Clinical courage can be described as a rural doctor's adaptability and willingness to undertake clinical work at the limits of their training and experience to meet the needs of their patients. This article describes the in-house development of survey items to include in a quantitative measure of clinical courage. The questionnaire development involved two key concepts: a second-order latent factor model structure and a nominal group technique, used to develop consensus among the research team members. The steps taken to develop a sound clinical courage questionnaire are described in detail. The resulting initial questionnaire is presented, ready for testing with rural clinicians and refinement. This article outlines the psychometric process of questionnaire design and presents the resultant clinical courage questionnaire.

Little is known about how medical school placements in rural areas impact key stakeholders such as patients, host organisations and the wider rural community. With engagement from rural communities crucial to the success of rural medical training, this case study sought to demonstrate the benefit that rural clinical placements can have on rural general practices (systems) and likely impacts on communities (health outcomes). Specifically, we describe how a series of consecutive short-term student placements in a single rural practice were the drivers of a series of clinical audits and interventions resulting in improved management of chronic disease. Data for this project were obtained from student research reports completed as part of a rural and remote medicine rotation at an Australian medical school. For this series of projects, eight consecutive students were based at the same rural medical centre, with each attending for 6 weeks across a 15-month period, completing a report for a quality improvement activity and evaluating the outcomes. Each project related to chronic kidney disease (CKD), with CKD chosen based on the needs of the medical centre and the higher burden of this disease in rural areas. Each project was developed and delivered in consultation with the practice, taking into account student interest and skills, and related projects completed prior or concurrently. Projects were related to database management (n=2), alignment between CKD management and best-practice guidelines (n=3), patient health literacy (n=3), and a summary and staff perceptions of the preceding quality improvement activities (n=1). The combination of student projects led to tangible improvements in CKD management at a rural general practice. All doctors at the medical centre (n=4) reported using the database management tools implemented by the students and felt the interventions were sustainable, long-term solutions for ensuring clinical investigations are not being delayed or missed. Following the various interventions completed by the students, clinician knowledge and implementation of best-practice CKD management increased, and some patients became more aware of their condition and how to manage it. This case study provides evidence that short-term rural clinical placements for medical students have the potential to greatly improve health care and clinical practice in rural and remote communities, when designed around a consistent topic within a medical practice. Outcomes of the student projects in combination demonstrate that addressing CKD management longitudinally led to improvements in administrative processes, clinical practices, and patient awareness and accountability, despite each student only being at the medical centre for a short period of time. Similar approaches to structuring rural clinical placements and defining community projects for medical students should be considered more broadly.

Tuberculosis (TB) remains a major global health challenge, killing millions of people, despite the availability of preventive TB medication. The majority of these infections and deaths occur in low-income countries. Therefore, practical public health strategies are required to reduce the global TB burden in these countries effectively. The purpose of this review was to examine the current evidence of tuberculosis infection control (TBIC) measures in reducing TB transmission and explore the barriers and enablers of TBIC measures in resource-constrained primary healthcare settings. The PRISMA framework was adopted to identify studies that report on the evidence and barriers and facilitators of administrative, environmental and respiratory control measures at healthcare settings in low- and middle-income countries (LMICs). ProQuest, Scopus, ScienceDirect, Embase and PubMed were searched for English language peer-reviewed studies published since the introduction of TBIC guidelines. Studies not relevant to the topic, were not on TBIC measures or were reviews or commentary-style papers were excluded. Included articles were evaluated based on their aim, study design, geography and health settings interventions (TBIC measures), economic setting (ie LMICs) and main findings. Our review of the 15 included studies identified a cough officer screening system, isolation of TB patients, modification of consultation rooms, and opening windows and doors as effective TB prevention measures. Lack of patient education, unsupportive workplace culture, inadequate supply of particulate respirators, insufficient isolation facilities and poor physical infrastructures were identified as barriers to TBIC practices. Triaging TB patients, maintenance of health infrastructure, appropriate use of personal protective equipment (PPE) and healthcare workers (HCWs) training on the correct use of PPE were reported as facilitators of TBIC in primary healthcare facilities. Our review provides consistent evidence of TBIC measures in reducing TB transmission in resource-constrained primary healthcare settings. This review has demonstrated that TB transmission can be successfully controlled using multiple and simple low-cost TBIC measures including administrative, environmental and respiratory controls. Effective implementation of triaging patients with suspected TB alongside maintenance of health infrastructure, appropriate use of PPE and robust HCWs training on TBIC could improve implementation of TBIC measures in primary healthcare settings. Healthcare management should address these areas particularly in rural and remote locations to improve the implementation of TBIC measures in primary healthcare facilities in LMICs.

Medical education is increasingly taking place in rural areas as this is known to help physician recruitment to rural areas. A medical school is planned for Prince Edward Island (PEI) that would use community-based learning as a core principle, yet little is known about the specific factors that influence our rural physicians' participation and engagement in medical education. Our objective is to describe these factors. Using mixed-methods, we conducted a survey of all physician-teachers on PEI and conducted semi-structured interviews with self-selected survey respondents. We gathered quantitative and qualitative data, and conducted an analysis of themes. The study is ongoing and will be completed before March 2022. Early survey results suggest that faculty teach because they enjoy it, and due to a sense of \"paying it forward\" and \"duty\". They face major workload challenges but are very interested in improving their teaching skills. They see themselves as clinician-teachers but not as scholars. Locating medical education in rural communities is known to alleviate physician shortages in those areas. Our early findings suggest novel factors such as identity, and traditional factors such as workload and resources, influence teaching engagement for rural physicians. Our findings also suggest that rural physicians' interest in improving their teaching is not being met by current methods. Our research contributes to the study of factors influencing rural physicians' motivation and engagement in teaching. Further research is required to understand how these findings compare with urban settings, and the implications of these differences for supporting rural medical education.

Knee pain is estimated to affect at least 25% of people older than 50 years. In Ireland, knee pain accounts for the greatest number of new consultations seen in publicly funded orthopaedic clinics and meniscal pathology is the most common knee diagnosis after osteoarthritis. Exercise therapy is recommended as first line treatment for degenerative meniscal tears (DMT), while clinical practice recommendations advise against surgery. Nonetheless, arthroscopy rates remain high internationally for menisectomy in middle aged and older adults. While Irish knee arthroscopy figures are not available, referral in substantial numbers to orthopaedic clinics suggests surgery may be considered a treatment option for patients with DMTs by some primary care practitioners. This warrants further investigation with the GPs themselves; therefore, the aim of this qualitative study is to explore GPs' views on managing DMT and factors influencing their clinical decision making. Ethical approval was granted by the Irish College of General Practitioners. Semi-structured interviews were conducted online with 17 GPs. Question topics included assessment and management approach, role of imaging and factors influencing referral to orthopaedics, and future supports that would enhance management of this type of knee pain. Transcribed interviews are being analysed using an inductive approach to thematic analysis guided by the research aim and Braun and Clarke's six-step approach. Data analysis underway. Results available for WONCA in June 2022Discussion: These results will contribute to the development of a knowledge translation and exercise intervention for the management of DMT in primary care.

The COVID-19 pandemic has caused huge disruption to all communities and health care worldwide. This ongoing pandemic has encouraged international collaboration and cooperation, and this important activity needs to intensify further. Open Data sharing offers researchers the opportunity to compare public health and political responses and subsequent COVID-19 trends. This project uses Open Data to summarise trends relating to COVID-19 cases, deaths and eventual engagement with vaccination campaigns for six countries in the Northern Periphery and Arctic Programme (i.e. Ireland, Northern Ireland, Scotland, Finland, Sweden, Norway). Countries examined fell into two groups - countries that achieved near elimination between smaller outbreaks, and those that did not. Rural areas generally experienced slower increases in COVID-19 activity than urban areas, presumably due to the lower density of population and other factors. Rural areas experienced approximately half the COVID-19 deaths when compared with more urbanised regions within the same countries. Interestingly, countries that opted for a more local approach to public health management, particularly Norway, seemed to control outbreaks more effectively than those with a more centralised approach. While contingent on the quality and reach of testing and reporting systems, Open Data can offer us useful insights to appraise national responses and provides context for public health-related decision making.

The USA has long wrestled with the challenges of delivering high quality care to rural areas and has developed an extensive set of policy interventions to support rural providers. The release of the results of a Parliamentary inquiry into rural health and care in the UK provides an opportunity to compare US and UK efforts to support rural health and share lessons learned from the USA. This presentation reviews the results of a study of US federal and state policy efforts to support rural providers dating back to the early 1970s. The lessons learned from these efforts can inform the work of the UK as it addresses the recommendations discussed in the February 2022 report from the Parliamentary inquiry. The presentation will review the major recommendations identified in the report and compare US efforts to address similar challenges. The results of the inquiry indicate that the USA and UK share common challenges and inequalities in rural healthcare access. The Inquiry Panel made 12 recommendations for change under four broad headings:Build understanding of the distinctive needs of rural areas;Deliver services suited to the specific needs of rural places;Develop a structural and regulatory framework that fosters adaption and innovation; andDevelop integrated services that provide holistic, person-centered care. This presentation will be of interest to policymakers in the USA, the UK, and other countries working to improve rural healthcare systems.

Roma, travellers and the homeless suffer from a higher risk of both COVID-19 infection and severe disease relative to the general population. The purpose of this project was to ensure as many members as possible from vulnerable groups in the Midlands availed of COVID-19 vaccines. Following on from successful testing of vulnerable populations in the Midlands of Ireland in March/April 2021, a collaboration of HSE Midland's Department of Public Health, Safetynet Primary Care and the HSE Midlands Traveller Health Unit (MTHU) operated pop-up vaccination clinics in June/July 2021, targeting the same populations. Clinics delivered the first dose of the Pfizer/BioNTech COVID-19 vaccine, registering clients for second doses in Community Vaccination Centres (CVCs). Thirteen clinics were hosted between 8 June 2021 and 20 July 2021, resulting in 890 first-dose Pfizer vaccinations delivered to vulnerable populations. Trust established months prior with our grassroots testing service resulted in strong vaccine uptake, with the quality service provided seeding further demand over time. This service integrated into the national system and allowed individuals to receive their second doses within the community.

Recruiting doctors in rural areas is challenging. Various educational interventions have been introduced in many countries. This study aimed to explore undergraduate medical education interventions introduced to recruit doctors to rural areas, and the results of these interventions. We undertook a systematic search using search words 'rural', 'remote', 'workforce', 'physicians', 'recruitment' and 'retention'. We included articles meeting the following criteria: educational interventions clearly described; study population consisted of medical graduates; and outcome measures included place of work (rural/non-rural) after graduation. The analysis included 58 articles and encompassed educational interventions in ten countries. There were five main types of interventions, often used in combination: preferential admission from rural areas; curriculum relevant to rural medicine; decentralised education; practice-oriented learning in rural areas; and compulsory service periods in rural areas after graduation. The majority of the studies (42) compared place of work (rural/non-rural) of doctors graduated with and without these interventions. In 26 studies, odds ratio for rural place of work was significant at a level of 5%, with odds ratios between 1.5 and 17.2. Significant differences in the proportion with a rural/non-rural place of work were shown in 14 studies, differences ranging from 11 to 55 percentage points. Changing focus of undergraduate medical education towards development of knowledge, skills and teaching arenas that equip doctors with competencies to work in rural areas has an impact on the recruitment of doctors in rural areas. Concerning preferential admission from rural areas, we will discuss if national and local contexts makes a difference.

To strengthen and demonstrate the ability of rural pharmacists to address their communities' health needs, we developed the first multi-state rural community pharmacy practice-based research network (PBRN) in the USA called the Rural Research Alliance of Community Pharmacies (RURAL-CP). Our objective is to describe the process for developing RURAL-CP and discuss challenges to creating a PBRN during the pandemic. We conducted a literature review of community pharmacy PBRNs and met with expert consultants to gain insight into PBRN best practices. We obtained funding to hire a postdoctoral research associate, conducted site visits, and administered a baseline survey, which assessed many aspects of the pharmacy, including staffing, services, and organizational climate. Pharmacy site visits were initially conducted in-person but were later adapted to a virtual format due to the pandemic. RURAL-CP is now a PBRN registered with the Agency for Healthcare Research and Quality within the USA. Currently, 95 pharmacies across five southeastern states are enrolled. Conducting site visits was critical for developing rapport, demonstrating our commitment to engage with pharmacy staff, and appreciating the needs of each pharmacy. RURAL-CP pharmacists' main research priority was expanding reimbursable pharmacy services, especially for diabetes patients. Since enrollment, network pharmacists have participated in two COVID-19 surveys. RURAL-CP has been instrumental in identifying rural pharmacists' research priorities. COVID-19 provided an early test of the network infrastructure, which allowed us to quickly assess COVID-19 training and resource needs. We are refining policies and infrastructure to support future implementation research with network pharmacies.