Tesi sul tema "Rural and remote health"

This research was stimulated by the knowledge that dental services to rural and remote consumers in Australia are unpredictable and will remain so into the future. Rural and remote consumers are disadvantaged in their access to dental services due to distance, scarcity of dentists, lack of choice· and variable quality of treatment and facilities. Nonetheless, it is clear that some rural and remote consumers are able to achieve sound oral health. This study examined these dental consumers in order to identify characteristics which may contribute to their success. Providing appropriate and adequate dental services to rural and remote towns is predicted to become more difficult and require greater travel due to both a reduction in the number of dentists and a smaller population base. Encouraging rural residents to become more effective as dental consumers may result in improved preventive practices, more positive attitudes to oral health and better dental status. Dental effectiveness is improved when the dentist-patient relationship is sound and when there is a source of routine and continuing dental care, features which should form part of public health policies and training of rural dentists.

Pulmonary rehabilitation, consisting of exercise training and education, is one of the most effective strategies for improving the health outcomes of people with chronic obstructive pulmonary disease (COPD) and reducing associated healthcare costs. Prior to the work presented in this thesis a description of the structure and content of pulmonary rehabilitation programs in Australia had not been published. In addition, whether existing programs met Australian recommendations for practice such as those contained in the Pulmonary Rehabilitation Toolkit, was unknown. Despite the significant benefits for both individuals with COPD and the community, access to pulmonary rehabilitation is limited, particularly for those in rural and remote regions. A lack of adequately trained healthcare professionals may contribute to difficulties with establishing and maintaining pulmonary rehabilitation. However, the effect of healthcare professional training on the availability of pulmonary rehabilitation had not been previously investigated. There were no published reports documenting existing knowledge and skill levels, evaluating training strategies to up-skill rural/remote healthcare professionals or evaluating the impact of such training on the delivery of pulmonary rehabilitation. The aims of the studies presented in this thesis were to: describe the current provision of pulmonary rehabilitation in Australia and the alignment of these pulmonary rehabilitation programs with evidence-based recommendations; determine the level of knowledge and skills of rural and remote healthcare professionals in the management of people with chronic lung disease; investigate the ability of an educational training program for healthcare professionals to improve knowledge and confidence and improve the availability and delivery of pulmonary rehabilitation in rural and remote regions and explore the attitudes, opinions and concerns of healthcare professionals regarding the delivery of pulmonary rehabilitation. The first study (Chapter 2) was a cross sectional, observational study using a purpose designed anonymous paper-based survey. The national database of pulmonary rehabilitation programs, maintained by Lung Foundation Australia (LFA), was used to identify known programs in all states and territories of Australia. All pulmonary rehabilitation programs listed on the database at that time were included (n=193). Healthcare professionals who coordinated pulmonary rehabilitation were invited to participate. This study had a response rate of 83% (n=163) and all states and territories in Australia were represented. The responses enabled the structure and content of Australian pulmonary rehabilitation programs to be elucidated. Most Australian pulmonary rehabilitation programs broadly met recommendations for practice contained in the Pulmonary Rehabilitation Toolkit in terms of included components (exercise training and education), program length, patient assessment and exercise training (duration, frequency and mode). Many respondents were not aware of major evidence-based practice guidelines (including the Pulmonary Rehabilitation Toolkit). Interestingly, despite not being aware of guidelines, most respondents indicated that they perceived a gap between current evidence and their practice in terms of exercise prescription and training. The studies presented in Chapters 4-7 were undertaken as individual components of a mixed methods study to evaluate the impact of the Breathe Easy Walk Easy (BEWE) program on healthcare professional knowledge and confidence, service delivery and patient outcomes in rural and remote Australian regions. The BEWE program was an interactive education and training program related to providing components of assessment and management (in particular pulmonary rehabilitation) for people with chronic respiratory disease. The BEWE program consisted of a training workshop, access to online resources, provision of community awareness-raising materials and ongoing telephone/email support. Details of the development of the BEWE program are presented in Chapter 1. Further information regarding the content and structure of the BEWE program along with relevant methods for the studies contained in Chapters 4-7, are presented in Chapter 3. The evaluation process was conducted by a researcher (the PhD candidate) who was independent of the development and delivery of the BEWE program. The study presented in Chapter 4 was a descriptive cross-sectional, observational survey design using a written anonymous questionnaire. Participants were healthcare professionals (n=31) who registered to attend the BEWE program initial workshop in either one rural or one remote Australian region. The main outcomes were participant attitudes, objective knowledge (case vignette-based) and self-rated experience, training, and levels of confidence. Participants were from a variety of professional backgrounds (allied health, medical, nursing) but were predominantly nurses (n=13) or physiotherapists (n=9). The main findings of this study were that that rural and remote healthcare professionals had low levels of experience, training, knowledge and confidence in providing components of management for people with COPD. Most participants reported that they had minimal or no experience or training in this area of practice. The scores in the measured knowledge quiz were generally poor, with mean knowledge score (number of correct answers out of 19) being 8.5 (SD=4.5). There were higher numbers of correct responses for questions relating to COPD disease pathophysiology and diagnosis than for questions relating specifically to pulmonary rehabilitation. In addition, most participants reported particularly low confidence in the delivery of pulmonary rehabilitation. Based on the findings of the study, the need for an education and training program for rural and remote healthcare professionals in the evidence-based management of people with COPD with an emphasis on pulmonary rehabilitation was evident. The effects of the delivery of an education and training program on healthcare professional knowledge and confidence in the management of people with COPD and on the availability of pulmonary rehabilitation were investigated and are presented in Chapter 5. This study was a quasi-experimental, before and after repeated measures design. Healthcare professionals (n=33) from various backgrounds who participated in the BEWE program were eligible to participate. The BEWE program was delivered in one rural and one remote region. Participant knowledge, confidence and attitudes were assessed via anonymous written questionnaire before, immediately after and at three and 12 months following the BEWE workshop. Participation in the BEWE program resulted in significant improvements in participants’ self-rated knowledge and confidence immediately after the workshop, and at three and 12 month follow-up. Measured knowledge (case vignette score out of 19) improved significantly immediately after the workshop compared to before (mean difference 7.6 correct answers, 95% CI 5.8 to 9.3). At 12-month follow-up, three locally run pulmonary rehabilitation programs had been established in participating regions. The availability of pulmonary rehabilitation following delivery of the BEWE program, as well as patient outcomes and the factors contributing to the change in service delivery were further explored and results are presented in Chapter 6. Data were collected regarding the provision of pulmonary rehabilitation services before and after delivery of the BEWE program and patient outcomes (six-minute walk test and health related quality of life) before and after pulmonary rehabilitation. Pulmonary rehabilitation was not available in any of the participating sites before the BEWE program. At 12-month follow-up three sites had established locally-run pulmonary rehabilitation programs which had a structure and content broadly meeting Australian practice recommendations for pulmonary rehabilitation. Initial patient outcome data for the six-minute walk test and the St George’s Respiratory Questionnaire demonstrated evidence of the effectiveness of these pulmonary rehabilitation programs in improving functional exercise capacity and health related quality of life. Providing targeted specific training, the retention of key staff and strong local healthcare organisational support were important factors which contributed to the successful establishment of pulmonary rehabilitation. A study involving interviews with key healthcare professionals involved in the delivery of pulmonary rehabilitation in rural and remote regions was conducted and is presented in Chapter 7. Those healthcare professionals who participated in the BEWE program and who were identified as key informants, were invited to participate in semi-structured interviews. The purpose of the interviews was to gain a deeper understanding of the participants’ attitudes and opinions regarding developing, establishing and delivering pulmonary rehabilitation in rural and remote regions. This study was designed to add perspective to the quantitative data rather than to inform the design of the evaluation process. Interviews occurred at three and 12 months following the BEWE workshop in the remote region and at 12 months following the BEWE workshop in the rural region. Interviews were recorded and transcribed verbatim. A process of thematic analysis was used to analyse the transcripts. Healthcare professional staffing levels, time and case load constraints, knowledge and confidence, ensuring sustainability, individual and community attitudes, and practical issues related to the setting, structure and content of pulmonary rehabilitation were identified as the main concerns of informants. The results of this study indicate that dedicated funding to support additional healthcare professional staffing and to assist with providing specific education and training may facilitate the availability and delivery of pulmonary rehabilitation in rural and remote regions. The body of work contained in this thesis has contributed to a greater knowledge of the practice and availability of pulmonary rehabilitation in the Australian rural and remote context and has provided evidence that the provision of a training program for healthcare professionals can facilitate the delivery of effective pulmonary rehabilitation in rural and remote Australian regions.

The way healthcare services are delivered in remote and rural Scottish communities is in a state of reconfiguration. At the same time the NHS faces pressure to plan these new services in partnership with communities themselves. Evidence, however, suggests that this is not necessarily being done well. This study considered the contextual aspects of remote and rural Scottish communities that may impact on healthcare-related engagement, and examined current understanding of what constitutes a ‘good’ engagement process. It then went on to consider a two-year action research project (RSF) that took place in four remote and rural Scottish communities to engage local residents in an anticipatory process co-designing their own future healthcare services. Finally, this study examined ways in which individuals were able to wield power within the engagement described in the RSF project, by using a combination of participant observation and Foucauldian Discourse Analysis. As well as making a number of practical recommendations for future engagement practice in a remote and rural context, this study makes three key contributions. Firstly, it contributes further contextual knowledge about the challenges of engaging with remote and rural Scottish communities for local healthcare service design; a topic about which little has been written. Secondly, it contributes a novel method for anticipatory healthcare budgeting aimed at a remote and rural Scottish context, namely the RSF Game. Thirdly, it draws the conclusion that individual (non-elite) community members have the ability to use French and Raven’s bases of social power to impact the engagement process at all stages, and also posits that discourse can be used within rural engagement as a new ‘base of power’, which contributes to the debate around individual power and agency within remote and rural community engagement for healthcare, which few studies have examined.

Interprofessional teamwork is being adopted as the best way to care for patients, but it is also important to determine how future healthcare providers view this model of patient care. What are their attitudes and beliefs after having the opportunity to work in an interprofessional team? The primary objective of this study was to determine changes in health profession students’ attitudes toward interprofessional collaboration through participation in a Remote Area Medical (RAM) event in rural Appalachia. Researchers hypothesized that working in interprofessional teams positively impacts students’ attitudes toward interprofessional practice. To explore these variables, RedCap was utilized to collect demographic information, generate a pre/post survey matching code, and administer previously validated interprofessional education (IPE) questionnaires to RAM clinic student volunteers (representing five ETSU health sciences colleges and various undergraduate programs) before and after the event. Students were allowed to voluntarily complete the pre-survey online prior to participating in the event or at sign-in and the post-survey at sign-out or online after the event. The Student Perceptions of Interprofessional Clinical Education-Revised Instrument, Version 2 (SPICE-R2), which is validated for use in pre- and post-surveys, utilized 5-point Likert-type questions (strongly disagree to strongly agree) to evaluate students’ perceptions of their role on the team and the team’s impact on healthcare and patient outcomes. The Interprofessional Collaborative Competency Attainment Scale-Revised (ICCAS-R), which is only validated for use in post-surveys, required students to simultaneously evaluate their ability to perform tangible interprofessional team skills before and after the event using 5-point Likert-type questions (poor to excellent). At the event, students were placed into interprofessional teams to provide care to patients. Faculty members from a variety of professions provided leadership to the teams and guidance as needed. The pre-survey had 107 responses and the post-survey had 108 responses. However, after matching the pre- and post-surveys with student-generated codes, there were 70 valid matched responses. Data analysis was conducted using SPSS version 25. There were no statistically significant changes in SPICE-R2 IPE constructs from the pre-survey to post-survey. However, high pre-survey scores indicated that this student cohort already had a high level of appreciation for interprofessional teams, with mean scores of 4.5 out of 5 for teamwork, 4 out of 5 for roles and responsibilities, and 4.36 out of 5 for healthcare outcomes. The mean overall composite score on the ICCAS-R increased from 3.65 out of 5 on the pre-event portion to 4.03 out of 5 on the post-event portion (p < 0.001) , indicating that students increased their self-evaluated ability to perform tangible skills used in the interprofessional team through participation in the RAM clinic. Findings of this research may allow educators in both classroom and healthcare settings to better understand how hands-on IPE experiences influence students’ interprofessional attitudes and beliefs.

Background/aim: Occupational therapy service delivery must be adapted when working with Indigenous communities, as there is a diversity of beliefs, values and customs. There are currently no evidence-based models of therapy service delivery to rural and remote Indigenous children and their families. This study aims to explore occupational therapy service delivery to rural and remote Indigenous children and their families. Methods: Semi-structured telephone interviews were conducted with seven occupational therapists with experience with Australian rural and remote Indigenous children and their families. A thematic analysis was conducted on each interview with constant comparison to refine themes across interviews. Results: A total of six service delivery themes emerged from the data gathered in the interviews; flexible and accessible services; tailored services; culturally sensitive therapist; culturally inclusive services; occupational therapy awareness; and collaboration. These results linked with the need for long-term solutions, as the limited access to occupational therapy within these communities is a social injustice. Conclusion: The findings demonstrate that each Indigenous community is unique. Therapists work in collaboration with the community and use their critical reasoning skills to adjust practice accordingly. Significance of the study: This study contributes to growing knowledge about occupational therapy service provision in rural and remote Indigenous communities with children and their families. The findings will assist therapist in these communities to provide culturally aligned services. They also advocate for these communities by emphasising the basic human right violations that Indigenous communities are experiencing by not having access to consistent and culturally appropriate occupational therapy services.

Pregnant First Nations women who live on reserves in rural and remote regions of Canada are routinely evacuated to urban cities to await labour and birth; this is commonly referred to as Health Canada’s evacuation policy. I produced two stand alone papers to investigate this policy. In the first, I investigated the development and implementation of the Canadian government’s evacuation policy. Archival research showed that the evacuation policy began to take shape in 1892 and was founded on Canada’s goals to assimilate and civilize First Nations. My second paper employed First Nations feminist theory to understand why the evacuation policy does not result in good health, especially for First Nations women. Because the evacuation policy is incongruent with First Nations’ epistemologies, it compromises First Nations’ health. I offer policy recommendations to promote First Nations health in a way that is consistent with First Nations’ epistemologies and goals towards self-determination and self-governance.

Aims To investigate the impact of organisational change on the delivery of health services in remote and rural Scotland using, as an example, changes in the organisation of out of hours primary care, and to identify the attributes of successful innovation in remote and rural health provision. Methods The thesis comprised a thematic literature review; in depth interviews with key stakeholders, and case studies based in remote communities. Results The literature review identified recurring attributes of successful innovation. Interviews with remote and rural GPs showed that working out of hours had been, or still was, an integral part of life as a GP. Most agreed there had been an impact on family life. Advantages and challenges of remote and rural working were identified; many GPs could not envisage a better way of delivering services. This was contested by managers. There were divergent views of the 2004 GMS contract. The GPs who opted out of 24 hour responsibility experienced a transformational change in working life. All in all, there was a lack of understanding, and trust, between organisations. NHS 24 and Scottish Ambulance Service were criticised. There had been little change in out of hours service delivery since 2005, and the present configuration was seen as expensive and unsustainable. Despite these acknowledged difficulties, the view was that difficult decisions had been avoided, and a long-term solution that fits the area was required. The case studies added detail and contextual understanding of delivery of services. This could vary even within a practice area. Service delivery on islands was different, with a stronger tie between community and practice, governed by transport logistics, and difficult to understand from an outside perspective. Conclusions. The delivery of out of hours services in remote and rural Scotland has been a difficult and contested issue. Context can have different impacts, even within a very small area. Failure to innovate was associated with lack of collaboration, lack of strategy, lack of understanding of local context, and avoidance of difficult decisions. The organisational change literature demonstrated that receptive contexts for change were not present.

Interprofessional collaboration in healthcare is vital to the nation’s health and interprofessional education is of significant interest in the current academic climate and practice environment. Remote Area Medical is a non-profit healthcare organization that partners with community hosts to provide dental, vision, and medical services to medically underserved patients in remote areas of the United States and abroad. RAM mobile clinics have served over 785,000 people since their founding in 1985, providing vital healthcare services free of charge through the volunteer services of healthcare professionals. RAM mobile clinics provide an excellent opportunity for interprofessional collaboration and interprofessional education as learners partner with volunteer professionals to serve the community. The RAM mobile clinic in Gray, Tennessee was first established in 2017 and implemented the innovate utilization of undergraduate and graduate health professional students from the East Tennessee State University Academic Health Sciences Center in student teams. Interprofessional student teams along with precepting faculty are flexible in location and services offered to best serve the needs of the mobile clinic at any given time. Interprofessional student teams work to improve patient utilization of services offered at the event and assist with medication histories and health screens while growing student interprofessional patient care skills in the process. The objective of this research is to describe the impact of interprofessional student teams on patient care at the Gray, Tennessee RAM mobile clinic during the first two years. Data was collected from the years 2017 and 2018 by the student volunteer coordinator then analyzed by student researchers. The interprofessional student teams consisted of 87 student volunteers that were training in Clinical and Rehabilitative Sciences, Medicine, Nursing, Public Health, or Pharmacy over the course of the three-day mobile clinic in 2017 and 109 different student volunteers in 2018. Student teams were precepted by interprofessional faculty and logged 2,332 interventions in 2017 and 1,130 interventions in 2018. The top two interventions in 2017 were Medication Histories and Blood Glucose Screens while the top two interventions in 2018 were Medication Histories and Health Screens. Variation in number of interventions logged and type of interventions logged can be explained by event characteristics that differed between the two years. Student participants commented positively on their engagement with one another and discussions they had to better understand each other’s professions between patient encounters. This research attempts to demonstrate that the impact of interprofessional student teams at a RAM mobile clinic is worth the investment of faculty resources in planning and execution to engage student learning while benefitting the patient population being served. This research also provided a hypothesis for additional research to be conducted around the 2019 Gray, Tennessee RAM mobile clinic.

This thesis examines the susceptibility of human health to climate-related stresses in the rural municipality of Addington Highlands, Ontario. Human health is sensitive to climatic variations and change, and public health systems play a role in managing climate-related risks. Canada is generally deemed to have considerable capacity to adapt to vulnerabilities associated with climate change, yet there is variability among communities in their exposure and ability to manage health risks. This thesis examines the health-related vulnerability of the community of Addington Highlands. Drawing upon data gained from key informant interviews and newspaper articles, as well as other secondary data sources, the thesis documents climate-related health risks, outlines the programs and services available to deal with those risks, and assesses the capacity of the community to adapt to future climate conditions and risks. Conditions such as storms, heat stress and forest fires currently present health risks in the area, and they are expected to become more prevalent with climate change. The health risks of Lyme disease, West Nile virus and algal blooms are likely to increase in the future as the climate continues to change. Adaptation to these risks is evident in several of Addington Highlands public health and emergency management programs. The community’s adaptive capacity is strengthened by its social networks and institutional flexibility, but it is constrained by its aging population, limits to the availability and access to health care services, and challenges relating to the retention of service providers. An important strategy to assist adaptation to climate change risks to health is the promotion of public awareness, a strategy to which this research contributes. This thesis research serves to identify and better understand vulnerabilities, and help stimulate actions toward preparing Addington Highlands for possible future climate-related risks.

Background to the study: The long term maintenance of lymphoedema depends on a daily regime of these physical therapies, which lend themselves to self-management by those with the condition (Lymphoedema Framework, 2006). It has been widely recognised in the literature for many years, e.g. Rose et al (1991) to Fu (2010), that achieving a reduction in volume of the lymphoedema and ensuring the ongoing maintenance of the condition is dependent upon knowledgeable healthcare professionals and patients, who are aware of the importance of self care and self management in the long term maintenance of the condition. The challenges for effective lymphoedema management may be exacerbated when the person lives in a very remote and rural area. It has been recognised by policymakers that sparsely populated and geographically remote areas need different healthcare solutions as many of the healthcare policies designed for urban areas are not applicable or sustainable in these areas (British Medical Association, 2005). Estimating the prevalence of the condition and considering the experience of a sample of people with lymphoedema who live in a very remote and rural area will contribute to the knowledge of the requirements for a lymphoedema service to be effective in such an area. Aims: To estimate the prevalence of lymphoedema/chronic oedema and to investigate the characteristics of the condition in a very remote and rural area of Scotland and to explore the experience of a sample of people living with the condition in that area. Methods: A mixed methods research strategy was used. An initial survey of GP practices was undertaken to estimate the prevalence of lymphoedema/chronic oedema and to generate a sample for the other two stages of the study. A postal questionnaire was used to collect quantitative and qualitative information from the initial sample, and to generate a smaller sample to participate in individual semi-structured qualitative interviews exploring the experience of living with and self-managing lymphoedema/chronic oedema in a very remote and rural area in the north of Scotland. Results: The estimated prevalence rate, based on GP report, was higher than that noted in prevalence studies in large urban areas. Based on questionnaire responses, 53% of participants stated their lymphoedema made no difference to how they felt about themselves. However, interviews revealed that frustration and anger was present despite acceptance of the situation; in particular, lack of information and effective treatment was a source of frustration. Many of the sample effectively self-managed their condition, based on their own commonsense experience. However, this resort to commonsense measures seemed to be as result of an apparent lack of awareness and intervention from health care professionals. Conclusions: The findings suggest that early recognition and even minimal support from a knowledgeable source at that early stage could help to maintain the lymphoedema and reduce the need for specialist treatments. Suggestions for the ways of improving early recognition of the condition and access to self-management support in a very remote and rural area are offered.

The purpose of this thesis is to describe the harvesting and dietary practices of two rural and remote Indigenous communities. The ethnographic methods of participant observations and semi-structured interviews availed an abundance of rich and detailed data that allowed for a clear understanding of the barriers these two communities face when accessing food. This is an articled-based thesis containing three parts. Part one is composed of a literature review that describes the barriers that have contributed to food insecurity problems in Indigenous communities. It finishes with a chapter dedicated to defining the postcolonial theoretical perspective and describing how and why it was employed during this research process. The postcolonial perspective was chosen to best understand the historical forces that caused food insecurity in Indigenous communities and justify my position as a non-indigenous researcher in the field of Indigenous health. The second part of the thesis is made up of two articles. Article one will describe the current situation of food access challenges and responses in Canada, more specifically in two rural and remote First Nations communities. The article illustrates how both First Nations are experiencing challenges obtaining healthy food from the market and from the land. The article describes what is involved in acquiring food in both communities, and the responses each community is taking to increase food access. The article concludes by pointing out how these initiatives are building more than just food capacity and why they deserve greater external support. The second article is focused solely in the community of Wapekeka, and is entitled The Cost of Local Food Procurement in One Northern Rural and Remote Indigenous Community. The purpose of the article is to provide a specific example of building local food capacity as strategy to address food insecurity. It documents the costs associated with traditional food procurement and compares these costs against the price of food available in the store. The final component of the thesis is the overall conclusion, highlighting the belief that the findings presented in this thesis will promote and emphasize the importance of land-based food initiatives as a way to foster positive health outcomes for all Indigenous peoples.

Introduction: Remote Area Medical (RAM), a non-profit organization serving underserved populations, partnered with East Tennessee State University to provide a unique learning opportunity for student volunteers at a clinic in rural Appalachia. Interprofessional student teams were established with undergraduate and graduate students in multiple professions. This study examined the impact on attitudes of students who participated and the impact of student teams on the event, hypothesizing that a positive impact would be seen on both. COVID-19 adjustments made were also evaluated. Methods: Surveys of student participants were conducted electronically utilizing REDCap before and after participation in the event. Surveys included demographic questions, validated surveys, and open-ended questions. Demographic questions gauged personal background, level of education, and history of interprofessional education or events. The previously validated surveys utilized were the Interprofessional Collaborative Competency Attainment Scale-Revised (ICAAS-R) and the Student Perceptions of Interprofessional Clinical Education-Revised Instrument Version 2 (SPICE-R2). Quantitative data was analyzed with SPSS version 25. Qualitative data was analyzed with deductive coding. Interventions were tallied by student teams during the event. Results: Eighty-nine students participated logging 1,213 interventions and 84 completed portions of the survey (94% response rate). ICAAS-R (n=79) displayed mean increases from 4.19 out of 5 in the pre-survey to 4.58 in the post-survey (p Conclusion: Statistically significant quantitative findings and qualitative themes supported the hypothesis that working in interprofessional teams at a RAM event would positively impact student attitudes towards interprofessional practice, and that student teams would have a positive impact on the event. COVID-19 adjustments made were well perceived. Findings can be summarized with the I.M.P.A.C.T. neumonic.

Background: The weak health network in post-war Liberia is likely a primary contributor to the unprecedented 2014 Ebola outbreak in West Africa. This paper seeks to assess gaps in the health system prior to the epidemic by evaluating changes in access to maternal and child health services in a remote region compared to rural averages from 2007-2013. Methods: We conducted a two-staged cluster survey in 2012 in the remote district of Konobo, Liberia. Our primary outcomes of interest were access to prenatal, peri-natal and postnatal care, and access to sick child services. We compared results from our survey to the rural sub-samples from the Demographic and Health Survey (DHS) in 2007 and 2013 to assess for differential service utilization in remote regions. Results: Although most child and maternal health indicators improved in the DHS rural sub-sample from 2007 to 2013, this progress was not reflected in the remote Konobo population. Fewer women received 4+ antenatal care visits (OR 0.28, P< 0.001) and any postnatal care (OR 0.25, P<0.001) in Konobo as compared to the 2013 DHS. Similarly, fewer children received professional care for common childhood illnesses, including acute respiratory infection (9% vs 52%, P<0.001) and diarrhea (11% vs. 46%, P< 0.001). Conclusions: Even before the Ebola epidemic, residents in remote areas of Liberia had severely limited access to basic services. Most indicators remain below 2013 levels, despite the overall progress seen elsewhere in rural Liberia from 2007-2013. As attention turns to rebuilding the healthcare infrastructure in Liberia, a specific focus on remote areas will be crucial.

Title Applying collective impact to improve health services for Aboriginal people in rural and remote communities. Aim The aim of this thesis was to examine whether utilising a collective impact model of design, implementation and evaluation improves effectiveness and efficiency of health care services for Aboriginal Australians. Background Colonisation had a devastating impact on the culture, health, population and wellbeing of Aboriginal Australians. The impacts of colonisation are complex, long standing, entrenched and wide ranging. Collective Impact is a structured five-stage and three-phase process which facilitates community engagement in resolving highly complex or wicked problems. The purpose of this research is to determine the efficacy of utilising collective impact in the design, implementation and evaluation of health care services for Aboriginal people in Australia. Methods Mixed methods are utilised in this research including: systematic reviews; interviewer assisted surveys; semi-structured interviews; and retrospective comparison of two data sets. The data is analysed descriptively and thematically; and the retrospective comparative data is analysed quantitatively. Results and discussion Quantitative and qualitative evidence is provided in this research to support the finding that collective impact is efficacious in engaging Aboriginal people in the design, implementation and evaluation of health care services intended for them. The collective impact approach is demonstrated to result in successful, well designed programs and increase the efficacy of health services. Conclusions Collective impact is a suitable tool for health care policy makers, managers and funders to utilise to expedite progress with improving health outcomes for Aboriginal Australians. Key words Aboriginal, health outcomes, collective impact, service design, workforce development, program evaluation.

The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) aims to improve access, safety, and service coordination of specialist emergency mental health care via telehealth technologies. The program was planned and developed in response to the population needs and unique geographic conditions to provide specialist care while maintaining and supporting the role of existing local services. It is the first to provide 24-hour access to a regionally-based team of specialists offering relevant and responsive information, support, and clinical services for all providers, patients, and residents needing emergency care from the rural and remote communities across western New South Wales (NSW), Australia. This evaluation of MHEC-RAP applied a case study methodology and the theory of access to determine whether the program provides accessible specialist emergency mental health care. The five individual studies reported here contribute to the evaluation aims of describing program activity, assessing the provision and experience of emergency mental health care through MHEC-RAP, examining program impact on access, and informing further program development, adaptation, and transferability. This evaluation is the first to examine emergency telepsychiatry use in EDs, to apply the time and motion study method to assess program efficiency, and to present a telepsychiatry model structure that may be adapted or implemented elsewhere. This evaluation offers evidence of a practical telepsychiatry program that is providing accessible emergency mental health care for consumers in communities across western NSW and is changing local practice and perspective. It also enhances the theory of access proposing a modification to the theory with the inclusion of a sixth concept - awareness. The individual study results can be used to guide the continuing development of MHEC-RAP as well as provide insights for program transferability or the development, delivery, and evaluation of other new and existing telepsychiatry services across Australia and abroad.

Librarians at the East Tennessee State University (ETSU) Quillen College of Medicine Library have provided consumer health outreach services to rural and underserved populations at Remote Area Medical (RAM) clinics since 2009. These outreach services heavily depend upon and promote consumer health websites and National Library of Medicine (NLM) resources in order to reach the largest number of people at the lowest possible cost. This article will provide a brief overview of RAM clinics in Wise, VA, and Gray, TN, served by ETSU librarians for years. Additionally, this article will discuss the evolution of ETSU QCoM librarian outreach initiatives relating to these clinics over the past decade. This article includes a list of online consumer health resources used to support these initiatives as well as a list of most commonly addressed consumer health topics.

Mental health has become an increasingly importantly focus in the UK policy landscape because of its social and economic impact. However, most research to date has focused on living with mental health issues, or providing mental health services, in urban settings. There is limited understanding of the experiences of rural dwellers with mental health issues or the role of the voluntary sector in terms of its contribution to mental health service provision in rural areas. Thus, this PhD explores the experiences of rural mental health service users and providers in Scotland and Canada, and also considers the contribution of mental health voluntary organisations in helping to overcome the challenges of social exclusion for service users, as identified in previous research. Two theoretical lenses were used to frame the research questions. First, the concept of social inclusion provided a lens to analyse the processes by which service users achieve, or not, a sense of belonging and connection in society (Philo 2000). Second, Putnam's (2000) theory of social capital provided a further analytical lens by which to explore the contribution of rural voluntary organisations. Social capital focuses on the features of populations such as social networks, trust and norms of reciprocity that shape the quality and quantity of social interactions (McKenzie & Harpham 2006). The aims of the research were to: To explore the impact of rural life for mental health service users' daily life and access of services To understand the contribution of rural mental health services to tackling social exclusion for service users The five research questions used in this thesis were: What does it mean to experience mental health problems in remote and rural areas? What are the challenges that service providers face in remote and rural areas? What benefits are there for service users attending voluntary groups in remote and rural areas?

This thesis describes the process of service provision and evaluates the non-invasive cardiac diagnostics of exercise stress testing and Holter monitoring between two Queensland rural and remote health facilities. A multi-site retrospective chart review was conducted to document testing process and quantitatively evaluate the impact of facility location on key test parameters including time frames, proportions, and the travel implications related to distance and cost to patients living in non-metropolitan areas. Findings demonstrate that patients requiring these investigations travel significantly longer distances, with a high proportion exceeding recommended process and outcome time frames compared to documented standards.

This study was conducted in the context of health service planning in an environment of changing government strategies for regional, rural and remote area health care and telecommunications infrastructure planning in Western Australia. The study provides an account of the State Government of Western Australia’s planning for the implementation of a telecommunications network infrastructure, and specifically the Telehealth Project, conducted between 1998 and 2002. The purpose of this study was to examine influences on community participation in planning within the dynamic political, economic and social forces that impact on the development of regional, rural and remote area health services. Specifically, the study outlines the issues and barriers in providing for significant local participation in projects that are centrally initiated and controlled. It examines the influences in planning for projects that incorporate local community based beliefs and needs, the requirements of collaborating with multiple state and national government departments, and the private sector. This study was situated within the interpretive paradigm, and is conceptualised within Donabedian’s (1969) framework for assessing and assuring quality in health care. The methodological approach is bound within a case study and consists of a participatory action research approach. The research method uses the single case to undertake in-depth interviews, observations and a survey to collect data from community, government and industry members as a basis for reflection and action. The findings of the study clearly indicated that there was consensus between all rural, remote and metropolitan area participants that telecommunications did offer the opportunity to provide increased, improved or alternative health services. However, there were a number of obstacles to the success of the planning process, including a lack of local community inclusion in planning committees, poor communication within central government agencies, overuse of external consultants, a bias toward the medical view, a limited scope of invitation to contribute, and local information being overlooked in the final implementation plan. Analysis of planning for the Telehealth Project reveals the implications of organisational and political stakeholders making final decisions about outcomes; and provides a reminder of the importance of engaging communities authentically when planning for health and telecommunications services which involve the public and private sectors. The originality and significance of this study stems from understanding how technology can advance community health; through measures such as the use of community participation strategies, through authentic community based leadership, truly representative participants, decentralised decision making, a focus on community based health needs and change management strategies that include all of these. Consequently, the study advances knowledge of community participation in planning, and the evidence suggests implications for practice, education and further research.

State dependency and the lingering impacts of colonialism dancing with Aboriginal peoples are known realities across the Canadian health care landscape. However, delving into the discourses of how to reduce health disparities of a colonized population is a sophisticated issue with many factors to consider. Specifically, nurses can play a central role in the delivery of essential health services to the ‘Other’ within isolated Northern Aboriginal communities. As an extension of the state health care system, nurses have a duty to provide responsive and relevant health care services to Aboriginal peoples. The conducted qualitative research, influenced by a postcolonial epistemology, sought to explore the roles and challenges of nurses working within rural, remote, and Northern Canadian Aboriginal communities, as well as individual, organizational, and system level factors that supported or impeded nurses’ work in helping to meet Aboriginal peoples’ health needs with meaningful care. Theorists include the works of Fanon on colonization and racial construction; Kristeva on semiotics and abjection; and Foucault on power/knowledge, governmentality, and bio-power were used in providing a theoretical framework to help enlighten the research study presented within this dissertation. Critical Discourse Analysis of twenty-five semi-structured interviews with nurses, physicians, and regional health care administrators was deployed to gain a better understanding of the responsibilities and challenges of nurses working in Northern Canada. Specifically, the research study was conducted in one of the three health regions within Northern Saskatchewan. Major findings of this study include: (1) the Aboriginal person did not exist without being in a relation with their colonial agent, the nurse, (2) being ‘Aboriginal’ was constructed as a source of treating illnesses and managing diseases, and (3) as a collective force, nursing was utilized as means of governmentality and as provisions of care situated within colonial laws. Historically, nurses functioned as a weapon to ‘save’ and ‘civilize’ Aboriginal peoples for purposes of the state. Primarily, present day nursing roles focused on health care duties to promote a decency of the state, followed by missionary tasks. In turn, the findings of this research study indicate that nurses must have a better understanding of the impact of colonialism on Aboriginal peoples’ health before they engage with local communities. Knowledge development through postcolonial scholarship in nursing can help nurses and health service providers to strengthen their self-reflective practice, in working towards de-signifying poor discourses around Aboriginal peoples’ health and to help create new discourses.

Australia has recently undergone a revolution in how people with disabilities access funding and choose supports – from supports administered or overseen by state/territory governments, to a national approach where individualised funding is allocated to people based on specific needs under the National Disability Insurance Scheme (NDIS). The power is now in the hands of the person with a disability, which has significant implications for consumers, clinicians and the business models of service providers. In rural and remote Australia, there has long been difficulty in accessing timely, person-centred disability supports and allied health services. Many families have continued to face these difficulties in the leadup to the NDIS transition, and following its implementation across Australia. The research undertaken in this thesis sought to understand family perspectives on past experiences of accessing allied health disability supports, their understanding of the language used to describe and deliver those services, and their expectations for the future given the sweeping changes in legislation and policy. Further, the research sought to use these data to inform at least one kind of solution – a solution which would make timely and person-centred allied health supports possible in rural and remote areas when there is a lack or shortage of existing local clinicians or clinical expertise. The research was carried out in two phases. In Phase 1, qualitative methods (semistructured interviews) were used to collect data from the parents or carers of children with intellectual disabilities in rural and remote Australia. The first study within this phase (Study 1) examined how families have experienced disability supports in the past and how they understood the principles applied in the design of those supports. The second study in this phase (Study 2) collected information regarding the families’ visions for the future. These data informed Phase 2 of the research. In Phase 2, four in-depth mixed methods case studies were carried out to examine the viability of delivering a person-centred allied health service to families in rural and remote Australia via a hybrid online and in person capacity-building approach (Study 3). Families identified a number of issues which affected their past experiences and expectations for the future. The in-depth case studies showed that a hybrid online and in-person capacity-building approach can be effective in some situations, and less effective in others, with one key factor of success including local key-worker support and expertise. With the expansion of digital service delivery models in 2020 as a result of the COVID- 19 pandemic, this research begins to build a foundation for further investigation of capacity-building approaches beyond a traditional one-to-one, in-person-only therapy delivery process. It has the potential to support policy and practice advancement in rural and remote communities across Australia and the world into the future.

Leptospirosis, a zoonotic disease caused by pathogenic spirochete bacteria (family Leptospiraceae, genus Leptospira), is endemic in developing tropical regions of the world. It occurs in epidemics and is endemic in Ecuador where environmental conditions are ideal for maintenance. The role of soil as a long term reservoir has been previously been documented. Geographic Information System (GIS) and Remote Sensing (RS) technology was used in our study to further explore the role of soil as an environmental reservoir and its potential use as a static risk indicator for disease. Red, Green, Blue (RGB) spectral band data from known leptospire positive soil sites were extracted from high resolution satellite images and used to construct the first ever remotely dependent soil-based model. The soil co-variates failed to demonstrate statistical significance; however, elevation was found to be statistically significant. The soil type most associated with soil samples where leptospire DNA was detected using real-time PCR analysis was cambisol, a soil type with a common distribution in Ecuador and Africa. This exploratory analysis presented a novel idea of combining environmental microbiological sampling and GIS/RS technology to better examine static risk indicators such as soil. Further analysis is warranted based on spatial relationships noted.

Introduction The Northwest Territories as a rural and remote region of Canada has higher colorectal cancer rates and lower uptake of colorectal cancer screening compared to the rest of the country. Understanding the complex health system processes involved in screening is necessary to develop informed solutions to improve screening access amongst marginalized populations. A systems approach to describe and understand the health care processes and system-level factors influencing colorectal cancer screening access was undertaken. Methods Semi-structured interviews with health care providers (N=29) involved in colorectal cancer screening in all health authorities within the Northwest Territories (N=8) were performed from September to December 2015. Interview transcripts were analyzed using qualitative content analysis methods within a Collaborative Information Behaviour (CIB) and Continuity of Care framework. Exploratory models of colorectal cancer screening processes were developed and translated into quantitative parameters for simulation modelling. Results Colorectal cancer screening access was defined by patient health care interactions supported by foundational information processes. Eighteen models of colorectal cancer screening access within the territory were identified, with varying complexity in care access seen across communities. Screening access problems included screening initiation, colonoscopy scheduling, screening recall and information silos, and were influenced by multiple contextual factors including a transient health work force, social health determinants, and patient travel. Qualitative models were translated into a system dynamics (SD) design framework for development of further quantitative modeling. Conclusions Colorectal cancer screening access in the Northwest Territories is a complex process comprising patient interactions and information processes linking primary care and hospital care processes, which are influenced by challenging contextual factors in the rural and remote health care environment. In developing screening access solutions the foundational role of information support and the need for system trade-offs in restructuring health system processes are necessary considerations. Optimizing information processes through the utilization of health informatics tools such as standardized referral forms and EMRs may also support health system transformation to improve screening access across the Northwest Territories. Understanding and evaluating system trade-offs may be best achieved using a combination of qualitative and quantitative modeling through future application of SD modeling research.

High-quality cardiopulmonary resuscitation (CPR) can increase survival from a cardiac event and better quality of life post event (Whitcomb & Schmied-Blackman, 2007). This can be made possible not only by an experienced team, but also by more frequent training and refreshers for health care providers (Hamilton, 2005). Rural and remote nurses may experience skill decay due to low-volume CPR use and location barriers that contribute to infrequent CPR recertification; two conditions that lead to low-quality CPR (Hamilton, 2005). Not available in Canada, online CPR training in the United States is accepted as a way to provide current, timely, and accessible recertification for health care professionals (ProCPR^©, 2009). To assess the effectiveness of online CPR training in meeting Canadian rural and remote nurses' recertification needs, I used both pre- and post-training intervention constructs. A total of 32 nurses self-reported their competency prior to and following an online CPR recertification training course. I obtained data to answer five research questions regarding current CPR practices, barriers to recertification, the extent that the online CPR course affected nurses' competencies, nurses' satisfaction with online CPR training, and the potential cost versus benefit for employers. On average, participants used CPR once in the last year. Within the total group, 14 of the nurses (43.8%) had an expired CPR certificate that had been outdated, on average, for over 17 months. Nurses both with expired CPR certification (56.2%) and with current CPR certification (56.2%) improved significantly from pre-training scores (M = 19.25, SD = 6.201) to post-training scores (M = 22.88, SD = 5.369) with p < 0.001; t (31) = -4.048. Cohen's d was .63. Nurses with expired CPR certification experienced a greater increase in competency post-training than nurses did with current CPR certification, confirming the implications of skill decay and lapses in training. Despite hesitation at refreshing a decidedly tactile skill online, the study participants voiced overwhelming satisfaction with the quality and impact on competency that they obtained through the online format. This study concludes with statistical, practical, clinical, and potentially substantial, economic significance for the implementation of online CPR recertification and online training in Canada.

The Sachigo Lake Wilderness Emergency Response Education Initiative represented a partnership between Sachigo Lake First Nation in northern Ontario Canada, and medical professionals and university researchers from outside the community. This study was one component of a larger community-based participatory research program to develop locally relevant first response training to address the isolation from emergency healthcare in Sachigo Lake. The aim of this qualitative study was to complete a formative evaluation to understand how a five-day comprehensive training course implemented in May 2012: (a) met the local needs of Sachigo Lake; and (b) fostered resilience and community capacity. The results of this study describe the unique features of delivering first aid training in a remote context and illustrate the intrapersonal and interpersonal impacts of the program. Health promotion through community based first aid education is a model with potential to improve emergency care in the absence of formal emergency medical services.

Remote area staff performing manual patient handling tasks in the absence of patient lifting hoists available in most health care settings are at an elevated risk of musculoskeletal injuries. The objective of this project was to identify the patient handling methods that have the lowest risk of injury. The patient handling task of lifting a patient from floor to a chair or wheelchair is a common task performed in a remote health care setting. The task was performed utilising three methods, these being: (1) heads/tails lift, (2) use of two Blue MEDesign?? slings and (3) use of a drawsheet. The task of the heads/tails lift was broken down into two distinctly separate subtasks: lifting from the (1) head and (2) tail ends of the patient load. These techniques were selected based on criteria including current practice, durability, portability, accessibility, ease of storage and cost to supply. Postural data were obtained using a Vicon 370 three - dimensional motion measurement and analysis system in the Biomechanics & Gait laboratory at the University of New South Wales. Forty reflective markers were placed on the subject to obtain the following joint angles: ankle, knee, hip, torso, shoulder, elbow, and wrist. The raw data were converted into the respective joint angles (Y, X, Z) for further analysis. The postural data was analysed using the University of Michigan???s Three-Dimensional Static Strength Prediction Program (3D SSPP) and the relative risk of injury was based on the following three values: (1) a threshold value of 3,400 N for compression force, (2) a threshold value of 500 N for shear force, and (3) population strength capability data. The effects on changes to the anthropometric data was estimated and analysed using the in-built anthropometric data contained within the 3D SSPP program for 6 separate lifter scenarios, these being male and female 5th, 50th and 95th percentiles. Changes to the patient load were estimated and analysed using the same computer software. Estimated compressive and shear forces were found to be lower with the drawsheet and tail component of the heads/tails lift in comparison to the use of the Blue MEDesign?? straps and head component of the heads/tails lift. The results obtained for the strength capability aspect of each of the lifts indicated a higher percentage of the population capable of both the drawsheet and tail end of the heads/tails lift. The relative risk of back injury for the lifters is distributed more evenly with the drawsheet lift as opposed to the heads/tails (tail) lift where risk is disproportionate with the heavier end being lifted. The use of lifter anthropometrics does not appear to be a realistic variable to base assumptions on which group of the population are capable of safely performing this task in a remote setting. This study advocates the use of the drawsheet lift in a remote setting based on the author???s experience and the biomechanical results obtained in this study. The drawsheet lift is both more accessible and provides a more acceptable risk when more than two patient handlers are involved, in comparison to the other lifts utilised lifting patients from floor to a chair.

Rural and remote areas of Australia remain the last bastion of health disadvantage in a developed nation with an enviable health score-card. During the last ten years, rural and remote health has emerged as a significant issue in the media and the political arena. This thesis examines print media, policy documents and interviews from selected informants to ascertain how they represent medical practitioners and health services in rural and remote areas of Australia, why they do so, and the consequences of such positions. In many of these representations, rural and remote medical practitioners are aligned with national and cultural mythologies, while health services are characterised as dysfunctional and at crisis point. Ostensibly, the representations and identity formulations are aimed at redressing the health inequities in remote rural and Australia. They define and elaborate debates and contestations about needs and claims and how they should be addressed; a process that is crucial in the development of professional identity and power (Fraser; 1989). The research involves an analysis and critical reading of the entwined discourses of culture, power, and the politics of need. Following Wodak and others (1999), these dynamics are explored by examining documents that are part of the discursive constitution of the field. In particular, the research examines how prevailing cultural concepts are used to configure the Australian rural and remote medical practitioner in ways that reflect and advance socio-cultural hegemony. The conceptual tools used to explore these dynamics are drawn from critical and post-structural theory, and draw upon the work of Nancy Fraser (1989; 1997) and Ruth Wodak (1999). Both theorists developed approaches that enable investigation into the effects of language use in order to understand how the cultural framing of particular work can influence power relations in a professional field. The research follows a cultural studies approach, focussing on texts as objects of research and acknowledging the importance of discourse in the development of cultural meaning (Nightingale, 1993). The methodological approach employs Critical Discourse Analysis, specifically the Discourse Historical Method (Wodak, 1999). It is used to explore the linguistic hallmarks of social and cultural processes and structures, and to identify the ways in which political control and dominance are advanced through language-based strategies. An analytical tool developed by Ruth Wodak, Rudolf de Cillia, Martin Reisigl and Karin Leibhart (1999) was adapted and used to identify nationalistic identity formulations and related linguistic manoeuvres in the texts. The dissertation argues that the textual linguistic manoeuvres and identity formulations produce and privilege a particular identity for rural and remote medical practitioners, and that cultural myth is used to popularise, shore up and advance the goals of rural doctors during a period of crisis and change. Important in this process is the differentiation of rural and remote medicine from other disciplines in order to define and advance its political needs and claims (Fraser, 1989). This activity has unexpected legacies for the rural and remote health sector. In developing a strong identity for rural doctors, discursive rules have been established by the discipline regarding roles, personal and professional characteristics, and practice style; rules which hold confounding factors for the sustainability of remote and rural medical practice and health care generally. These factors include: the professional fragmentation of the discipline of primary medical care into general practice and rural medicine; and identity formulations that do not accommodate an ageing workforce characterised by cultural diversity, decreasing engagement in full time work, and a higher proportion of women participants. Both of these factors have repercussions for the recruitment and retention of rural and remote health professionals and the maintenance of a sustainable health workforce. The dissertation argues that the formulated identities of rural and remote medical practitioners in the texts maintain and reproduce relationships of cultural, political and social power. They have also influenced the ways in which rural and remote health services have been developed and funded. They selectively represent and value particular roles and approaches to health care. In doing so, they misrepresent the breadth and complexities of rural and remote health issues, and reinforce a reputational economy built on differential professional and cultural respect, and political and economic advantage. This disadvantages the community, professions and interest groups of lower value and esteem, and other groups whose voices are often not heard. Thus, regardless of their altruistic motivations, the politics of identity and differentiation employed in the formulated identities in the texts are based on an approach that undermines the redistributive goals of justice and equity (Fraser 1997), and works primarily to develop and advantage the discipline of rural medicine.

Rural and remote areas of Australia remain the last bastion of health disadvantage in a developed nation with an enviable health score-card. During the last ten years, rural and remote health has emerged as a significant issue in the media and the political arena. This thesis examines print media, policy documents and interviews from selected informants to ascertain how they represent medical practitioners and health services in rural and remote areas of Australia, why they do so, and the consequences of such positions. In many of these representations, rural and remote medical practitioners are aligned with national and cultural mythologies, while health services are characterised as dysfunctional and at crisis point. Ostensibly, the representations and identity formulations are aimed at redressing the health inequities in remote rural and Australia. They define and elaborate debates and contestations about needs and claims and how they should be addressed; a process that is crucial in the development of professional identity and power (Fraser; 1989). The research involves an analysis and critical reading of the entwined discourses of culture, power, and the politics of need. Following Wodak and others (1999), these dynamics are explored by examining documents that are part of the discursive constitution of the field. In particular, the research examines how prevailing cultural concepts are used to configure the Australian rural and remote medical practitioner in ways that reflect and advance socio-cultural hegemony. The conceptual tools used to explore these dynamics are drawn from critical and post-structural theory, and draw upon the work of Nancy Fraser (1989; 1997) and Ruth Wodak (1999). Both theorists developed approaches that enable investigation into the effects of language use in order to understand how the cultural framing of particular work can influence power relations in a professional field. The research follows a cultural studies approach, focussing on texts as objects of research and acknowledging the importance of discourse in the development of cultural meaning (Nightingale, 1993). The methodological approach employs Critical Discourse Analysis, specifically the Discourse Historical Method (Wodak, 1999). It is used to explore the linguistic hallmarks of social and cultural processes and structures, and to identify the ways in which political control and dominance are advanced through language-based strategies. An analytical tool developed by Ruth Wodak, Rudolf de Cillia, Martin Reisigl and Karin Leibhart (1999) was adapted and used to identify nationalistic identity formulations and related linguistic manoeuvres in the texts. The dissertation argues that the textual linguistic manoeuvres and identity formulations produce and privilege a particular identity for rural and remote medical practitioners, and that cultural myth is used to popularise, shore up and advance the goals of rural doctors during a period of crisis and change. Important in this process is the differentiation of rural and remote medicine from other disciplines in order to define and advance its political needs and claims (Fraser, 1989). This activity has unexpected legacies for the rural and remote health sector. In developing a strong identity for rural doctors, discursive rules have been established by the discipline regarding roles, personal and professional characteristics, and practice style; rules which hold confounding factors for the sustainability of remote and rural medical practice and health care generally. These factors include: the professional fragmentation of the discipline of primary medical care into general practice and rural medicine; and identity formulations that do not accommodate an ageing workforce characterised by cultural diversity, decreasing engagement in full time work, and a higher proportion of women participants. Both of these factors have repercussions for the recruitment and retention of rural and remote health professionals and the maintenance of a sustainable health workforce. The dissertation argues that the formulated identities of rural and remote medical practitioners in the texts maintain and reproduce relationships of cultural, political and social power. They have also influenced the ways in which rural and remote health services have been developed and funded. They selectively represent and value particular roles and approaches to health care. In doing so, they misrepresent the breadth and complexities of rural and remote health issues, and reinforce a reputational economy built on differential professional and cultural respect, and political and economic advantage. This disadvantages the community, professions and interest groups of lower value and esteem, and other groups whose voices are often not heard. Thus, regardless of their altruistic motivations, the politics of identity and differentiation employed in the formulated identities in the texts are based on an approach that undermines the redistributive goals of justice and equity (Fraser 1997), and works primarily to develop and advantage the discipline of rural medicine.

"In the main, contemporary research on Evidence Based Practice (EBP) has taken place within metropolitan locations, and has offered urbocentric solutions and insights. However the transferability of these developments to rural services is untested empirically. In addition, evidence development and studies on the implementation of this evidence have tended to be discipline-stream-specific; there has been very little research into either the development of multi-disciplinary evidence guidelines or the implementation of EBP from the perspective of individual practitioners working within multi-disciplinary teams. This research shortfall has provided the rationale for this study...."
Doctor of Philosophy

"In the main, contemporary research on Evidence Based Practice (EBP) has taken place within metropolitan locations, and has offered urbocentric solutions and insights. However the transferability of these developments to rural services is untested empirically. In addition, evidence development and studies on the implementation of this evidence have tended to be discipline-stream-specific; there has been very little research into either the development of multi-disciplinary evidence guidelines or the implementation of EBP from the perspective of individual practitioners working within multi-disciplinary teams. This research shortfall has provided the rationale for this study...."
Doctor of Philosophy

"In the main, contemporary research on Evidence Based Practice (EBP) has taken place within metropolitan locations, and has offered urbocentric solutions and insights. However the transferability of these developments to rural services is untested empirically. In addition, evidence development and studies on the implementation of this evidence have tended to be discipline-stream-specific; there has been very little research into either the development of multi-disciplinary evidence guidelines or the implementation of EBP from the perspective of individual practitioners working within multi-disciplinary teams. This research shortfall has provided the rationale for this study...."
Doctor of Philosophy

Maldistribution of healthcare professionals persists in remote and rural communities throughout the world. Adoption of a Community Paramedic (CP) program could improve access to quality healthcare for rural communities. The conceptual framework defined rural communities by their distinct characteristics — community efficacy, weaknesses, attitudes, assets, deficits, local culture, and the driving and restraining forces — and not defined by their small populations or distances to cities. The theoretical foundation was a synthesis of theories of Bandura, Rogers, and Lewin. This study assessed community characteristics that may influence the likelihood of success, sustainability, or program failure of the Australian CP model in a single remote Texas border community. In this qualitative formative bounded case study, 3 bounded groups were examined; data collection was by in-person interviews. Group members were purposively selected: 5 residents and 3 EMS members. The 3rd group consisted of 4 randomly self-selected resident interviews, field observations, news articles, and local social media. Data transcripts were coded using theoretical coding based on the conceptual framework and theoretical foundation. Strong individual and group efficacy, efficacy resilience, adaptability, strong communications, overlapping groups, and a strong sense of community program ownership were evident in this study. The probability of establishing an effective CP program based on the Australian model is high based on study findings. Improved access to quality healthcare in remote and rural communities could result in improved health of community members and significant social change.

This study was conducted in the context of health service planning in an environment of changing government strategies for regional, rural and remote area health care and telecommunications infrastructure planning in Western Australia. The study provides an account of the State Government of Western Australia's planning for the implementation of a telecommunications network infrastructure, and specifically the Telehealth Project, conducted between 1998 and 2002. The purpose of this study was to examine influences on community participation in planning within the dynamic political, economic and social forces that impact on the development of regional, rural and remote area health services. Specifically, the study outlines the issues and barriers in providing for significant local participation in projects that are centrally initiated and controlled. It examines the influences in planning for projects that incorporate local community based beliefs and needs, the requirements of collaborating with multiple state and national government departments, and the private sector. This study was situated within the interpretive paradigm, and is conceptualised within Donabedian's (1969) framework for assessing and assuring quality in health care. The methodological approach is bound within a case study and consists of a participatory action research approach. The research method uses the single case to undertake in-depth interviews, observations and a survey to collect data from community, government and industry members as a basis for reflection and action. The findings of the study clearly indicated that there was consensus between all rural, remote and metropolitan area participants that telecommunications did offer the opportunity to provide increased, improved or alternative health services. However, there were a number of obstacles to the success of the planning process, including a lack of local community inclusion in planning committees, poor communication within central government agencies, overuse of external consultants, a bias toward the medical view, a limited scope of invitation to contribute, and local information being overlooked in the final implementation plan. Analysis of planning for the Telehealth Project reveals the implications of organisational and political stakeholders making final decisions about outcomes; and provides a reminder of the importance of engaging communities authentically when planning for health and telecommunications services which involve the public and private sectors. The originality and significance of this study stems from understanding how technology can advance community health; through measures such as the use of community participation strategies, through authentic community based leadership, truly representative participants, decentralised decision making, a focus on community based health needs and change management strategies that include all of these. Consequently, the study advances knowledge of community participation in planning and the evidence suggests implications for practice, education and further research.

This study was conducted in the context of health service planning in an environment of changing government strategies for regional, rural and remote area health care and telecommunications infrastructure planning in Western Australia. The study provides an account of the State Government of Western Australia's planning for the implementation of a telecommunications network infrastructure, and specifically the Telehealth Project, conducted between 1998 and 2002. The purpose of this study was to examine influences on community participation in planning within the dynamic political, economic and social forces that impact on the development of regional, rural and remote area health services. Specifically, the study outlines the issues and barriers in providing for significant local participation in projects that are centrally initiated and controlled. It examines the influences in planning for projects that incorporate local community based beliefs and needs, the requirements of collaborating with multiple state and national government departments, and the private sector. This study was situated within the interpretive paradigm, and is conceptualised within Donabedian's (1969) framework for assessing and assuring quality in health care. The methodological approach is bound within a case study and consists of a participatory action research approach. The research method uses the single case to undertake in-depth interviews, observations and a survey to collect data from community, government and industry members as a basis for reflection and action. The findings of the study clearly indicated that there was consensus between all rural, remote and metropolitan area participants that telecommunications did offer the opportunity to provide increased, improved or alternative health services. However, there were a number of obstacles to the success of the planning process, including a lack of local community inclusion in planning committees, poor communication within central government agencies, overuse of external consultants, a bias toward the medical view, a limited scope of invitation to contribute, and local information being overlooked in the final implementation plan. Analysis of planning for the Telehealth Project reveals the implications of organisational and political stakeholders making final decisions about outcomes; and provides a reminder of the importance of engaging communities authentically when planning for health and telecommunications services which involve the public and private sectors. The originality and significance of this study stems from understanding how technology can advance community health; through measures such as the use of community participation strategies, through authentic community based leadership, truly representative participants, decentralised decision making, a focus on community based health needs and change management strategies that include all of these. Consequently, the study advances knowledge of community participation in planning and the evidence suggests implications for practice, education and further research.

Living in a community with adequate availability of nutritious food, and the capacity to access and utilise it, are key food security determinants (FSD). However, inequities relating to these determinants exist between regional and remote Western Australian (WA) communities, particularly regarding fruit and vegetables (F&V). This negatively impacts vulnerable populations, especially children. In order to understand determinants, prevalence and predictors of F&V and food security (FS), three concepts were explored in this PhD; (1) F&V consumption among regional and remote WA children (including determinants of F&V consumption, quantities, types, varieties of F&V consumed); (2) FS among regional and remote WA children (children’s FSD, prevalence of child food insecurity (FI) and socio-demographic predictors of FI); and (3) the relationship between FSD and F&V consumption among regional and remote WA children (FSD predictors of F&V consumption). Methods This mixed-methods study included semi-structured interviews with 20 key informants, to explore determinants of F&V consumption and FS among regional and remote WA children. Cross-sectional surveys were completed by caregiver-child dyads (n = 256), to understand children’s F&V consumption behaviours, determine child FI prevalence and assess whether FSD predicted adequate F&V consumption. Twenty-four hour food diaries measured F&V amounts and varieties consumed. Data analyses were conducted using IBM SPSS (version 23), Microsoft Excel and QSR NVivo (version 10). Results The determinants of children’s F&V consumption were explored using an Ecological Model of Health Behaviour. F&V quantities, types and varieties consumed were then quantified; more children achieved adequate fruit serves (65.8%) than vegetable serves (15.4%). Quantities consumed did not differ between regional and remote locations, however, F&V types and varieties consumed did. The FSD across food availability, access and utilisation dimensions were examined, illuminating inequities relating to food supply, social support and nutrition education. The calculation of prevalence and socio-demographic predictors of child FI revealed that one in five children were FI; family receipt of government income support (p = 0.022) and residency in a location of ‘Medium disadvantage’ (p = 0.023) predicted child FI. Subsequently, the association between FSD and adequate fruit intake among WA children was examined. After controlling for socio-demographic predictors, no determinants were significantly associated with fruit intake. However, FSD were associated with vegetable consumption; varieties and types of vegetables consumed (p = 0.007), health message promotion (p = 0.017), location of food outlets (p = 0.027) and price (p = 0.043) significantly predicted adequate vegetable consumption. Conclusion This study contributed a greater understanding of the complex, interwoven factors that influence FS among regional and remote WA children, namely food availability, access, utilisation, and the impact on F&V consumption. Findings provide a basis for advocacy to improve inequities across WA, relating to food supply, social support and nutrition education. It also provides focus for health promotion practitioners who work with target groups affected by FI, to customise strategies to improve F&V consumption based on FSD, and has identified valuable future research pathways.

Background: Australian public policy prioritises the development of evidence-based and culturally appropriate oral health promotion to improve the oral health of Aboriginal people, including children. Aim: This thesis aims to identify themes of effective and culturally appropriate oral health promotion targeting Indigenous children in high-income nations; develop, implement and evaluate oral health promotion for Aboriginal children in rural and remote communities in NSW and determine if these strategies are effective and sustainable. Methods: A collaboration took place with three Aboriginal communities in Central Northern NSW, Australia, in 2014 to collect baseline oral health status of Aboriginal children and inform potential oral health promotion strategies. In 2015, a suite of oral health promotion strategies were co-designed with Aboriginal communities in Central Northern NSW including in-school toothbrushing, installation of refrigerated and filtered water fountains, water bottle program, distribution of fluoride toothpaste and toothbrushes; dental health education and a structured fluoride varnish program. These strategies were implemented in three schools in the region in 2016. The fluoride varnish program was also implemented in seven schools in NSW in 2017 piloting Aboriginal dental assistants to apply fluoride varnish. Oral health promotion was evaluated to determine feasibility, sustainability and impact. Results: Community-led oral health promotion strategies significantly reduced dental caries among children, increased positive oral hygiene behaviours and were considered sustainable. School fluoride varnish programs are feasible and Aboriginal dental assistants can safely provide children with at least three fluoride varnish applications per year using this approach. Discussion and Conclusion: Co-designed and community-led oral health promotion is effective and sustainable and may be a solution to improving the oral health of Aboriginal children.

Staffing remote rural areas with health workers is one of the main challenges facing middle and low income countries looking to achieve the Millennium Development Goals including reducing the maternal death rate. Sudan is an African low income country faced with a shortage of health workers. This shortage is coupled with a misdistribution of health workers. Most of the doctors and specialists prefer to work in the capital Khartoum. However, in the last few years, Sudan has succeeded in reducing maternal death. This research aimed to undertake a realistic evaluation of the key strategies adopted by the Sudanese government to staff remote underserved areas by health workers. A literature review followed by documentary analysis aided the construction of two separate but interconnected attraction and retention frameworks and the development of the context- mechanism- outcome-configurations (CMOCs) related to staffing remote rural areas with maternal health workers. Next, qualitative semi-structured interviews were conducted in order to test these CMOCs. The interviewees included policy makers, executive health managers and health workers, both those currently working in rural areas and those who had done so in the past. The findings are presented with respect to identified CMOCs and the proposed attraction and retention frameworks. The findings have been presented in the form of what works, what does not, how, for whom and under what circumstances. The findings were analysed and discussed with respect to the relevant literature to facilitate development of recommendations which need to be considered to achieve better staffing of rural health facilities. This research has explained the past and current initiatives adopted by the Sudanese government to staff underserved areas with maternal health workers. It also showed how the “context” affected the success or failure of these strategies. This research is useful for other low income countries that suffer from inequitable distribution of its health workforce. The research has contributed to new understanding by developing separate attraction and retention frameworks for doctors and midwives. In addition to that effective interventions which are found in Sudan but not previously found in the literature have been identified and summarised.

Thesis Title: Community-Campus Partnerships and Service-Learning in Rural and Remote Australian Contexts: Moving from intervention to engagement with communities in their health service design and workforce development. ABSTRACT Providing children with the best possible start in life is critical if they are to achieve their optimal outcomes and be afforded the opportunity to become valued community members. The Australian Charter of Health Care Rights (Australian Commission on Safety and Quality in Health Care [ACSQHC] 2008) stated that health care access is a fundamental human right for all Australians. However, children residing in rural and remote Australian communities are more likely than their metropolitan counterparts to experience socio-economic, educational and health disadvantages that contribute to developmental vulnerabilities and delays. These same children are less likely to have access to essential allied health services, such as occupational therapy and speech pathology, to prevent, identify and intervene early to address these delays. For some families, this inequity of access to allied health services is an intergenerational experience. A failure to address developmental delays can result in: lifetime disadvantage; higher cost burdens for health sectors, individuals and communities through curative interventions and remediating social and educational strategies in later life; and continuing cycles of intergenerational poverty. Even though rural and remote health has been the focus of Australian policy for a number of decades, these communities continue to be confronted with simultaneous and multiple health disadvantages. Contributing factors include: geographical isolation; lower socio-economic status of populations; resource allocations that fail to address existing health needs; a lack of focus and health expenditure on prevention, health promotion, early identification and intervention strategies; limited community engagement in their health care agendas; health workforce mal-distribution and shortages; and the development of poorly equipped health professionals for population health practice in these contexts. Strategies to address these challenges have typically been undertaken by health and higher education sectors in isolation from each other and the intended recipients of their health service and workforce strategies, the rural and remote communities themselves. Health sector reforms are required. These reforms need to ensure health care alignment to community needs and priorities, the design of care that enhances service accessibility and acceptability across diverse rural and remote contexts, and care that is provided by responsive health professionals. This will necessitate the provision of ‘the right care, in the right place, at the right time’, provided by health professionals who have received the ‘right education’ and ‘right practice exposure’ to rural and remote Australian communities, their health care expectations and aspirations. In seeking to achieve these outcomes, it is recognised that no single policy or government sector, has the capacity to overcome all of the challenges that contribute to developmental vulnerability and service inequities in rural and remote Australian locations. New approaches to health care design and workforce development are required. These approaches need to be informed by perspectives that consider issues in their entirety, drawing on collaborative partnerships with communities in determining their health needs, solutions identification, implementation and evaluation. It is imperative that communities are meaningfully engaged in their health care agendas. Civically engaged health care has the potential to enhance service accessibility, acceptability and sustainability, contributing to improved health outcomes for disadvantaged communities. Several Australian University Departments of Rural Health—key stakeholders in rural and remote health service design and workforce development—are already engaging in the formation of community-campus partnerships, that include communities in the identification of their health issues , potential solutions and strategies for solutions implementation. Community-campus partnerships underpin the development of service-learning programs. Service-learning programs align health student placements with the provision of student-led services that address the identified unmet health needs of communities through emerging approaches to collaborative partnerships, service provision and the education of health students in Australia. These emerging partnerships and service approaches within the Australian context are heavily informed by international experiences and evidence. Despite the benefits associated with participation in community-campus partnerships and service-learning programs for universities, students and community agencies, limited evidence exists that describes who initiates these partnerships and for what purposes, how these partnerships are formed, and whether these partnerships and service models provide substantive gains for communities and quality learning outcomes for students, specifically evidence informed from community and rural and remote Australian perspectives. This thesis discusses community and campus participant perspectives and experiences of participation in the formation of a community-campus partnership and the development of an associated service-learning program. This partnership sought to address the unmet allied health needs of children residing in far west New South Wales, Australia, through the development of a service-learning program that aligned the delivery of student-led allied health services, occupational therapy and speech pathology to address the unmet developmental needs of these children. In the latter half of 2008, primary school principals in far west New South Wales approached the University of Sydney’s Broken Hill University Department of Rural Health to express their concerns about the detrimental educational, social and health outcomes experienced by children with developmental delays who were unable to access allied health services, in the first instance, speech pathology services. The department facilitated the formation of a local partnership between health and school education sectors to explore the challenges faced by allied health service provision, past strategy failings and potential solutions. The department then drew on its organisational relationship with the University of Sydney to engage the Faculty of Health Sciences, which has carriage of allied health education, in contributing to solutions identification and implementation. The result was the formation of a community-campus partnership where community and campus participants worked collaboratively on the development of an allied health service-learning program, the Allied Health in Outback Schools Program. The program was operationalised in early 2009. In the initial stages, the program aligned senior speech pathology student placements with the provision of speech and language services to Broken Hill primary school children. These services were delivered on school sites in Broken Hill to enhance service accessibility. The program was expanded in 2010 to include occupational therapy students, extending the type of allied health services available to children and providing students with the opportunity to participate in an inter-professional service-learning model. The geographical coverage of the program was expanded to include the remote outlying communities of Menindee and Wilcannia. Serial cohorts of speech pathology and occupational therapy students now participate in the program as inter-professional teams. Students undertake placement in the program across the four school terms contributing to service continuity and consistency. Under the supervision of qualified clinicians, students provide screening, assessment, services and referral activities in 12 primary school campuses across three regional communities. Approximately 150 school children access these student-led allied health services annually. Although not explicit in the early stages of partnership formation and program development, a developmental evaluation approach was adopted. Local partners were aware of the challenges associated with developing and sustaining innovative approaches to addressing complex and protracted rural and remote health service inequities. External representatives from the Faculty of Health Sciences were cognisant of the additional challenges of ensuring quality educational experiences for their students within an emerging rural and remote Australian service-learning initiative. However, the potential benefits of partnership and program participation were identified early. These benefits included: improved allied health service accessibility; enhanced developmental outcomes for children; growth in rural and remote placement capacity for allied health students; enhanced allied health student learning outcomes through ‘real-world’ practice experiences; and allied health student exposure to alternative health care practices such as population health in community-based settings. Despite these perceived benefits and internal program evaluations, no formal research had been undertaken to explore: the conditions that made the partnership necessary; the processes associated with partnership formation, service-learning program development and evolution; or the clinical, professional and civic impacts of partnership and program participation for community and campus participants. In answering these questions, this doctoral study has been guided by three primary research goals: 1) to describe and understand the formation of the community-campus partnership; 2) to describe and understand the development and adaptation of the service-learning program (with [1] and [2] from the perspectives of community and campus participants); and 3) to develop a greater understanding of the impacts of participation in the partnership and program for community and campus participants. Four key questions were posed to inform the study design and approach. These questions focused on understanding: 1) What factors contributed to the initiation, formation and participation of community and campus partners in the community-campus partnership and associated service-learning program? 2) What were the impacts of participation in the partnership and program for community and campus participants and for the civic and higher education sectors in which they were located? 3) How did community and campus participants interact with each other to fulfil the shared purposes of enhancing allied health service accessibility and allied health student educational outcomes? 4) How did participation in the partnership and program impact on the clinical, professional and civic learning outcomes of allied health student participants? In order to achieve these goals and answer these questions, this pragmatic qualitative study was designed and conducted. The study explored community (school principals and senior managers from local facilitating agencies) and campus (allied health students and academics) perspectives and experiences of partnership and program participation. This doctoral research contains six papers: a descriptive paper and five papers that discuss findings from this research. The descriptive paper, Paper 1, contextually locates the study, describing the formation of the partnership, and the development and adaptation of the service-learning program between 2009 and 2015. This paper has been co-authored by executive representatives from partner organisations, school education, health and higher education sectors, and the University Department of Rural Health. Paper 2 presents community participant perspectives of the conditions and catalysts that influenced their participation in the partnership and program, as well as the civic impacts of participation, Paper 3 presents campus participant perspectives of the conditions and catalysts that influenced their participation in the partnership and program, as well as civic impacts of this participation. Paper 4 addresses campus perspectives on the participation impacts on allied health student acquisition of work-readiness attributes and their future employability. In Paper 5, campus perspectives on the impact of participation on students’ inter-professional skills, knowledge and practice are presented. Paper 6 describes the key features that contributed to community engagement in the partnership and program sustainability within this context. This doctoral research extends our current understanding of community-campus partnerships and service-learning pedagogy as a community engagement strategy and educational approach. It provides deep insight into who initiated the partnership and for what purposes, how the service-learning program was developed and adapted, and the impacts of participation from the perspectives of community and campus participants, specifically within a rural and remote Australian context. A conceptual framework is presented in Chapter 4 and provides a comprehensive andmore nuanced approach to informing health and higher education sector approaches toward the engagement of rural and remote communities in health service design and the development of their health workforce. The framework has been informed by study findings and an exploration of existing theories and principles. Importantly, this framework has been informed by community perspectives and experiences of health care engagement. As a complete thesis and series of papers, this research forms a body of evidence that can be drawn upon by health and health workforce policy makers, health and higher education sectors, and other rural and remote communities. The thesis and associated papers can contribute to informing health sector processes in the formation of community engaged community-campus partnerships and the development and adaptation of service-learning initiatives. In addition, this thesis describes the challenges and benefits of engaged approaches as they pertain to these contexts. This thesis adds to the evidence base to support: the alignment of health care to rural and remote community needs and contexts; the need for new community engaged approaches to enhance health service accessibility, acceptability and sustainability; the imperative to align health workforce skills, knowledge and practice to rural and remote community contexts; with, the ultimate aim of improving the health outcomes of rural and remote Australian communities.

In 1998 World Health Organisation Europe outlined a vision of a new community-based nurse called the Family Health Nurse (FHN) who would help individuals, families and communities to cope with illness and to improve their health. Scotland was the first European country to develop this idea through policy, education and practice. The two phase national pilot project (2001-2006) primarily involved remote and rural regions. Despite its vanguard position, Scottish family health nursing has been subject to little in-depth critical analysis. This thesis addresses this deficit by analysing why and how family health nursing developed in Scotland. The research methods used are: critical review of textual sources; empirical research into policy, education and practice; and critical review and application of relevant theoretical perspectives to enable interpretation. Grounded primarily in constructivism, this approach builds explanation of the development of family health nursing in Scotland as a phenomenon in contemporary nursing history. This explanation highlights the importance of key factors and processes, particularly: agency at policy formulation level; use of the piloting mechanism to mediate knowledge production, containment and expansion; tensions between generalism and specialism as manifest within the promulgated FHN concept, the educational programme, and the FHN role as it was variously enacted in practice; related difficulty in engaging substantially with families; and the strong influence of local context on the nature and scope of FHN role development, especially in terms of situated power and embedded culture of place. The explanation is summarised as a synoptic story. A new integrative, explanatory model of the development of family health nursing in Scotland is also posited. This knowledge is then examined in relation to contemporary community nursing and primary care in order to understand influence and implications. This highlights the importance of the development of family health nursing in shaping the new Community Health Nurse (CHN) role which emerged from the Review of Nursing in the Community in Scotland 2006. The new explanatory model constructed within the thesis is then applied in its more generic MAPPED format (Model for Analysing Policy to Practice Executive Developments) to analyse the new policy formulation advancing the CHN role and to anticipate key developmental factors and processes. On this basis, the thesis argues that the MAPPED model is potentially valuable for the analysis of developments that require purview from policy through to practice. The thesis concludes by summarising its contributions to understandings of community nursing policy, practice, research and theory, and makes a number of related recommendations.

The purpose of this thesis was to aid in the development of a web-based physical activity intervention for people with type 2 diabetes living in remote and rural areas. Chapter 1 introduces the research area, the design of the thesis and the key research questions. The thesis is then made up of 5 key studies. Study one, a systematic review of the literature was conducted and reported in chapter 2. This review identified the technologies that have previously been used to promote physical activity in type 2 diabetes, it identified the methodological quality of each included technology and the key components for effective change. Web based technology was the most commonly used and the most effective in increasing physical activity using components such as goal setting and physical activity trackers. These results informed study 2 (chapter 3) which explored patient and health professional's views on diabetes, physical activity and use of the internet. The need for clear information was identified with regard to diabetes as well as the call for accurate physical activity advice in relation to diabetes for both patients and health professionals. Study 3 (chapter 4) explored key information and components for an effective website. Included features were the need for a personalised approach; detailed advice on how the body responds to physical activity; a physical activity tracker and goal setting. The need for a 'virtual trainer' for support, advice and help with goal setting and interactive maps showing physical activity opportunities were all deemed important. The fourth study, chapter 5 described the design of the website and its features as well as the protocol for a six month pilot randomised controlled trial to examine the effectiveness of the development website, with and without interactive design elements. The final study in this thesis (chapter 6), describes the physical activity, physiological and biochemical results from a randomised controlled trial to test the effectiveness of the website and its features. The final chapter summarises the findings in response to the research questions and the future recommendations based on the outcomes.

Chronic disease is the most significant contributor to the mortality gap between Australia’s First Nations people and the overall Australian population. This study explored chronic disease self-management and health literacy in First Nations adults living in remote Queensland. Key findings were poor communication by healthcare providers coupled with limited health literacy abilities of individuals were the major barriers to active engagement with managing chronic disease. Providing a supportive health literacy environment and the provision of appropriate health information delivered in a cultural safe way using clinical yarning, may assist with closing the gap in First Nations people.

This study is based on data collected for a large project that investigated social literacies and various aspects of the literacy culture of members of three rural communities in Queensland. This study draws on ideas from current critical literacy theory and research and post-structural writings. It reports a distinctive set of observations which aim to contribute to social and educational knowledge in respect of centre-margin relationships, literacy-empowerment relationships, the changing socio-economic and political landscape in rural Australia, and the need for a new conceptual landscape to define the foundations of a 'postprogressive pedagogy'. This study delineates some of the distinctive features of rural communities, and investigates the connections that people construct between schooling and economic change and the future, and between literacy and schooling and various aspects of the culture of the community. It interprets how schooling and literacy are socially constructed by members of the rural communities studied. One hundred and fifty-eight residents of three rural/remote communities were interviewed and their responses recorded and analysed. The residents represented the full range of ages and occupations. A selection of data from these interviews is taken for this study, based on themes and issues emerging from the data. A theoretical and empirical framework for the study is provided by reviewing current literature on rurality and rural living, on communities and schooling and cultural practices; literature on qualitative research methodology, specifically ethnomethodology, methods of interview analysis and the application of these methods, is also reviewed. Ethnomethodology is used for this study and the specific analytic procedures of Membership Categorisation Analysis. This specific type of qualitative research methodology is chosen because of its power to take the everyday conversations of community members and, through analytical procedures, to make explicit in those members accounts the interaction of their experiences with the organisational and social forces (the social realities) which permeate their relationships with one another and with the context of the community where they live, work and recreate. This study makes use of recent systematic procedures developed for interrogating interview data. It adds to the research literature on ideologies of family and community literacies and social practices in Australian rural communities. The study provides information relevant to rural development planners, and education policy developers and curriculum writers, for the purpose of enhancing schooling for rural students and better understanding of rural lifestyles. This study's focus on rural communities has highlighted the complexities and diversities of the rural communities that are studied. The different approaches and debates about 'defining rural' must continue, and researchers must avoid promoting a unidimensional category of 'rural'. The changing and developing nature of the rural communities has also been prominent in this study. The implications of these complexities and changes are that rural communities should be studied regularly so that the effects of the changes can be traced and documented. There is a varied set of understandings among rural dwellers about education. For some, education is bringing knowledge and skills to life in the rural location and enabling residents to avail themselves of the urban offerings that may enhance their occupations and leisure activities thus utilising the benefits of two cultures to their best advantage. For others, there are the expectations that education will enable them to move away from the rural areas, to go to the city, to take up other careers, to lead a different lifestyle. Hypotheses and generalisations that express negative approaches to rural cultures and to rural education must be reduced and the positive aspects promoted. Any centre-margin discourse must be scrutinised for its relevance and the feasibility of the assumptions on which it is based. Education policy developers, social researchers and rural policy planners need to re-evaluate the philosophical premises on which the current concept of success is based: success for the individual school student, success for education and schooling, and success in adult life. A number of recommendations are developed in an attempt to make a vision of excellence in rural education a central part of rural agenda. Curriculum in rural schools needs to be matched to rural resources and rural occupations and lifestyles, and to encourage enterprise. While education remains a centralised provision, it needs to provide a context for training in the communication skills that shape rural people's views of their communities. Rural secondary students may be disadvantaged by not having access to a wide range of curriculum offerings, and at tertiary level by inequities (mostly financial) of access, but technology could be used to assist in broadening the range of offerings at secondary level, and library resources across the country could be better utilised. Social and education research could benefit from further studies using this methodology, for example, studies in mining communities, rural ethnic communities, rural tourist communities.
Thesis (Masters)
Master of Philosophy (MPhil)
School of Cognition, Language and Special Education
Arts, Education and Law
Full Text

The development of techniques for the detection of water leaks from underground pipelines is seen as a high profile activity by water companies and regulators. This is due to increasing water demands and problems with current leak detection methods. In this thesis optical reflectance and microwave backscatter were used to identify optimal indices for detecting water leaks amongst a variety of different land cover types at different growth stages. Ground-based surveys and modelling techniques were used to establish optimal wavelengths for detection. Results from these studies suggested that in the optical domain visible/middle infrared ratios show potential for leak detection for a wide range of leak types, under a variety of vegetation canopies at different growth stages. Given the sensitivity of L-band radar to moisture, and the ability to separate contributions from canopy and ground surface, it is possible to detect surface water beneath a range of vegetation canopies. The optimal leak detection indices were then used to idenitfy leaks on airborne image data. The available image data was L - band fully polarimetric E-SAR data, and 126 channel HYMAP hyperspectral airborne data which were acquired over an 8km section of the Vrynwy aqueduct (UK), which included a high concentration of leaks. Four of the five leaks were identifiable on the optical image data and none of the leaks were detectable on the microwave data. However the E-SAR data was obtained under unfavourable conditions. The results of both approaches are used to infer limits of detection in terms of season and meteorological conditions for a range of land covers. Preliminary findings suggest that leaks may be optimally detected when canopy height is low, surrounding soil is dry after a period of no rain, and the leak has been present for at least 2 days. The results from this work suggest that remote sensing is both an effective and feasible tool for leak identification.

This thesis offers a review of the historical development of telemedicine services in remote health care. It addresses the professional concerns in practising medicine in isolated conditions, and the advances in telecommunications technology since the telephone was invented. It also examines the application of telemedicine in remote environments across the world, such as in indigenous communities, remote industrial work sites and at scientific bases in Antarctica. At its most exotic, a review is offered of the health care for space crews. The literature review highlights a number of concerns about the state of the art knowledge on remote health care services. These concerns are the minimal training requirements of individuals who act as health care practitioners in the remote environment, the additional training requirement upon the advising medical practitioner, and the design of a system for the collection of clinical information from the patient. In response to the above a two year study was conducted. Quantitative and qualitative observation of remote health care consultations was undertaken. The environments studied were simulation cases occurring in the UK and Antarctica, and real cases presenting on oil installations in the North Sea. The study results answer the original concerns about the training levels, data collection and communications components of a remote health care service. In addition, they offer valuable input towards the design of a telemedicine model for remote health care. The telemedicine model is presented as a framework upon which future developments in the field of telemedicine may be approached.