Volume 10

This Editorial invites Rural and Remote Health readers to participate in a return to traditional values in healthcare delivery, by promoting compassionate rural health care.

What do adolescents eat? This detailed study of the diet of 100 rural Greek adolescents has some interesting findings to add to the developing knowledge base of the lifestyle and health-risk profile of the most recent Mediterranean generation.

Secondhand smoke and its health impacts on children is an issue of great importance in public health. What do we know about SHS exposure and rurality in Alaskan children? This population-based survey adds to our knowledge.

This Letter to the Editor reports a unique clinical opportunity to identify a rural African population LESS likely to suffer from sickle cell disease - with consequent implications for the preservation of scarce laboratory resources.

Parental attitudes have been found to inhibit childhood vaccination in some world regions. This brief letter from Uganda suggests this may not be the main different barrier to achieving high levels of child immunisation in developing rural communities.

From the analysis of data input to the national health information system, the Papua New Guinea government monitors the performance of its health system. In an era when anything IT is seen as the ultimate authority, this cautionary article is a reminder to information custodians not to lose sight of the reality of local (rural) service level when looking at the Big Picture.

This study of 388 rural South Australian high-school students used a multidimensional process model - encompassing individual, family and community factors - to investigate the determinants of mental health problems. The researchers' comprehensive approach makes a substantial contribution to the scant existing database on the mental health of rural adolescents in South Australia - an important but currently under-researched population.

This is a Comment on the recently published Commentary, "Attracting and retaining doctors in rural Nepal". The Commentary author's Reply will be published shortly.

Mental health services are limited in rural areas. Are computer-based programs that address mental health a possible solution? This article focuses on rural womens' experiences of depression and examines their use of an on-line social support program.

Clincial educators are challenged to prepare students not only for practice, but also for the larger environmental context within whcih they work. This article focuses on preparing nursing students for rural environments, specifically their sense of belonging during a rural hospital preceptorship.

Enduring natural disasters can undermine the wellbeing of those effected, with responses ranging from feelings of loss of control to helplessness and fear. The stress of prolonged drought, floods and other recent pressures on Australian farmers has increased their vulnerability to mental health issues and psychiatric morbidity. In response, the 2007 pilot 'Mental Health First Aid' training was offered to a range of non-health rural workers Queensland, such as landcare officers, financial counsellors and farm inspection officers, with the aim of early recognition of symptoms, referral and support for the farmers encountered in their daily work. This study re-visits the training offered in this unique program, and evaluates its impact on participants.

The Australian Government encourages the regional resettlement of refugees. However, for people used to urban living or those with a background of disruption, torture and trauma, relocation to a rural area requires sensitive, appropriate support. This article describes the development of a basic manual and additional support materials for the use of volunteers and caseworkers in regional Australia.

Much has been written internationally about the access of rural populations to health care; however, until now there has been no information from Hungary. This letter informs readers of a landmark survey in the year 2000, which established the difference between the rural and urban populations' health care in Hungary.

Rural health research is continually needed to demonstrate the links between place and health. This article, focusing on older rural women and breast cancer, provides information about these links and also some surprising information about support and breast cancer treatment.

This Editorial coincides with the recent launch of the WHO guidelines "Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendations". The Editorial and a linked review of the Guidelines (which includes the WHO URL for free Guidelines download) will be of interest to all who are concerned with improving the recruitment and retention of health workers in underserved areas.

How do we prepare health care professionals for geriatric practice in rural areas? We can all learn from this project report which provides details and examples from the author's experiences in New York State.

Women with gestational diabetes (GDM) have an increased risk of developing type 2 diabetes mellitus, although this risk can be reduced by behavioural changes. The group of rural women with GDM studied by these authors showed one intriguing difference from urban women. The authors' skilful application of the Stages of Change Model also focused issues in the promotion of the lifestyle behaviour changes that are so important for the long-term health of this special group of women.

The debate about loan repayments and other incentives continues. Do they result in more primary care? Do they result in more basic health access in locations short of physicians? Do they result in changes in physician locations to the most needed locations? What does a loan repayment really accomplish that is above what the recipient would have done anyway? How much do short term obligations accomplish in the context of 30 or more years in the career of a physician? While the questions will continue, this study provides some answers.

Sometimes we would like to show differences in interventions that lead to better care or more rural workforce, but studies often fail to have proper controls or use arbitrary definitions. Similar problems often involve studies of origins and admission, or outcome and studies of healthcare quality. This study examined out-of-pocket healthcare costs. It included controls for healthcare insurance coverage, healthcare utilization, and patient income. These are factors known to be different for rural populations. Are out-of-pocket costs different relative to rurality - or are other factors at play here?

What factors influence patients' choice of primary care facility for an episode of care? This question was asked in a bid to understand - and ease - the pressure on primary care in many parts of Canada. In a microcosm of the larger picture, the researchers analysed the pattern of medical visits to 6 primary care facilities in rural Quebec. The results provide a first insight into the influence of patients' location, sex and age.

When patient needs require rural generalists to venture into specialist areas, professional and ethical issues are raised. This thought-provoking study from Queensland, Australia, reports on a survey of rural physiotherapists who have also provided patient care in the specialist field of paediatrics. The findings raise important questions about the nature of rural and remote practice and its impact on the confidence of generalist health professionals, and also rural patients requiring specialist care.

The retention of GPs in remote parts of Australia is an urgent workforce issue, and the Northern Territory is a case in point: it has the highest GP turnover and few 'home grown' practitioners; the sense of adventure that promotes NT recruitment works against retention. In the context of too many short-stay GPs, these authors applied the theory of 'place attachment' to the highly mobile NT medical workforce. Although their sample was small, this article offers a fresh look at a constant issue - and provides an intriguing model for remote area retention that could apply across disciplines.

This article offers information about three specific chronic diseases including their incidence and management among the rural population. The investigation is a welcome addition for those keen for greater precision regarding rural health status.

It started when the Warlpiri Aboriginal community in Central Australia wanted to bring their old people home from distant nursing homes. The subsequent development of the Yuendumu Old Peoples Programme and its Family Model of Care shows how this was achieved - and so much more. When government and community worked together respectfully, the power of the traditional system of care based on Law, kinship and 'country' transformed the everyday setting of community based Indigenous aged care - and the final years of many older people.

What are GPs' community management issues for chronic heart failure patients in rural and remote Scotland? And has the recent community based nurse-led heart failure service improved care, as intended? These questions and the views of the first Highlands CHF specialist nurses are explored in this postal survey of all Highlands GPs.

How do rural undergraduate students get their health information? This US study from the time of the 2009 influenza A (H1N1) pandemic offers useful information for health educators as well as those responsible for emergency preparedness plans.

Are rural health workers at a disadvantage in regard to injury and disability? This comprehensive review provides insight about rural-urban differnces on this topic and offers recommendations for future research.

Addressing the epidemic of type 2 diabetes among First Nations peoples is an ongoing challenge. These authors reflect on their clinical practice and research endeavors, providing useful insights that health workers can use to engage with First Nations communities in these efforts.

Does eating shellfish live protect against the transmission of pathogens? How is Ash Monday related to an epidemic of gastroenteritis? The answers to these and other questions are provided in this report of a recent public health outbreak investigation on the remote Greek island, Agios Efstratios. The authors describe epidemiological methods that would be useful in any remote setting where the source of an epidemic must be tracked despite limited or absent laboratory support.

Are there differences in early childhood caries (ECC) among religious agricultural groups? This report is the first study to examine ECC among Hutterite children in Manitoba.

In developing countries where TB is endemic and co-infection with HIV is rising, disfiguring cutaneous TB is a re-emerging pathology, due in part to the treatment access barriers of rural and remote patients. This case report gives some practical advice for health personnel in district health posts where effective diagnostic tests may not be available.

In common with other countries, the recruitment, retention and training of rural mental health workers is a major concern in Australia. What are the views and perspectives of their managers? The information provided by this research complements studies of the clinicians themselves, and so offers a unique contribution to achieving a sustainable and effective rural mental health workforce.

Are Australian medical students on rural clinical rotation disadvantaged by being sent in small groups to very small, remote locations? The answer is clear in the qualitative and quantitative evidence from the Rural Clinical School of Western Australia.

The equation's wrong: those who live in rural and remote areas have higher rates of mental illness - but often lack access to specialist mental health services. The Australian Rural Nurses and Midwives identified a need, and took the opportunity to up-skill Australian rural and remote generalists to promote effective management of mental health emergencies locally. This report on the evaluation of the short course 'Managing Mental Health Emergencies' shows how this was done.

Amid the global nursing workforce crisis, this Australian review investigated the experience of overseas trained nurses in rural practice. Despite the many well-documented issues related to the international migration of nurses, issues specific to rural practice have been neglected. These authors make a start in their contribution to this important literature.

In rural Tanzania, the common belief that medical injections can kill - can be fatal, especially for a child with malaria. However, is it possible that such a commonly held mis-belief has its origin in fact? This clinical case report discusses widespread infection control issues associated with medical injections (including IV therapy) in Tanzania and other parts of Africa. Hopefully, in Tanzania, this will soon be history. The 2010 Tanzanian policy initiative reported may also be transferable to other, similar states and countries.

Much has been written about traditional midwives, the caregivers of choice or necessity for many birthing women in areas such as rural Western Kenya. This small local study gives voice to traditional midwives about their relationships with skilled (professional) birth attendants. The recommendations reference a wider debate, offer ways to improve the specific issues identified and, ultimately, benefit mothers and their newborn children.

The association of physical inactivity with chronic disease is not limited to affluent societies. Even in the developing world, the physical activities associated with daily living are diminishing - firewood comes chopped, maize is purchased already ground. In resource-poor rural South Africa, the attitude that organised exercise belongs to a more affluent 'white' lifestyle was challenged by the introduction of a physical activity chronic disease prevention program. The unique insights offered by these authors add to the literature of health promotion.

Studies of rural health professionals have been dominated by centralized urban academic perspectives for decades. Not surprisingly studies about rural practice have focused on areas such as lack of health care resources, lack of professional resources, and isolation. Some of these may represent differences in perception as few studies attempt to capture the nature of practice for rural health professionals. There are indications that some of these perceptions are changing. Even definitions of resources, support, isolation, and appropriate training may be changing due to improvements in communication. Occupational therapists in rural Canadian locations may not consider themselves isolated, may not indicate a lack of professional resources, and may not even believe themselves rural or isolated enough to fit study criteria. New studies are needed as rural and remote locations enjoy improved communication technologies and social support. Some therapists indicated potential mismatches of urban-based support and education. Indeed rural providers have had to retool continuing education to fit rural practice needs. Others listed rural advantages related to autonomy, flexible work schedules, teamwork, and the types of patients and problems encountered. Researchers would do well to assume less based on past studies and to focus more on the current Brave New World.

In common with many of its South Asian neighbours, Nepal's rural population suffer from a maldistribution of the medical workforce. What strategies from the international literature could be applied to this small kingdom - and others like it?

Does the quality of primary care for patients with type 2 diabetes in a rural Italy reach international standards? This small comparative study offers a tentative answer.

Rural medical educational exposure has been associated with an increased interest in pursuing a career as a rural doctor. However, if medical students are conscripted to rural clinical experience, they may view the whole experience negatively and decline graduate rural practice. This Australian multi-university study identifies which factors medical students consider in their decision to attend a rural clinical school - and there are some surprises.

This report of a recent large scale partnership between the Brazilian Ministry of Health and 82 municipal governments identifies factors that facilitated telecardiology solutions for rural and remote patients in Brazil. This is a unique study, not only because it shows the role of local organization and action in facilitating grant funding, but also in reminding government that less organized locations can lose out in grant funded programs.

Enhancing birth outcomes among vulnerable groups in rural and remote areas remains a priority. This retrospective cross-sectional chart review provides useful information about smoking and pregnancy among the Inuit in Nunavut, Canada.

The Editor of this Rural and Remote Health supplement, Campbell Murdoch, says in his Introduction: "...An old adage in the academic world about research is that 'if it hasn't been published, it hasn't been done'. Many things 'get done' in rural and remote medicine but they are usually carried out away from the eyes and ears of others..." These authors presented at the 2009 Annual Scientific Meeting of the Rural Clinical Schools of Western Australia in Bunbury, WA. They have not only written it down, but have also submitted to review and revision. Their work is published in this supplement.

We know there are differences in stroke incidence between rural and urban residents. If so, what can explain this gap? Could it be as simple as the weather? The report of this Japanese cohort study has something interesting to say about the weather and strokes among rural women in Japan.

The 2010 Chalmers Oration was delivered by Dr Tom Calma on 15 August 2010 at Flinders University in Adelaide, South Australia. Dr Calma's presentation concerned the groundbreaking roles that he and the Close the Gap Campaign have played in making a difference to the health of Indigenous Australians, especially those who live in rural and remote Australia. The text of his speech will be required reading for all those who are concerned about the health disadvantage of Indigenous Australians, and to those with an interest in Australian Indigenous health policy.

While biosand water filters are an important public health intervention for the 1 billion people who still lack access to safe drinking water, questions have been raised about their effectiveness. Do those who use the filters understand the concept of recontamination? Is there bias in their survey responses due to fear of losing their filters? Do studies adequately examine important associated outcomes, such as overall health improvement? Does reporting bias influence research approaches, business operations, funding institutions or even government? This study considered some of these important questions when it assessed the performance of existing filters in rural Nicaraguan households.

Indigenous Australians have among the highest rates in the world of acute rheumatic fever and rheumatic heart disease. For some, the timing of essential medication can be problematic. This unique study of clients and primary care providers in Central Australia reports on 'The Full Moon Strategy' which uses the natural world as a reminder for monthly penicillin prophylaxis.

For almost a decade, Australian medical students have been attending rural clinical schools in a national strategy to boost the diminishing rural medical workforce. Among the now 13 state and territory universities conducting undergraduate- and graduate-entry RCS programs there are distinct curricula. Despite diversity, is the RCS program on track to achieve its goals? In this report on part of the first multi-institution study, the medical students of 6 RCS have their say.

Recognised family stresses following the birth of a premature infant can be compounded when rural parents must relocate to be with an infant who neeeds specialized care and life support. This small Australia studies offers a privileged insight into rural parents' experiences, and identifies their coping strategies which are both rually unique and universal.

Back in the 1970s when the Australian rural GP's role was procedurally broad, singer/songwriter Joni Mitchell warned 'you don't know what you've got 'til it's gone'. In the decades that followed, the rural GP's role contracted - or so this research found when it examined the 'the hidden heart' of Australian rural health (the GP proceduralist workforce) and found it to be peril.

Healthcare professionals are always needed in rural areas; recruiting and retaining them is linked to undergraduate clinical rotations. What are the experiences of undergraduate nursing students in rural areas - and their challenges? This literature review provides some answers as well as useful implications and suggestions for educators, faculty and decision-makers.

Consumer-driven community mental health services play an important role in the recovery of rural people with mental illness. At best they capture the essence of a rural community's concern for the wellbeing of its members. They overcome the power differential between health professionals and patients/clients. While information about the benefits and limitations of such services in rural Australia is scarce, this article makes a start by reporting the evaluation of The Station Inc, in South Australia.

Three of Australia's midwifery leaders present their strategies for improving maternal health of Aboriginal women in regional, rural and remote Australia.

Have you ever wondered whether 'social capital' could be applied to the study of rural children? This article from Sweden uses the concept to explore the contribution of 'neighbourhood' to the health and wellbeing of rural pre-teens. The findings reveal unique features of the physical and social landscape that impact on the child's experience of growing up rural.

Pharmacists are a potentially underutilised source of expertise in rural and remote areas. This article from Western Australia describes the additional activities undertaken by pharmacists, asks if these have increased and identifies on-going barriers to expanding services.

A decade after health sector reform, public health services in rural Cambodia remain under-used, despite strategies to improve public sector performance. Qualitative data from TB control health providers in rural Kampong Speu Province is analysed here to identify social and structural barriers and solutions. The findings of this local study offer a potential way forward to providing effective health care to those most in need.

What does one small rural community have that others do not? This was the question that sparked research into why the West Australian town of Tambellup outperformed others in an early child development index. The important findings of this small study tell the success story of the Tambellup community, whose strengths so effectively promote the wellbeing and healthy development of its children in their crucial early years.

The rate of dementia among older rural and remote Indigenous Australians is much higher than for other Australians, and it is predicted to double in the next 12 years. This Letter reports the research themes and priorities that emerged from the recent workshop 'Recognising and responding to dementia in Indigenous communities', making it a must-read for interested clinicians, researchers and policy-makers.

America has entered a 20 year period of rapid increases in the older and oldest and increased access to care for those previously left behind. The likely yield is a record demand for primary and other health care, particularly in primary-care dependent rural areas, despite medical association reports emphasizing the need for more subspecialty and hospital workforce. This timely grassroots study should remind US policy-makers of health workforce priorities in rural areas (and most other US populations) for basic nursing and primary care workforce. The surveyed rural hospital CEOs bring a unique perspective to a now critical issue: the challenges of rural workforce - its varieties, recruitment, retention, shortages and solutions.

This article discusses an innovative Rural and Isolated mental health toolkit for use by mental healthcare services throughout rural and isolated Canada. There is much of interest here for those providing similar services in North America.

The potential of swine flu to spread rapidly challenges rural public health management, where such resource-heavy tasks as contact tracing and case tracking must be spread among available staff. These authors show it can be done effectively. They share the lessons of their successful containment of a recent pandemic A/H1N1/2009 cluster in the remote Scottish Highland.

What are the pain experiences of Indigenous peoples? And are they different from the experience of other groups? This report explores pain experience and related beliefs in the South American Quicha (Inca) peoples.

Rural and Remote Health is proud to announce its special issue 'Human Health at the ends of the earth'.

Guest editors Dr Laura Arbour (UBC Medical Genetics and the Island Medical Program) and Dr Alan Parkinson (Centers for Disease Control & Prevention's Arctic Investigations Program (CDC), along with RRH's co-North American Regional Editor Professor Judith C Kulig, invite you to read these special articles ON CIRCUMPOLAR HEALTH WITH THESE PARTICULAR THEMES: the impact of place on health; the health status of individuals living in circumpolar regions; the accessibility of health services; and the preparation of health professionals.

Take the link in this alert to the issue Editorial, the gateway to this unique collection, which concludes: "...all the articles ...inform us about the complexity of health and healthcare services in circumpolar regions. They ...remind us that terms such as 'rural,' 'remote' and 'northern' are contextual experiences where place matters everyday on an individual and collective level."

This US research examined provider perceptions of diabetes education and its accessibility, according to Appalachian regional "economic distress" and rurality. Read the conclusions of those who know - the answers may surprise you.

This commentary from India opens with a quote from Nehru: "You can tell the condition of a nation by looking at the status of its women". If this is so, then in terms of the five key issues in women's health these authors discuss, all is not well in rural India.

Being overweight is a common issue worldwide for both urban and rural children. Surprisingly this NZ study finds it to be a greater problem among-- (read the article to find out!).

Coordinated care is a hallmark of optimal cardiac care post-discharge, but this can be challenging when patients, cardiologists and primary care physicians are all in different locations. This study compared the hospital re-admissions of urban and rural veterans after congestive heart failure episodes. While all patients need good follow-up care, the situation of rural older veterans illustrates the importance of coordinated care approaches.

Japan attempted to resolve rural physician shortages using standard approaches but still came up short. Their ultimate solution appears to have been in the design of Jichi Medical University, a rural medical school that involves all levels of government, aligning selection and specific training for a guaranteed rural workforce. Could this model work in other countries?

Rural Americans have served in the military at high levels, a pattern that continues today. These rural veterans can face extreme barriers to health care, including disability, poverty and typical highly centralized US healthcare facilities. In a compassionate project, telehealth monitoring was trialled to improve outcomes and support for older rural veterans with complex care needs. The authors describe a unique initiative that could also improve the disadvantage suffered by other hard-to-reach rural populations.

What is the role of rural residence in treatment delay during myocardial infarction? The answer may seem obvious, but this small study from the Greek island of Crete had some unexpected findings.

Rural versus urban is always an interesting perspective. Training in rural sites and urban sites does result in a different experiences for emergency medicine residents. However, rural plus urban training may complement the training of emergency physicians, equipping them to address a broader array of emergency care needs.

This recounting of program experience from the USA offers a generalizable "how to" guide for using medical education to address the workforce needs of a rural state.

When the Canadian Community Health Survey was used to test the relative income hypothesis as it relates to health status among rural and urban Canadians there were some surprising findings. This article has significant policy implications for public health.

It has been said that rural individuals with a diabetes diagnosis do best when their self-care is skilfully monitored by an appropriate healthcare professional. Read what Appalachia healthcare providers have to say about diabetes services in this underserved rural US region.

Question: How can scarce eye care services be maximised for those with visual impairment in the rural, developing world? Answer: By producing skilled program managers. To find out how, read this short report from the Postgraduate Diploma in Community Eye Health course at South Africa's University of Cape Town.

What do rural North Carolinians know about renal health and the treatment for chronic kidneys disease? This US study identifies barriers to renal knowledge and health care, along with community members' suggestions for marketing renal health information and screening.

Neuropsychiatric complications of typhoid fever are not uncommon in the tropics, however a patient presenting with depressive features can confound the rural physician. For one patient with typhoid fever, self-medication and a belief that psychiatric problems are caused by demons resulted in a delay in presentation. Intervention by a social worker in a community psychiatric centre meant that she received belated but appropriate care.

How do we deal with the obesity and related diabetes epidemic among First Nations peoples in Canada? These authors suggest taking a 'whole school framework' approach among First Nations students in rural and remote communities in British Columbia, Canada. They emphasize the feasiblity of their evaluation, and its results.

Impoverished areas in rural locales around the world struggle with an insufficient number of healthcare professionals. This article discusses a residency training program in Loreto, providing a Peruvian perspective on this global issue.

You've read about it in Africa, Australia, the UK and US: fewer medical students are going into general practice, and fewer still are prepared to work in a rural area. Now read about this issue from the perspective of German GPs. Their thoughts and solutions, both unique and familiar, add to this well researched phenomenon.

Public or private, the grass always appears greener on the other side - the Australian rural healthcare system wouldn't survive without both. This article gives an insight into some of the issues and perceptions of rural allied health professionals working in private practice.

This retrospective, cohort study focused on healthcare utilization or location of death for rural persons with respiratory illnesses. Among other information, readers will find out which factors were different for rural and urban residents with this type of illness.

For rural residents the world over, access and equity are prognostic considerations for cancer survival. This large-scale study from New Hampshire USA asks the question: is geographic access to mammography screening related to a woman's late or early stage at breast cancer diagnosis? The authors examine the evidence, including the contribution of age, health insurance status and seasonal influence.

What is the desired rural practice environment for generations X and Y GPs? "Latte rural"! To find out what coffee has to do with rural workforce, read this intriguing Australian research into the motivation of the next generations of rural GPs.

This letter from Norway continues a conversation on pre-hospital trauma data.

Women in over 130 small Australian rural communities can no longer deliver their baby in their home town. Instead they face the hazards of many hours road travel to their planned birthing centre while in labour. This qualitative study shows the profound impact of this change on many.

This letter alerts RRH readers to the plight of India's forest-dwelling tribal communities who are suffering unintended health consequences from official conservation policies.

"...This is the way we do it in the real world." The transition from theoretical setting to clinical practice site can be an anxious time for student nurses. When there is a difference between what was taught and what is practised, do students fall into the theory-practice gap? This interesting article explores a crucial issue.

Hypertension is a major public health problem and its prevalence increases with age. This unique rural Greek study shows that, where the elderly are concerned, greater efforts are required in hypertension prevention and control.

Rural women in Turkey have unique characteristics but their low access to specialist health care is common with the rural women of many countries. This study assessed the use of the universally adopted Menopause Rating Scale as a screening tool to assist Turkish primary healthcare providers identify rural women in need of specialist referral for the management of their menopausal symptoms.

This letter from a Thai researcher identifies potential differences in rural children's obesity patterns between developed and developing countries.

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Providing acute, 24 hour healthcare services for those in small rural communities is a real challenge. This study offers important data about the type of patients who use such small health units.

In the developing world, natural disasters can increase the morbidity of those most economically vulnerable, often rural dwellers and their families. The findings of this study into child abuse and injuries during flooding in Bangladesh calls for effective interventions to break an identified cycle of suffering.

This letter from Nepal provides further evidence of the need for a multisectorial approach to maternal and, ultimately, child health.

Life in the country can be more dangerous than the city. This compelling article highlights how and how many injuries happen in rural communities.

In response to the difficulties posed by distance for New Zealand medical students on rural general practice attachments, a novel system of distance teaching was devised by the Waikato Clinical School.

The rural health workforce is in crisis worldwide. This assessment of the influence of curricula type on the practice location of medical and nursing graduates in Uganda adds another element to understanding a complex and concerning global issue.

Trauma has been a neglected cause of child mortality in resource-poor rural settings due to the burden of infectious diseases such as HIV. However this letter from rural Uganda suggests that simple preventative measures could reduce the number of injured children.

These authors from New Zealand have reported on selected features and the evaluation of the University of Auckland's first regional-rural medical education program, Pūkawakawa, a 27 week curriculum for year 5 students.

Malnutrition among children under 5 years is a tenacious problem in the developing world. The underlying factors are diverse and the consequences long-lasting for malnourished individuals. This Malaysian study looked at causal relationships in child malnutrition and provides useful insights for those designing intervention programs, especially for use in resource-low contexts such as a rural areas.

Occupational noise injury and hearing loss are a common features of agricultural workforces internationally. In Australia 60-70% of Australian farmers have measurable hearing loss, compared with 27% of the general population, and their families are also affected. With such a level of acquired injury it is astounding that this article is the first report of a community based initiative to specifically address hearing health issues in farming communities.

Are your staff training programs relevant and effective? Or, as this study of rural health worker training found, could better use be made of dedicated resources? Although set in Uganda, the fundamental issues highlighted here will prompt a re-evaluation of training systems and procedures in any rural area.

This tribute to Dr John A J Macleod (1935-2009), celebrates his service as a dedicated rural Scottish GP and signifiant contributer to the international rural medical community as honorary life member of Wonca.

In the USA, rural residents suffer multiple disadvantages in their access to health care. Is this also true for quality of care? These authors sought the answer to this question by comparing rural and urban primary health carers' blood pressure management of patients with diabetes.

How can Nigeria's critical shortage of rural and remote health personnel be addressed? After years as a public health physician in Africa's most populous nation, this author offers a personal perspective on strategies for change.

Chronic disease self management programs (CDSMP) have been shown to be effective in improving health and well-being across settings and conditions. But implementing such programs on a small scale in a rural town and in a country without a tradition of CDSMP presents challenges. This paper from rural Western Australia describes the experiences of one such attempt and gives advice to other rural health practitioners, managers and researchers considering similar programs.

This letter argues for changes to the way decisions are made about rural resource allocation in Sub-Saharan Africa.

Developing e-health agendas have become commonplace, although a description of the process is not often readily available. This unique article discusses in detail the development of an Aboriginal e-health agenda based on Canadian Aboriginal culture, values and approaches to consensus. It has something to offer all researchers concerned with cultural safety.

Mainstream education has consistently undervalued Indigenous knowledge and this can be quite frustrating for educators and students of Aoriginal origin. Has this failure to teach from a broad cultural orientation resulted in the under-representation of Aboriginal persons in health and science occupations? A unique collaborative initiative grew from Canada's University of Lethbridge Support Program for Aboriginal Nursing Students: the 2009 Aboriginal Science Symposium. Academics worldwide interested in developing more inclusive curricula should review the recommendations from this Symposium.

Are there rural-urban differences for hospitalization in the 30 days before death? This Canadian article examined administrative health records to answer this question and others relating to end-of-life access to health care. Implications for consideration are provided for others who live and work in similar rural areas.

This case report from rural Nigeria discusses an unexpected diagnosis of the parasitic infection trypanosomiasis in an infant with no known exposure to the vector, the notorious Tsetse fly.