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Background Access to clinical trials is limited for rural, regional and remote Australians, adding to the current health inequity between rural and metropolitan populations. The Australasian Teletrial Model was developed to bring clinical trials “closer to home”. In 2020, the Australian Teletrial Program was funded to expand and support the uptake of the model across six Australian states and territories. The aim of this study was to explore and describe the clinical trial landscape in Australia prior to the implementation of the Australian Teletrial Program with a particular focus on rural, regional and remote health services. Methods This qualitative study provides a descriptive exploration of the clinical trial landscape across rural, regional and remote Australia. Data were obtained from semi-structured interviews ( n  = 33) and one focus group ( n  = 5) involving clinical trial stakeholders between August 2022 and May 2023. Deductive then inductive thematic analysis used the broad topic areas of the interview schedule as a framework, as follows: education and training, workforce, equipment and services, clinical trial sites, participant recruitment and clinical trial approval process. Results This study identified barriers that are generalizable to the Australian clinical trial landscape and those specific to the rural, regional and remote health service context. The main barriers to conducting clinical trials in rural, regional and remote areas were lack of investment and engagement on the part of health service executives, workforce limitations, inconsistent training, lack of physical infrastructure and competing clinical priorities. Despite these challenges, clinicians reported enthusiasm for conducting clinical trials, and opportunities were reported for these health services to partner with larger metropolitan/regional health services, regional universities and communities to support the growth of clinical trial capability and capacity. Conclusions The clinical trial landscape in Australian health services varies in terms of quality and availability of training, workforce capacity, executive support, site capability and approval processes. The Australian Teletrial Program has an immense opportunity to overcome some of the reported challenges by supporting capacity and capability building. Ultimately, however, sustainable reform to bring trials closer to home requires a collaborative approach that considers implementation strategies across all levels of the health service and government, alongside other initiatives.

The COVID-19 pandemic has increased the use of digital solutions in medical care, especially for patients in remote areas and those requiring regular medical care. However, internet access is essential for the implementation of digital health care. The digital divide is the unequal distribution of access to digital technology, and the first level digital divide encompasses structural barriers. Brazil, a country with economic inequality and uneven population distribution, faces challenges in achieving internet access for all. This study aims to provide a comprehensive overview of the first-level digital divide in Brazil, estimate the relationship between variables, and identify the challenges and opportunities for digital health care implementation. Data were retrieved from the Brazilian Institute of Geography and Statistics National Continuous House survey database, including demographic, health, and internet-related variables. Statistical analysis included 2-tailed t tests, chi-square, and multivariate logistic regression to assess associations between variables. Our analysis included 279,382 interviews throughout Brazil. The sample included more houses from the northeast (n=99,553) and fewer houses from the central west (n=30,804). A total of 223,386 (80.13%) of the interviewed population used the internet, with urban areas having higher internet access (187,671/212,109, 88.48%) than rural areas (35,715/67,077, 53.24%). Among the internet users, those interviewed who lived in urban houses, were women, were younger, and had higher income had a statistically higher prevalence (P<.001). Cell phones were the most common device used to access the internet (141,874/143,836, 98.63%). Reasons for not using the internet included lack of interest, knowledge, availability, and cost, with regional variations. The prevalence of internet access also varied among races, with 84,747 of 98,968 (85.63%) White respondents having access, compared to 22,234 of 28,272 (78.64%) Black respondents, 113,518 of 148,191 (76.6%) multiracial respondents, and 2887 of 3755 (76.88%) other respondents. In the southeast, central west, and south regions, the numbers of people with internet access were 49,790 of 56,298 (88.44%), 27,209 of 30,782 (88.39%), and 27,035 of 31,226 (86.58%), respectively, and in the north and northeast, 45,038 of 61,404 (73.35%) and 74,314 of 99,476 (74.7%). The income of internet users was twice the income of internet nonusers. Among those with diabetes-related limitations in daily activities, 945 of 2377 (39.75%) did not have internet access, and among those with daily activity restrictions, 1381 of 3644 (37.89%) did not have access. In a multivariate logistic regression analysis, women (odds ratio [OR] 1.147, 95% CI 0.118-0.156; P<.001), urban households (OR 6.743, 95% CI 1.888-1.929; P<.001), and those earning more than the minimum wage (OR 2.087, 95% CI 0.716-0.756; P<.01) had a positive association with internet access. Brazil's diverse regions have different demographic distributions, house characteristics, and internet access levels, requiring targeted measures to address the first-level digital divide in rural areas and reduce inequalities in digital health solutions. Older people, poor, and rural populations face the greatest challenges in the first level digital divide in Brazil, highlighting the need to tackle the digital divide in order to promote equitable access to digital health care.

Purpose To explore the experiences of people caring for someone with cancer, while living in rural Australia, and the impact of the cancer-caring role on their well-being. Method Eighteen adults in regional or remote (‘rural’) Australia who cared for a person with cancer took part in semi-structured telephone interviews. Participants were aged 32–77 years and mainly female (66%). Data were analysed using thematic analysis and an essentialist approach. Results Eight themes were identified: (1) travel is hard, but supports are available; (2) frustration with systems that do not demonstrate understanding of the rural context; (3) the importance of lay and peer support; (4) the impact of access to trusted, local health care services; (5) the importance of access to rurally relevant information (particularly on relevant services and what to expect); (6) living with uncertainty and balancing loss with hope; (7) reluctance to seek or accept psychological support; and (8) the gendered nature of care. Conclusion Rural cancer carers’ roles can be made easier by improving health systems and coordination to ease the burden of travel, providing information about available support and what to expect throughout cancer treatment that is relevant to the rural context, and increasing access to quality health, community, and support services, including palliative care, in rural areas. More training on the specific needs of rural patients and their carers is needed for urban health care professionals. Peer support groups may have particular value for cancer carers in rural settings, where there are known to be multiple barriers to accessing professional sources of psychosocial support.

Background Commissioning for health services has been implemented as one approach to improve the quality and access to healthcare for First Nations, regional and remote populations. This review systematically scoped the literature for studies that described or evaluated the governance, funding, implementation and outcomes from health service commissioning targeting these groups in Canada, Australia, Aotearoa/New Zealand and the United States (CANZUS nations). Methods Seventeen databases were searched for relevant peer reviewed and grey literature studies published in English from 2010 to 2023. Grounded theory methods were used to identify the enablers and strategies or processes that support commissioning and any challenges to implementation. Results Overall, 29 Peer reviewed and 18 grey literature studies remained after screening. The studies reported enabling conditions for effective commissioning including operating models that were responsive to beneficiary needs, workforce and technical capability, flexibility and duration of contracts, adequate funding, and achievable health outcomes and indicators. Supporting strategies focussed on multi-actor collaboration, relationship building, and service innovation. Reported impacts included improved access to care, and self-determination and wellbeing for First Nations populations. Challenges related to inflexible funding, high transaction costs, overcompliance, and poor relationships. Most studies were process evaluations or descriptions of the application of commissioning to various health areas, with comparatively limited assessment of the impacts across the health system, or on health status. Conclusion Findings suggests that a relational model drives success in commissioning for health and wellbeing services for First Nations, regional and remote populations. The relational model presented in this review is supported by the following attributes: responsive, resourced, collaborative, equitable, innovative and self-determined: and when applied by multiple actors in the commissioning process can address the complex health and wellbeing needs of end users.

We propose a new method of using the public geocodes in the Demographic and Health Surveys for integrating environmental context into analysis. Currently, the public geocodes in the DHS are produced by randomly displacing rural cluster locations by up to 5km (10km for 1 percent of points). DHS currently advises researchers using these geocodes to average environmental characteristics over a 5-10km buffer. We hypothesize that a smaller buffer around a neighboring settlement—even an incorrect settlement—is a better measure of true environmental context in rural areas than the large buffer around the published point. This hypothesis is motivated by the rapid growth of literature pointing to the importance of connecting geographic measures of context to the lived experiences of individuals and by our assumption that smaller buffers more adequately measure those lived experiences. We test our hypothesis on an analysis that combines DHS data with fine-scale measures of human agricultural activity, with the truth provided by access to the confidential true cluster location.

Background Many factors contribute to engagement in rural and remote (RR) medical practice, but little is known about the factors associated with rural and remote medical practice in such remote locations as the Maluku Province of Indonesia. This study describes factors associated with actual RR practice, preferred RR practice, and intention to remain practice in Maluku Province. Methods An online survey of work-related experience and intentions for future rural work was administered to 410 doctors working in the Maluku province of Indonesia. Participant characteristics were described using descriptive statistics, associations between the independent variables with the location of the workforce, intention to remain practice in Maluku, preference for future RR practice in Maluku were analysed using Chi-square tests and logistic regression. Results A total of 324 responses (79% response rate) were recorded, comprising 70% females and 30% Pattimura University graduates of doctors employed in Maluku. Doctors working in RR areas were more likely to be a GP (OR 3.49, CI 1.03–11.8), have a monthly salary of more than IDR 6 million (OR 11.5, CI 4.24–31.1), and have no additional practice (OR 2.78, CI 1.34–5.78). Doctors intended to stay practice in Maluku were more likely to be born in Maluku (OR 7.77, CI 3.42–17.7) and have graduated from Pattimura University (OR 3.06, CI 1.09–8.54), and less likely to be a temporary employee (OR 0.24, CI 0.10–0.57). Doctors who prefer future RR practice in Maluku were more likely to experience rural living (OR 2.05 CI 1.05–3.99), have a positive indication of the impact of community exposure during medical schools on their current practice (OR 2.08, CI 1.06–4.09), currently practising in RR Maluku (OR 8.23, CI 3.27–20.8); and less likely to have bigger take-home pay (OR 0.30, CI 0.13–0.70). Conclusion This study indicates that special attention should be given to recruiting doctors with a rural background and ongoing support through attractive opportunities to build a sustainable RR workforce. Since a regional medical school helps supply doctors to the RR areas in its region, a sustained collaboration between medical schools and local government implementing relevant strategies are needed to widen participation and improve the recruitment and retention of RR doctors.

Background A key determinant of diet quality in outer regional to very remote areas is the higher cost of food. This systematic scoping review aims to identify evidence gaps on drivers of the cost of food, to guide future research and policy development to improve food security across outer regional to very remote areas of Australia. Methods The Joanna Briggs Institute three step literature search was utilised and the review was conducted in accordance with PRISMA guidelines. Five electronic databases (Ovid MEDLINE, CINAHL, Informit, Embase, Scopus) were systematically searched in September 2024. Peer-reviewed literature set in outer regional to very remote regions of Australia were included if they were on the topic of food and food price and the drivers influencing these. Title and abstract screening were performed by two authors, as well as double screening of full texts by two authors. Data were extracted from included articles regarding remoteness category, aims, sampling, methodology, drivers influencing food price, outcomes and implications on policy, as well as author commentary on the drivers of food price. The CREATE tool for research involving Aboriginal and Torres Strait Islander communities was completed by two authors, with guidance from two First Nations authors and the senior author. Results Twenty articles published between 1987 to 2022 met the inclusion criteria. Most studies reported on remoteness itself as the determinant of high food price. Other drivers of food price included freight, high operating costs of smaller stores and weather events. Conclusion Those living in outer regional to very remote Australia pay more for food, however there is a lack of empirical detailed evidence on the drivers of higher food price. To effectively address the higher cost of food in outer regional, rural, and remote Australia and promote food security in these areas, empirical evidence on system determinants could complement existing expert evidence for targeted policy and government support.

Background Telehealth has the potential to mitigate maternal and child health access challenges, reduce health system dependency and healthcare expenditures, and facilitate the delivery of healthcare to women and children remotely. Methods Exhaustive searches of the literature were performed across multiple databases, including PubMed, Scopus, PDQ-Evidence for Informed Health Policymaking, CINAHL, EconLit, International Health Technology Assessment (HTA), Google Scholar, and the UniSQ RISE Research Repository. These searches targeted peer-reviewed, English-language articles published from inception to February 2024. The quality of the reports was assessed via CHEERS 2022. Results In this review, 20 studies comparing telehealth to usual care for maternal and child healthcare in remote, rural, and regional (RRR) Australia were included. Of these, 18 found telehealth to be a cost-saving option, while two reported comparable costs and outcomes. These findings were assessed from a range of perspectives, including those of the health system, society, family, providers, and third-party payers. The review findings indicate that telehealth has potential for addressing health disparities among women and children in remote, rural, and regional Australia. Health disparities are reduced by overcoming access barriers, reducing expenses, fostering healthy behaviors, increasing service utilization, shortening hospital stays, and enhancing care coordination. Conclusions This review highlights that telehealth is a predominantly cost-saving alternative to usual care for maternal and child health services in remote, rural, and regional Australia. It has the potential to reduce health inequality among women and children residing in remote, rural, and regional Australia. A broader evaluation incorporating societal costs and benefits, along with a long-term view of the clinical and economic impacts of telehealth, is essential for its wider implementation. Systematic review registration PROSPERO CRD42024518089.

Background Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. Methods An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access –spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. Results 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. Conclusions Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

Studies of ‘smart cities’ in Canada primarily focus on large cities but not small, rural and remote communities. As a result, we have a limited understanding of the incentive structures for smaller, remote and rural communities to pursue smart city development. This knowledge deficit is concerning, since the introduction of technology can hold a number of unique benefits for these communities, including easier connections to the rest of Canada and large urban centres, reputation building, improved service delivery and enhanced opportunities for residents. Drawing upon localised forms of knowledge creation, policy development theories, adoption and local competition literature and primary interviews with private and public officials, we examine the challenges and opportunities of ‘smart city’ implementation through case studies of small and rural municipalities in Annapolis Valley in Nova Scotia and a remote community, Iqaluit, Nunavut. We find that collaboration is essential for rural and remote pursuit of smart city development and is necessary to counteract the limitations of capacity, scale and digital divides. Challenges aside, however, the primary rationale for adoption of smart city technology remains the same regardless of size: enhanced quality of life for residents and sustained community health. 加拿大对“智慧城市”的研究主要集中在大城市，而不是小城市、农村和偏远社区。因此，我们对小型、偏远和农村社区追求智慧城市发展的激励结构了解有限。这种知识不足令人担忧，因为技术的引入可以为这些社区带来许多独特的好处，包括更容易与加拿大其他地区和大型城市中心联系、建立声誉、改善服务提供和增加居民的机会。借助本地化形式的知识创造、政策发展理论、采纳和当地竞争文献以及对私营和公共官员的初步访谈，我们通过对新斯科舍省安纳波利斯谷的小城镇和农村城镇以及努纳武特省伊卡路特的一个偏远社区的案例研究，审视了实施“智慧城市”的挑战和机遇。我们发现，协作对于农村和偏远地区追求智慧城市发展至关重要，对于抵消容量、规模和数字鸿沟的限制也是必要的。然而，撇开挑战不谈，无论规模如何，采用智慧城市技术的主要理由都是一样的：提高居民的生活质量和持续的社区健康。