerged as a key tool for measuring healthcare access in rural areas. However, the choice of catchment size, a key component of the 2SFCA method, is problematic because little is known about the distance tolerance of rural residents for health-related travel. Our study sought new evidence to test the hypothesis that residents of sparsely settled rural areas are prepared to travel further than residents of closely settled rural areas when accessing primary health care at times of need., Methods: A questionnaire survey of residents in five small rural communities of Victoria and New South Wales in Australia was used. The two outcome measures were current travel time to visit their usual doctor and maximum time prepared to travel to visit a doctor, both for non-emergency care. Kaplan-Meier charts were used to compare the association between increased distance and decreased travel propensity for closely-settled and sparsely-settled areas, and ordinal multivariate regression models tested significance after controlling for health-related travel moderating factors and town clustering., Results: A total of 1079 questionnaires were completed with 363 from residents in closely-settled locations and 716 from residents in sparsely-settled areas. Residents of sparsely-settled communities travel, on average, 10 min further than residents of closely-settled communities (26.3 vs 16.9 min, p < 0.001), though this difference was not significant after controlling for town clustering. Differences were more apparent in terms of maximum time prepared to travel (54.1 vs 31.9 min, p < 0.001). Differences of maximum time remained significant after controlling for demographic and other constraints to access, such as transport availability or difficulties getting doctor appointments, as well as after controlling for town clustering and current travel times., Conclusions: Improved geographical access remains a key issue underpinning health policies designed to improve the provision of rural primary health care services. This study provides empirical evidence that travel behaviour should not be implicitly assumed constant amongst rural populations when modelling access through methods like the 2SFCA.

Publication rates are a vital measure of individual and institutional performance, yet many nurse academics publish rarely or not at all. Despite widespread acceptance of the need to increase academic publication rates and the pressure university faculty may experience to fulfil this obligation, little is known about the effectiveness of practical strategies to support academic writing. In this small cohort study (n=8) comprising nurses and other professionals involved in university education, a questionnaire survey was used to evaluate the effectiveness of a one-week "Writing for Publication" course combined with a monthly writers support group to increase publication rates. Two year pre and post submissions increased from 9 to 33 articles in peer-reviewed journals. Publications (in print) per person increased from a baseline of 0.5-1.2 per year. Participants reported increased writing confidence and greater satisfaction with the publishing process. Peer support and receiving recognition and encouragement from line managers were also cited as incentives to publish. Writing for publication is a skill that can be learned. The evaluated model of a formal writing course, followed by informal monthly group support meetings, can effectively increase publication rates.

Objective: This paper reports on the design and testing of a new questionnaire, "Perspectives on the Use in Communities of CAM" (the PUC-CAM-Q [questionnaire])., Design: The questionnaire consisted of scales and questions for 27 concepts considered to affect complementary and alternative medicine (CAM) usage. Scales encompassed 13 beliefs about nature, scientific medicine, and the environment, as well as personal characteristics, such as stoicism and resilience. A matrix provided space for respondents to indicate their use, or likelihood of use, of 23 of the most commonly available CAM modalities. Also included were questions about the reasons for CAM use and sources of health information., Location: The questionnaire was mailed to a randomly selected sample of people in a pilot study of two metropolitan and five rural localities in Victoria, Australia., Results: The response rate was 40% (n = 459). The majority of the questionnaires were completed consistently, and the reliability and validity and questions were satisfactory. Seven (7) of the 13 scales that explored the beliefs and concerns about CAM use and the characteristics of the respondents had Cronbach alphas of above 0.7. Refinement of the other six scales resulted in alphas of between 0.6 and 0.7, with good corrected item-total correlations for included questions. Responses to the matrix question on the use, or likelihood of use, of individual CAM modalities were also good. However, some adjustments to the layout would provide more comprehensive information for future use of the PUC-CAM-Q., Conclusions: This questionnaire provided good data that were appropriate for the exploratory nature of this PUC-CAM study. After more attention to the scales, as well as some refinement of some nonscale questions, the PUC-CAM-Q would be a practical instrument for further studies on CAM use.

Objective: To assess the effect that the presence of an emergency physician in the ED has on the access indicators of the Australian Council on Healthcare Standards., Methods: A retrospective study was carried out in a 265 bed regional referral hospital in Victoria. The performance of the ED over a 6 month period, during which time there was incomplete emergency physician coverage, was monitored using The Australian Council on Healthcare Standards (ACHS) access indicators as the benchmark. These indicators are waiting time by triage category, and access block., Results: A total of 11 999 patient presentations were eligible for inclusion in the study. Emergency physicians were present for 76.5% of these presentations. All the indicators show a trend towards improvement when an emergency physician was present. However, the only indicator that shows a significant improvement is waiting time by triage category, and this is due mainly to an improvement within triage category 4., Conclusions: There is some evidence that the presence of an emergency physician improves performance within this group of access based indicators within a rural ED, however, the effect seen here is small. More studies are needed on this topic and also on the development of quality indicators for rural ED.

Medical education in Australia is currently entering a new era, including support for the significant extension of medical students and general practitioner (GP) registrars' training programs in rural communities. This commitment to rural medical student and general practitioner recruitment and retention has made the provision of accommodation in rural communities a vital issue. This study has found that approximately half of all medical students on placement with rural GPs are currently accommodated with their GP supervisor or with other practice staff. This is a burden for many GPs and when the anticipated increase in the frequency and length of rural placements occurs what is currently a burden will become unsustainable. The changing gender and cultural demographics of medical students and rural general practitioners will also contribute to stresses on this accommodation system. It is important to have a systematic approach towards more appropriate and sustainable models of accommodation for both medical students and GP registrars.