Rural: Overview

This Virtual Issue draws together a number of articles that have recently been published in The Australian Journal of Rural Health (and elsewhere) exploring dimensions and impact of the implementation of the National Disability Insurance Scheme (NDIS) on people, services and the workforce in regional, rural, and remote areas of Australia. It draws attention to some of the challenges, limitations, and undue complexity, experienced by rural people with disability and their families negotiating the system.

Abstract
Introduction: Oral and maxillofacial (OMF) injuries encompass all forms of trauma to the tissues of the oro-facial complex, the face, jaws and mouth. In rural areas, where healthcare access is often limited, OMF injuries pose unique challenges. These challenges are compounded by environmental factors, occupational hazards and socioeconomic disparities, making rural populations particularly vulnerable to such injuries. This study explores the epidemiology and geographical variation of OMF injuries in Queensland, Australia.

Methods: Data for injury from several Queensland hospital emergency departments were obtained from state register Queensland Injury Surveillance Unit for the years 2015-2021. Data parameters included patient demographics, mechanism, intent and location of injury.

Results: The data (n=9095) revealed that OMF injuries are more prevalent in rural areas and increasing in incidence. Those in inner and outer regional areas sustained injuries 1.8-2.2 times more than the metropolitan population and the incidence was 8.7-11.7 times higher in remote and very remote locations (p<0.05). Approximately 70% of injuries occurred among males in all populations, with peak age of injuries noted as 15-24 years. Assault-related injuries were the predominant cause of injury, notably more common in regional (35.6%) and remote (45.7%) areas compared to metropolitan regions (19.8%) (p<0.05).

Conclusion: The high proportion of OMF injuries experienced in rural areas signifies a considerable health concern. This may be attributable to engagement in risk-taking behaviours, contributing as aetiology or exacerbators. These findings underscore the need for targeted interventions aimed at addressing the mental health and risky behaviour patterns in rural communities. Further research should consider wider aetiological and exacerbating factors including social determinants of health, ethnicity and cultural factors that underlie interpersonal violence in these communities.

Abstract
Purpose: To reduce risk of cardiovascular disease (CVD) in adults, as assessed by primary care doctors in rural NSW, Australia. Medical nutrition therapy (MNT) was delivered by Accredited Practicing Dietitians (APDs) using telehealth.

Methods: The study was a 12-month pragmatic cluster randomised controlled trial. All primary care practices (PCPs) within a large rural region were invited to participate, with enrolled practices stratified based on rurality and practice size. Patients at moderate to high CVD risk were recruited via practices. Usual care (UC) was provided by the patient's general practitioner (GP). In addition to UC, the intervention group received two hours of MNT telehealth (video calls) consultations from an APD during five sessions over 6 months. The primary outcome was total serum cholesterol. Secondary outcomes included LDL cholesterol, triglycerides, blood glucose control, blood pressure, weight and waist circumference. Changes were analysed using Bayesian linear mixed models and posterior probability.

Findings: Sixteen PCPs recruited 132 eligible participants (n = 91 intervention, n = 41 UC), with 79% (72/91) and 80% (33/41) respectively completing a primary or secondary outcome. No significant differences were found between groups for total cholesterol, LDL cholesterol or blood pressure at 12-months. However, the intervention group had significant improvements in blood glucose control (HbA1c: -0.16%, 95%CI: -0.32, -0.01) and decreased body weight (-2.46 kg, 95%CI: -4.54, -0.41) compared to UC at 12-months.

Conclusions: Results indicate that two hours of MNT delivered by an APD via telehealth is a synergistic adjunct therapy to support the usual care provided by GP, with benefits continuing to 12-months.

Keywords: Cardiovascular disease; Dietitian; Medical nutrition therapy; Primary health care; Rural health; Telehealth.

Abstract
Indigenous communities internationally have demonstrated remarkable strength despite significant challenges. Health disparities among Indigenous peoples persist due to historical injustices and ongoing racial discrimination, not inherent vulnerabilities. Disparities are rooted in a legacy of colonisation, systemic exclusion, and socio-economic inequities impacting access to healthcare, education, and employment. Preliminary searches show limited literature on models of care for remote living Indigenous children. This review aimed to identify internationally, effective models of care for Indigenous children in rural and remote areas. A scoping review was conducted, analysing literature on models of care for remote Indigenous children. This study followed the JBI's Scoping Review Guidance and PRISMA Scoping Review guideline. Inclusion criteria were aged ≤18, rural or remote areas, majority Indigenous, reported health outcomes, described a model of care, in English, and published since 1990. Data were systematically extracted, quality appraised using the 'Aboriginal and Torres Strait Islander Quality Appraisal Tool' then analysed using descriptive-analytical methodology. This review included 16 papers: 8 case series, 3 qualitative studies, and 5 trials. Of these, 7 studies were in Australia, 7 in the USA and 2 in Canada. All studies primary aim was to improve quality of care. Models of care described in the included papers varied, being delivered in traditional healthcare settings, homes, and elsewhere in the community. This review provides insights into the design and implementation of models of care in remote communities with primarily Indigenous populations. The authors recommend 1) that future reviews privilege 'realist evaluation' when examining models of care, 2) designers consider whether a model of care will run for a fixed-period versus ongoing as they have different requirements for success and 3) a toolkit approach to model of care development like the Qungasvik toolkit which provides evidenced modules adaptable to local conditions, easing workload on local people developing programs.