Rural: Overview

Abstract
Background: Together with addressing social determinants of health, culturally safe healthcare provision is essential for closing the health outcomes gap experienced by Aboriginal and Torres Strait Islander (Indigenous) Australians. Rural placements potentially provide students of the health professions with opportunities to enhance their knowledge and skills regarding cultural safety. We used rural placements data systematically collected from allied health students, including commencement- and end-of-placement questionnaire responses, to investigate the determinants of confidence in working with Indigenous people.

Methods: The study comprised data from all students who provided survey data at both commencement and end of their first placement directly supervised by the administering University Department of Rural Health during the period 2019-2022. Five-point ordered responses to the question 'How confident do you feel about working with Aboriginal people?' were used to assess student and placement-related determinants of confidence (Confident/Very confident versus other) at baseline and increased confidence (≥ 1 point) during the placement using crude and adjusted multivariable robust Poisson regression.

Results: Participating students (N = 489) were from diverse allied health disciplines (including pharmacy n = 94, 19.2%; chiropractic n= 66, 13.5%; physiotherapy n= 65, 13.3%; social work n = 59, 12.1%; and occupational therapy 58, 11.9%). Confidence in dealing with Aboriginal people was lower at commencement among females compared with males (adjusted relative risk [aRR] 0.65; 95% confidence interval [CI] 0.53-0.80), and higher among students of Australian rural origin compared with others (aRR 1.49; CI 1.22-1.83) and those who reported previous experience working with Indigenous people compared with those reporting none (aRR 1.40; CI 1.14-1.72). Placement attributes associated with increased confidence working with Indigenous people between placement commencement and end were interaction with Indigenous people within the placement (aRR 2.32; CI 1.24-4.34), placement model reflecting more structured academic supervision (aRR 1.18; CI 1.02-1.37), and placement length (aRR per additional day 1.002; CI 1.001-1.004). These associations were robust to modelling that accounted for a ceiling effect on increased confidence.

Conclusions: While influenced by students' demographic attributes and prior experiences, confidence of allied health students in working with Indigenous people is enhanced during rural placements, particularly through direct contact with Indigenous people.

Abstract
Background: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality and residing in a rural and remote region is associated with an increased risk. The impact of rurality on CVD outcomes needs to be fully elucidated.

Objectives: The purpose of this study was to assess the difference in mortality, readmission within 30 days, total readmissions, survival, and total emergency department (ED) presentations following an index CVD admission among patients from rural or remote areas as compared to metropolitan areas.

Methods: This retrospective observational study included all index hospitalizations with heart failure (HF), atrial fibrillation (AF), or acute coronary syndrome (ACS) within the Hunter New England region of Australia, between January 1, 2008, and December 31, 2021.

Results: There were 27,995 ACS admissions, 15,586 HF admissions, and 16,935 AF admissions. Patients from a rural or remote area presenting with CVD presentations had increased 30-day readmission (OR: 1.19; P < 0.001), an increased number of readmissions (incident rate ratio: 1.19; P < 0.001), and more ED presentations (incident rate ratio: 1.39; P < 0.001) as compared to patients from metropolitan areas. This was consistent across patients presenting with ACS, HF, and AF. There was no difference in mortality (HR: 1.01; P = 0.515). However, in the ACS subgroup, there was increased mortality in the rural and remote population (HR: 1.05; P = 0.015).

Conclusions: This study highlights the increased incidence of ED presentations and hospital readmissions, for those living in rural Australia, illustrating the disparity in health care provided, and the ongoing need for interventions that address poorer access to specialized health care in the early discharge phase of hospitalization.

Abstract
Objective: To evaluate the importance of rural internships to observed medical workforce distribution outcomes up to 8 years post-medical school.

Design and setting: Cohort study of medical graduates of The University of Queensland (UQ), Australia.

Participants: UQ graduates who were medical interns in Queensland's public health system between 2014 and 2021 and observed working in Australia in 2022. Internship location was defined as being metropolitan or rural, along with other key rural exposures of whether they are of rural origin (childhood) and whether at least 1 year of clinical training at medical school was in a rural location.

Primary outcome measure: Current work location was collected from the Australian Health Practitioner Regulation Agency (AHPRA) in 2022, classified as either rural or metropolitan and measured in association with their internship location.

Results: From 1930 eligible graduates, 21.5% took up a rural internship, which was associated with rural origin (OR 1.5, 95% CI 1.2 to 2.0) and medical school rural immersions of either 1 year (OR 2.8, 95% CI 2.1 to 3.7) or 2 years (OR 5.8, 95% CI 4.4 to 7.7). Completing a rural internship was associated with currently working rural (47% vs 14%, OR 4.6, 95% CI 3.5 to 5.9), which weakened the observed (adjusted) effect of rural origin (OR 1.5, 95% CI 1.2 to 2.0) or medical school rural immersions (1 year: OR 1.4, 95% CI 1.0 to 1.9; 2 years: OR 1.7, 95% CI 1.2 to 2.3). All combinations of the key rural exposures that included rural internship had the highest proportions currently working rurally (range 32-69%) compared with the combinations with a metropolitan internship (range 12-22%).

Conclusions: Internship location appears to be a critical factor in shaping medical workforce distribution decisions. This evidence supports the need for strengthened and expanded rural training pathways after medical school. In particular, clearer pathways into specialty programmes via rural internships are likely to support increased numbers choosing (with confidence) to preference rural internship first and subsequently more working in rural areas long term.