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Rural and Remote Health (Workshops and Lectures) 

Despite rural Australian health being much worse than metropolitan Australians rural and remote people have lower access to health care because of distance, time factors, costs and transport availability

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This is made worse by shortages of health facilities and health professionals, and rural people’s perceptions of health

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The greatest shortage is in doctors closely followed by pharmacy

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Nurses make up the largest health workforce in Australia and are the best-distributed rural health workforce but are still in short supply in rural and remote areas.

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Health professionals in rural and remote practices require a broader and deeper range of knowledge and skills because in rural Australia there is less access to specialists.

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Thus it is important to learn about rural and remote health because it is a prevalent social issue and study may lead to the development of a more suited model of health care for these areas.

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Rural Health should be: o

Accessible

o

Needs based

o

Accepted by the community

o

Comprehensive and multidisciplinary

o

Integrated and co-ordinated

o

Provide continuity of care

o

Sufficiently flexible to respond to changing needs

Life expectancy of rural and urban Australians 

Urban males = 78yrs and urban females = 83yrs

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Rural Australians are expected to die 4 years earlier

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These unique health concerns relate directly to rural peoples' understanding of health, their living conditions, social isolation, and socioeconomic disadvantage.

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Rural people are also known to smoke more, drink more and have a much higher incidence of road accidents than city people.

Life expectancy of indigenous Australians

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Indigenous populations are expected to die 17-20 years earlier

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Compared with non-Indigenous Australians, Indigenous Australians generally have poorer education levels, more unemployment, and are more likely to be on social support benefits with little material wealth and little disposable income: all factors that limit life choices.

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More than two-thirds of indigenous Australians live in areas classified as ‘remote’.

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Remote areas have poor public health infrastructure and substandard living conditions.

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As a result, Indigenous Australians suffer higher rates of diabetes, cardiovascular disease, mental illness, infectious diseases, respiratory disease, end-stage renal disease, cancers, sexually transmitted disease and other communicable diseases than non-Indigenous Australians.

Aboriginal Health Services 

Aboriginal Community Controlled Health Services (ACCHS) is the most significant system of primary health care delivery to indigenous Australia



Provides: o

Large multidisciplinary co-ordinated primary clinical care, health promotion and population intervention

o 

Small primary health advocacy and referral support services in rural/remote areas.

Aboriginal Medical Service first established in Redfern in 1971 places emphasis on community participation and political change in response to the prevailing attitude of the dominate culture toward indigenous people.

Rural View of Health 

The way we view our health is important, as it reflects the way in which we approach it

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The old bush ethos of enduring hardship, being tough and having a 'she'll be right' attitude when it comes to illness, is seen as the norm in rural Australia.

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Being sick or injured somehow implies a weakness and a loss of social acceptability.

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They are known to be suspicious of 'newcomers' so in most cases they are unwilling to seek professional help.

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Their view of health is based on the absence of disease; they link their well-being to productivity and being able to carry on their daily tasks

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It is often only when they cannot carry out their daily tasks because of ill health or disability that they present for health treatment (sometimes very late in the course of the disease when I has become much more complicated)

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They see health services as curative services meaning they will only go to the doctor for curative rather than preventive procedures, like routine health screening and tend to make do with problems that are not visually evident, like depression and mental health conditions.

Differences in health status between rural and Urban Australia 

Life expectancy – less

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Fertility- Lower

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Death rates – higher

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Hospitalisation-higher

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Risk factors- greater

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Health resources – less

Determinates of health that impact on the health of rural Australians

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People who live outside large urban centres have higher mortality rates and higher rates of risk factors for ill health (e.g. smoking, excessive alcohol use, poor diet, and less physical activity) than their urban counterparts.

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Studies of socioeconomic risk factors show that rural Australians are less educated, have lower incomes, have poorer access to health services, are less likely to own their own home, are more likely to be unemployed, work in hazardous industries (e.g. farming, mining) and engage in risk behaviours (e.g. speeding and driving extremely long distances at a time).

Australia’s 3 tiered Health System

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Residents of small rural and remote communities are required to travel to larger regional centres for secondary and tertiary care (transport is critical and sometimes may not be available)

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Even some small communities have limited access to primary care.

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Language and cultural barriers may hinder primary care in some indigenous towns.

Case Study One: different ways in which patients are managed in an urban, rural or remote setting It demonstrates the subtle differences in the knowledge and skills required to manage this acute condition, which increases with geographical remoteness. It also demonstrates the substantial differences in the process of care, including the multidisciplinary nature of rural and remote practice. “Sharon, aged 19, presents with vaginal bleeding after 8 weeks of no menstrual bleeding. She uses no contraception and has experienced nausea and nipple soreness over the last week or so. On examination she is very tender on her left side and a small amount of bright red blood is seeping from her cervix. A urine pregnancy test is weakly positive. The doctor recognises the possibility of an ectopic pregnancy.”

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In an urban setting a doctor will make the initial assessment and then refer the patient to a more suitable specialist (obstetrician) or to a women’s hospital for treatment. Here the doctor can identify the problem but is not trained enough to help with treatment however because specialists appropriate facilities are available and the patient is able to receive the best treatment possible.

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In a rural context there is no nearby specialist and thus the monitoring of the patient solely relies on the broad knowledge of the doctor who has admitting rights to a small rural hospital. If necessary the local team comprising of midwives and theatre nurses and the doctor could remove the foetus and perform all followup monitoring. Here the treatment of the patient is restricted by geography.

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In a remote context treatment of the patient relies on the Royal Flying Doctors Service RFDS who are contacted by the remote nurse/midwife or aboriginal health worker. This means that the patient could have

to wait hours before they are attended to. Additionally the RFDS has to consider the risk management of the issue and in some circumstances flights could be delayed if it seems unsuitable at that time and the patient would have to be monitored until weather etc was more appropriate.

Workforce Shortage 

It is both difficult to recruit and retain pharmacists in rural/ remote towns

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People that do work in country towns tend to have a rural background and family ties there or have experienced rural placement before.

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Strategies that have been made in order to increase recruitments include o

Scholarships for student with a rural background (however there these numbers are insufficient and many don’t even return to the rural setting anyway)

o

Rural Campus to encourage students to develop relationships in the rural area

o

Rural placements

Why do we need to classify different parts of Australia? 

Enable the recordings of populations of towns and where particular groups of people, who may have special needs, live.

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Allow Governments to allocate resources and services - such as the number of banks, schools, health care facilities, vets - required to meet the population’s needs.

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Provide information to make sure that the services provided are affordable so that those who suffer socioeconomic disadvantage are not further disadvantaged by where they live.

What is the classification systems used to define rural and remote Australia? 

The typical distinctions used to describe the differences between rural and urban areas in Australia are large distances, inaccessibility to services and lower population numbers.

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The classification systems used to define rural and remote Australia include o

The Rural, Remote and Metropolitan Areas (RRMA) :

o

The Accessibility Remoteness Index of Australia ARIA

o

ARIA +

What is the classification System used in pharmacy? What are the categories and how are they determined?

?

Give examples of towns in each classification in the RRMA and the pharmacy classification system.

? Issues rural and remote pharmacists in Australia have to deal with including both lifestyles, professional, and geographical factors.  Transportation of supplies and cost  Internet/ telephone networks imposes possible communication problems  Interaction with local cultures  Greater responsibility for the pharmacists as they’re most likely the only ones within proximity to the community  You have less professional support and less trained staff. 

Isolation of practitioners both on a personal and profession level (they can get no help from fellow pharmacists and can get lonely)

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Shortages of locum or replacement (lack replacements if pharmacists is sick or needs time off)

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Difficult to continue education and update knowledge, especially when network connections are limited

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Difficulty in adapting to the remote/rural lifestyle due to inadequate preparation or difficulty for their families to adapt (children and education)

Social issues for a pharmacist (from video in workshop)  Rural and remote communities tend to be friendlier and tight knit this is advantageous as it allows greater monitoring of people and their medications, more socially rewarding, and the pharmacists is able to have insight into the individual’s health and personal background and thus is better able to advise them on the best possible treatments.  On the one hand the nature of the working environment is more relaxed and easy going, however as they are most likely the only pharmacist in the area this makes demand greater  They are less anonymous and the role becomes not just a day job but they can expect to be called up at any time of the day or night with requests by community members.  Pharmacies in rural Australia are more affordable and therefore higher profitability as o

Rent is lower

o

They have a larger area to service

o

High rate of disease

o

Only pharmacy in a particular district

 There is also the issue of small town politics: and your choices regarding moral and ethical issues can have social bearing and can risk being isolated from the community.  Additionally pharmacists within rural and remote Australia are held with a higher degree of respect by their community and thus it is more difficult for a pharmacist to let their hair down and do something disreputable and this can decrease their social acceptance. Rural Culture 

Characterised by mutual support, participation in networks, trust, common interest, pro-activity and reciprocity.

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Disadvantages of such a social capital include o

The development of a common set of values and norms where conformity is expected

o

Definite social ladder and power structures

o

People are afraid to be real

o

People who are different can be ostracised or problems ignored.

The Rural and Remote Pharmacist  The role of pharmacists in rural and remote Australia encompasses a diverse array of roles whereas in urban areas these roles become less as there are more people and resources available for more specialised people to take care of the alternative duties.  Pharmacists within rural and remote Australia work in many areas of pharmacy including: o

Hospital pharmacy

o

community pharmacy

o

Consultant Pharmacy (not actually working in a pharmacy but in divisions of general practice ensuring quality use of medicines and conducting medicines reviews)

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o

Academic Pharmacists (associate themselves with learning centres and universities)

o

Remote Pharmacists

As well as providing many additional roles such as aiding in aboriginal health programs, researching, nursing, becoming members of local council and naturopaths.

Rural Community Pharmacy 

On the surface pharmacies in a rural community look the same, however they have a tendency to be much larger or maybe look a bit old fashioned.

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These community pharmacists provide a more comprehensive range of services than their urban counterparts, this is because in an urban setting there is an abundance of health professionals spanning many different specialities and many facilities however in a rural setting all services need to found in the one place as there is no other alternative.

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Pharmacies in the outback thus play a great role in health related services such as o

o

Disease screening: helping to detect disease earlier 

Blood pressure and cholesterol testing for cardiovascular disease

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Blood sugar testing for diabetes

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Bone mineral density testing for osteoporosis

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Bowel scanning for Cancer

Disease State management: provide ongoing support for patients in addition to medications 

for chronic illnesses such as Diabetes (regular planned pharmacy visits for blood glucose review, dietary advice, healthy lifestyle encouragement and improvement of diabetes control) and Asthma (lung function testing, discussion on trigger avoidance and goal setting to achieve good peak flow)

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E.g. Japps Pharmacy in Hay NSW provides service to aged care facilities, blood glucose and blood pressure testing, home healthcare sales and hire (crutches, wheelchairs), methadone and buprenophrine program and a baby club.

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E.g. Cape Tribulation (QLD) provides first aid, currency exchange, care and bike hire, souvenirs, special tropical medicines as well as the normal pharmacy duties.

Rural Hospital Pharmacy 

Wide range of experience and lacks specialisation that urban hospitals have e.g. concord speciality in burns.

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The hospitals in rural centres must be able to cope with everything

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Other health professional may work in the pharmacists role as there is a huge shortage of rural pharmacists

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Medicinal supply may come from the community pharmacy rather than a separate hospital pharmacy as seen in most urban hospitals (e. Ceduna (SA)Hospital is supplied by the local Chemplus pharmacy)

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Most rural hospitals have outreach serves to several remote centres and aboriginal health centres. e.g. Port Augusta Hospital (SA), Broken Hill (NSW)

Remote Pharmacies 

Due to the shortage of pharmacists in a remote setting the role of a pharmacist may be completed by other health professionals

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They play a role in a health care team which includes nurses, Dr’s (who fly or tele conference), Aboriginal Health workers (members of the local community that speak local language, may not have any educational background), pharmacy technicians and assistants.

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Remote pharmacists need to innovative in the ways they reach patients o

Boat (Lynn Short of Thursday Island, pharmacist who services 15 island clinics and 5comunities in the Torres strait from a 52 foot boat)

o

Plane

o

Royal Flying Doctors Service

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In some cases there may be no direct contact with the patients

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Your roles include o

Provision of products to aboriginal Medical service

o

Training of staff (nurses and Aboriginal Health workers) that actual dispense medicines to local community

o

Ensuring quality use of medicines in remotes sites

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Being a remote pharmacist requires cultural awareness.

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E.g Andrew ‘Robbo’ Roberts who works on the border of SA, NT and WA(changed his name due to the aboriginal tradition that one cannot share the name of someone who has died within that region)

Aboriginal Health Section 100-National Health ACT 

Covers the supply of medicines to Aboriginal Health Services in remote areas (not small rural communities)

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Special government agreement that Includes a list of basic drugs agreed for emergency supply to treat both chronic and acute conditions

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No prescription is necessary and medicines are supplied free

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Useful as PBS is not realistic in this setting as there is no Medicare Australia facilities

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Pharmacists put in tender for contract to supply, and then are able to send of the medication required by the communities but relies on the Aboriginal Health workers working with patients at clinics as they may be located 1000km’s away.

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The pharmacists receive an allowance by the government and receive reimbursement for each item dispensed, however the profit margin is much less than an urban pharmacist....