Rural Clinical School - Research Publications

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    Perspectives of Aboriginal issues among non-Aboriginal residents of rural Victorian communities
    Bourke, L ; Malatzky, C ; Terry, D ; Nixon, R ; Ferguson, K ; Ferguson, P (WILEY, 2017-09)
    Abstract Racism, in various forms, remains a dominant feature in Australian society. Aboriginal Australians are commonly targets of racial discrimination. However, understanding racism is difficult given that racial attitudes vary towards particular groups of people, across place and time and are difficult to measure. This paper presents responses of residents across four rural shires in Victoria to questions about attitudes towards Aboriginal people/issues. Responses indicated that attitudes towards Aboriginal people were diverse and that individuals varied in their attitudes on specific items. There were subtle differences between the four sites and association between demographic characteristics and some items in particular sites. This suggests that respondents are inconsistent in their attitudes relating to Aboriginal people/issues and that there are place‐based influences on these attitudes. We conclude that the many varied understandings of racism and Aboriginal Australians allow the discourses of exclusion, disempowerment and othering to be maintained.
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    Prioritising the cultural inclusivity of a rural mainstream health service for First Nation Australians: an analysis of discourse and power
    Malatzky, C ; Nixon, R ; Mitchell, O ; Bourke, L (ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 2018)
    In the context of persisting health inequities within many multicultural and socially diverse countries like Australia, there is a call for health services to implement culturally inclusive systems and practices. Nowhere is this more important than in regional, rural and remote Australia where consumers are diverse, health services are scarce, and services designed for particular groups of the population are lacking. Drawing on interviews with 20 staff of a rurally-based, mainstream community health service, this article examines the role of discourse in the transition to a culturally inclusive health centre. In doing so, the power struggles inherent in such a process are highlighted. The article contends that improvements in the health outcomes of First Nation and culturally Other groups within the Australian population is contingent upon systematic resistances that disrupt and re-arrange existing dominant discourses. This calls for a disruption of current race relations in both broader social fields as well as those supporting biomedical assumptions about the delivery of healthcare in the mainstream health sector. Alternative discourses must be promoted in both these fields.
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    Chronic ill health in a regional Victoria setting: A 13-year comparison
    Glenister, K ; Bourke, L ; Terry, D ; Simmons, D (WILEY, 2019-12)
    OBJECTIVE: High-quality data regarding the prevalence of chronic disease in rural areas are essential in understanding the challenges faced by rural populations and for informing strategies to address health care needs. This study compared the prevalence of a range of self-reported chronic conditions and utilisation of GP services and emergency department in a regional Victorian setting between two studies conducted in the same region in 2001-2003 and 2014. DESIGN: Repeat cross-sectional studies conducted over a decade apart. SETTING: The projects were conducted in the Goulburn Valley in regional Victoria. PARTICIPANTS: The earlier study randomly selected households from local government lists. The later study randomly selected householders from the telephone directory. MAIN OUTCOME MEASURES: Participants were asked whether they had been diagnosed with a range of chronic health conditions and how often they had visited a general practitioner or emergency department in the past 12 months. RESULTS: The age-standardised prevalence of depression was higher in the 2014 study than the 2001-2003 study in men (increased by 8.0% (95% CI 4.5, 11.5%)) and women (increased by 13.7% (95% CI 8.4, 19.0%)). Similarly, the prevalence of age-standardised diabetes and hypertension was higher in 2014 than 2001-2003 (men increased by 3.6% (95% CI 0.7, 6.5% (diabetes)) and 13.6% (95% CI 8.6, 18.6% (hypertension)), women increased by 3.1% (95% CI 0.3, 6.5% (diabetes)) and 8.4% (95% CI 2.3, 14.5% (hypertension))). CONCLUSION: The results of this study indicate that the prevalence of self-reported depression, diabetes and hypertension has increased in this regional Victorian area over the past 13 years. The reasons for these observed increases and the subsequent impact on the health care needs of regional communities warrants further investigation.
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    More than just numbers! Perceptions of remote area nurse staffing in Northern Territory Government health clinics
    Dunbar, T ; Bourke, L ; Murakami-Gold, L (WILEY, 2019-06)
    OBJECTIVE: The need for more Remote Area Nurses in the Northern Territory is clear. This paper investigates the perspectives of Remote Area Nurse workforce issues among multiple stakeholders. The aim is to identify how Remote Area Nurse staffing issues are perceived by clinic managers, Remote Area Nurses themselves, Aboriginal colleagues and community members in seven remote communities in the Northern Territory. DESIGN: This is a qualitative study that uses interviews and focus groups to identify key messages of local stakeholders about Remote Area Nurse workforce issues. A content analysis was used for data analysis. SETTING: Seven diverse remote Aboriginal communities in the Northern Territory with government-run health clinics were visited. PARTICIPANTS: Non-random sampling techniques were used to target staff at the clinics at the time of field work. Staff and community members, who agreed to participate, were interviewed either individually or in groups. Interviews were conducted with 5 Managers, 29 Remote Area Nurses, 12 Aboriginal staff (some clinics did not have Aboriginal staff) and 56 community residents. Twelve focus groups were conducted with community members. RESULTS: Content analysis revealed that participants thought having the "right" nurse was more important than having more nurses. Participants highlighted the need for Remote Area Nurses to have advanced clinical and cultural skills. While managers and, to a lesser extent, Remote Area Nurses prioritised clinical skills, Aboriginal staff and community residents prioritised cultural skills. CONCLUSIONS: Participants identified the importance of clinical and cultural skills and reiterated that getting the "right" Remote Area Nurse was more important than simply recruiting more nurses. Thus, retention strategies need to be more targeted and cultural skills prioritised in recruitment.
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    Different perspectives on the key challenges facing rural health: The challenges of power and knowledge
    Malatzky, C ; Bourke, L (WILEY, 2018-12)
    OBJECTIVE: To examine the effects of dominant knowledge in rural health, including how they shape issues central to rural health. In particular, this article examines the roles of: (i) deficit knowledge of rural health workforce; (ii) dominant portrayals of generalism; and (iii) perceptions of inferiority about rural communities in maintaining health disparities between rural- and metropolitan-based Australians. DESIGN: A Foucauldian framework is applied to literature, evidence, case studies and key messages in rural health. Three scenarios are used to provide practical examples of specific knowledge that is prioritised or marginalised. RESULTS: The analysis of three areas in rural health identifies how deficit knowledge is privileged despite it undermining the purpose of rural health. First, deficit knowledge highlights the workforce shortage rather than the type of work in rural practice or the oversupply of workforce in metropolitan areas. Second, the construction of generalist practice as less skilled and more monotonous undermines other knowledge that it is diverse and challenging. Third, dominant negative stereotypes of rural communities discourage rural careers and highlight undesirable aspects of rural practice. CONCLUSION: The privileging of deficit knowledge pertaining to rural health workforce, broader dominant discourses of generalism and the nature of rural Australian communities reproduces many of the key challenges in rural health today, including persisting health disparities between rural- and metropolitan-based Australians. To disrupt the operations of power that highlight deficit knowledge and undermine other knowledge, we need to change the way in which rural health is currently constructed and understood.
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    A modified Continuous Quality Improvement approach to improve culturally and socially inclusive care within rural health services
    Mitchell, O ; Malatzky, C ; Bourke, L ; Farmer, J (WILEY, 2018-06)
    BACKGROUND: The sickest Australians are often those belonging to non-privileged groups, including Indigenous Australians, gay, lesbian, bisexual, transsexual, intersex and queer people, people from culturally and linguistically diverse backgrounds, socioeconomically disadvantaged groups, and people with disabilities and low English literacy. These consumers are not always engaged by, or included within, mainstream health services, particularly in rural Australia where health services are limited in number and tend to be generalist in nature. OBJECTIVE: The aim of this study was to present a new approach for improving the sociocultural inclusivity of mainstream, generalist, rural, health care organisations. DESIGN: This approach combines a modified Continuous Quality Improvement framework with Participatory Action Research principles and Foucault's concepts of power, discourse and resistance to develop a change process that deconstructs the power relations that currently exclude marginalised rural health consumers from mainstream health services. It sets up processes for continuous learning and consumer responsiveness. RESULTS: The approach proposed could provide a Continuous Quality Improvement process for creating more inclusive mainstream health institutions and fostering better engagement with many marginalised groups in rural communities to improve their access to health care. CONCLUSION: The approach to improving cultural inclusion in mainstream rural health services presented in this article builds on existing initiatives. This approach focuses on engaging on-the-ground staff in the need for change and preparing the service for genuine community consultation and responsive change. It is currently being trialled and evaluated.
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    Participation in rural community groups and links with psychological well-being and resilience: a cross-sectional community-based study.
    Lyons, A ; Fletcher, G ; Farmer, J ; Kenny, A ; Bourke, L ; Carra, K ; Bariola, E (Springer Science and Business Media LLC, 2016-04-08)
    BACKGROUND: Fostering the development of community groups can be an important part of boosting community participation and improving health and well-being outcomes in rural communities. In this article, we examine whether psychological well-being and resilience are linked to participating in particular kinds of rural community groups. METHODS: We conducted a household survey involving 176 participants aged 18 to 94 years from a medium-sized rural Australian town. We gathered data on psychological well-being (Warwick-Edinburgh Mental Well-being Scale), resilience (Brief Resilience Scale), and the types of community groups that people participated in as well as a range of characteristics of those groups, such as size, frequency of group meetings, perceived openness to new members, and whether groups had leaders, defined roles for members, hierarchies, and rules. RESULTS: Univariable regression analyses revealed significant links between particular group characteristics and individual psychological well-being and resilience, suggesting that the characteristics of the group that an individual participates in are strongly tied to that person's well-being outcomes. Multivariable analyses revealed two significant independent factors. First, psychological well-being was greatest among those who participated in groups without a hierarchy, that is, equal-status relationships between members. Second, resilience was greater among those who reported having a sense of influence within a group. CONCLUSIONS: Our findings suggest that policymakers wishing to promote participation in rural community groups for health and well-being benefits may do well to encourage the development of particular characteristics within those groups, in particular equal-status relationships and a sense of influence for all group members.
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    Remote health workforce turnover and retention: what are the policy and practice priorities?
    Wakerman, J ; Humphreys, J ; Russell, D ; Guthridge, S ; Bourke, L ; Dunbar, T ; Zhao, Y ; Ramjan, M ; Murakami-Gold, L ; Jones, MP (BMC, 2019-12-16)
    BACKGROUND: Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention. MAIN TEXT: Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'. CONCLUSION: Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.
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    Longitudinal study of health, disease and access to care in rural Victoria: the Crossroads-II study: methods
    Glenister, KM ; Bourke, L ; Bolitho, L ; Wright, S ; Roberts, S ; Kemp, W ; Rhode, L ; Bhat, R ; Tremper, S ; Magliano, DJ ; Morgan, M ; Marino, R ; Adam, W ; Simmons, D (BIOMED CENTRAL LTD, 2018-05-30)
    BACKGROUND: High quality, contemporary data regarding patterns of chronic disease is essential for planning by health services, policy makers and local governments, but surprisingly scarce, including in rural Australia. This dearth of data occurs despite the recognition that rural Australians live with high rates of ill health, poor health behaviours and restricted access to health services. Crossroads-II is set in the Goulburn Valley, a rural region of Victoria, Australia 100-300 km north of metropolitan Melbourne. It is primarily an irrigated agricultural area. The aim of the study is to identify changes in the prevalence of key chronic health conditions including the extent of undiagnosed and undermanaged disease, and association with access to care, over a 15 year period. METHODS/DESIGN: This study is a 15 year follow up from the 2000-2003 Crossroads-I study (2376 households participated). Crossroads-II includes a similar face to face household survey of 3600 randomly selected households across four towns of sizes 6300 to 49,800 (50% sampled in the larger town with the remainder sampled equally from the three smaller towns). Self-reported health, health behaviour and health service usage information is verified and supplemented in a nested sub-study of 900 randomly selected adult participants in 'clinics' involving a range of additional questionnaires and biophysical measurements. The study is expected to run from October 2016 to December 2018. DISCUSSION: Besides providing epidemiological and health service utilisation information relating to different diseases and their risk factors in towns of different sizes, the results will be used to develop a composite measure of health service access. The importance of access to health services will be investigated by assessing the correlation of this measure with rates of undiagnosed and undermanaged disease at the mesh block level. Results will be shared with partner organisations to inform service planning and interventions to improve health outcomes for local people.
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    Improving inclusion in rural health services for marginalised community members: Developing a process for change
    Malatzky, C ; Mitchell, O ; Bourke, L (GRIFFITH UNIV, SCH HUMAN SERVICES & SOCIAL WORK, 2018-01-01)
    Australia’s mainstream health services located in rural contexts are mandated to provide health care to the entire local population. However, complex power relations embedded and reflected within the cultures of mainstream generalist health services are excluding the most marginalised residents from health care. This paper argues that unless inclusion in rural, generalist mainstream health services is improved, the health experiences of these residents will not substantially change and Australia will continue to report significant health differentials within its population. The concept of culturally inclusive health care is difficult for Australian mainstream generalist health practitioners to engage with because there is limited understanding of what culture is and how it operates within diverse communities. This makes it challenging for many in mainstream health institutions to begin deconstructing how it is that exclusion occurs. Frequently, ‘culture’ is assigned to ‘Others’, and there is little recognition that all people, including White, mainstream Australians, are cultural beings, and that health disciplines, services and systems have particular cultures that make assumptions about how to be in the world. Consequently, current approaches to the provision of culturally inclusive health care are not shifting the power relations that (re)produce exclusion. In this paper, we outline a new interdisciplinary methodology that operationalises Foucault’s concepts of power, resistance and discourse within a Participatory Action Research (PAR) design and utilises Continuous Quality Improvement (CQI) processes to respond to these power relations and provide health institutions with a process to improve their inclusivity, specifically for Australia’s most marginalised residents. It is suggested that employing this new methodology will promote a different way of thinking and acting in health institutions, producing a deconstructed process for health services to adapt to improve their inclusivity.