Building capacity for rural health : the role of boundary crosser and the impact of their behaviours on community readiness partnerships

The concept of partnership has entered policy rhetoric and is urged as good practice in a variety of domains including health. Rural communities tend to have fewer resources available for the provision of services such as health than their metropolitan counterparts, and so could be expected to benefit from partnerships with external agencies. Indicators of coalition maturity for working in partnership with external agents in order to build stronger communities are distilled from the group development and partnership research literature and considered in the light of the experiences of the University Department of Rural Health in community engagement. The chapter draws on experiences of two rural community coalitions working to plan and negotiate health service provision. The coalitions were analysed against the indicators. A key indicator of maturity and readiness for working in partnership with external agents is related to the behaviour of ‘boundary crossers’. Boundary crossers are defined as people who move freely between two or more domains and who understand the values, cultures and language, and have the trust, of both. Domains can be within a community or be the community and an external sector. Community health professionals, especially those in senior positions, often act as boundary crossers between the community and broader domains such as regional/state health services or policy, although other community members can fill the role. Other key indicators of coalition maturity for working in partnership with external agents include local leadership that empowers the community, a willingness of community coalitions to take risks and mould opportunities to meet their vision, and a culture of critical reflection and evaluation of past actions.

This chapter analyses the impact of boundary crossing behaviour on community readiness and partnerships with external agents that are intended to build rural community capacity to plan and negotiate health service provision. It is argued that the characteristics and modus operandi of boundary crossers who are members of rural community coalitions affect the level of maturity of the coalitions and community readiness to work with external agents. An understanding of the characteristics and modus operandi of boundary crossers provides valuable insights for external agents in designing their approach to partnerships that build rural community capacity for health.

Developing effective learning programs : what extension can learn from the fields of adult education and learning communities

Learning is an investment in capacity building that has and will continue to reap rewards for primary producers and government in terms of increased sustainable production, profitability, exports, jobs and sustainable rural communities. Primary production operates in a context of continual change and requires up to date, complex and varied skills of primary producers and land managers.

A recent national research project funded by the Department of Agriculture, Forestry and Fisheries Australia confirmed that application of best practice from the theory of adult education in designing and developing learning programs in primary industry results in learning activities that provide information that is relevant to farmers’ needs, delivered in an entertaining way, and that draws on examples directly relevant to the participants. As a result, the training often exceeds the expectations of the participants.

The project produced a self-assessment checklist to identify ways of improving the development and delivery of training for extension practitioners and training providers. The key issues include continuous monitoring of client’s needs, and actively seeking opportunities to meet and work with industry organisations, other training providers and funding bodies.

There appear to be two drivers for the development of learning programs. One is problems or opportunities identified by people and organisations that could be termed ‘scanners’ and who tend not to be potential participants, the other is learning needs expressed by individuals or enterprises who want to participate in learning activities (participants). Scanners are typically industry organisations, government agencies and researchers, but may include providers and participants. Extension practitioners are well-placed to act as scanners.

It is very important that farmers and farmer organisations contribute to the development of new learning programs. Without industry input and support, extension practitioners and training providers cannot be expected to ensure they meet client needs. In other words, to develop effective learning programs, there must an industry learning community of producers, industry organisations, extension practitioners and training providers and other stakeholders such as supply chain enterprises, government and researchers.

Our health in our hands : building effective community partnerships for rural health service provision

This paper reports findings from a study in two small Tasmanian rural communities that examined the process of developing and sustaining partnerships between health services and their communities. It identifies a generic framework for partnership development that appears to be common to partnerships, regardless of their purpose or of partners involved. The framework comprises ten predictors or indicators of effectiveness, and a sequential nine-stage partnership development process. Integral to the framework are social capital, and the leadership practices of health service and community leaders. The influence of context on the partnership development process is also examined, with reference to historical precedent, age or maturity of the partnership, and community readiness.

Multi-level rural community engagement in health

Community participation in health is consistent with notions of democracy. A systems perspective of engagement can see consumers engaged to legitimise government agendas. Often community participation is via consultation instead of partnership or delegation. A community development approach to engagement can empower communities to take responsibility for their own health care. Understanding rural place facilitates alignment between health programs and community, assists in incorporating community resources into health care and provides information about health needs. Rural communities, health services and other community organisations need skills in working together to develop effective partnerships that transfer some power from health systems. Rural engagement with national/state agendas is a challenge. Community engagement takes time and resources, but can be expected to lead to better health outcomes for rural residents.

Vietnamese-born health professionals : negotiating work and life in rural Australia

Introduction: Australia is a culturally diverse nation due to migrants from a wide variety of countries creating a multicultural society. The health professions are highly valued by the younger generation of overseas-born migrants who have acculturated into Australian society; many have chosen health care as their profession in Australia. However, most migrants settle in metropolitan areas and young health professionals may find working in rural or remote Australia culturally and professionally highly challenging. The present study of migrant health professionals examined the life experiences and acculturation strategies of Vietnamese-born health professionals working and living in rural Australia. Objectives: The two main study objectives were to: (1) examine aspects of the acculturation of overseas-born and Australian-trained health professionals in the Australian health discourse; and (2) identify key coping strategies used by them when in working in the rural context.

Methods: Six overseas-born, Australian-trained health professionals were invited to participate in this qualitative study using a snowball sampling technique. The participants were all born in Vietnam and had experienced working in rural Australia. They included three medical doctors, a dentist, a physiotherapist and a nurse. The interviews were recorded and four participants also provided additional written responses to some of the open-ended interview questions. The interview data were transcribed and later coded for thematic analysis. Topics and themes that emerged focused on the issues and strategies of acculturation to the rural health context.

Results: The study showed that the acculturation process was affected by the participants’ views about and attitudes towards working in an Australian rural context. The study identified these essential strategies used by the participants in adapting to a new workplace: collaborating, distancing, adjusting, repairing, and accommodating.

Conclusion: The study provides insights into the lives of these health professionals in a rural context, and particularly their experience of cultural shock and the coping strategies they may use. A need is identified for a larger study to inform recruitment and retention of these health professionals to rural Australia, and to assist universities to prepare such students and their clinical supervisors for rural placements.

Supporting beginning rural teachers : lessons from successful schools

Across Australia and internationally, the vexed problem of staffing rural school remains a major issue affecting the educational outcomes of many rural students and their families. TERRAnova, (New Ground’ in Teacher Education for Rural and Regional Australia), is the name of a large Australian Research Council funded (2008-2010) project involving: a national study of pre-service preparation and rural incentive schemes offered by both University and State government agencies, a longitudinal study of beginning teachers who take up rural appointments and a study of communities where teacher retention is high. In 2008 calls for nominations for rural schools with high rates of retaining beginning teachers were sought (over three years), and twenty-four of nearly fifty nominated schools were selected as case studies. Each case study has involved researchers from the TERRAnova team travelling and staying as close to the community nominated as possible. Numerous teaching staff, parents and community members were invited to be interviewed and their recordings were transcribed. Five of these case studies have now been completed, and this paper examines common themes derived from the strategies that support beginning teachers in these rural communities. Key factors emerging to date from the data relate to particular models of rural school leadership, ongoing teacher learning and mentoring, and school support and innovative community practices.

Study of small rural schools in a climate of rapid change

An investigation of interactive factors affecting educational outcomes in small rural primary schools in a climate of rapid change. Demonstrates that the school-community relationship in small rural communities is a complex symbiosis. Teachers' understandings of how the small rural community context, the curriculum and pre-service experiences interact and work in these settings are crucial to maximising educational outcomes.

Forgotten outcomes for rural areas in central policy-making : the case of blue gums in Australia

The expansion of private forestry and the partnership between government and private sector timber growers and processors highlights the issues associated with a functionally based rather than a place based approaches to changing patterns of land use in rural areas. Rural development through blue gum forestry was promoted as a means of revitalising rural communities, providing both economic and social gains to regional areas. The purpose of this study is to examine the economic consequences of policies designed to promote plantation forestry at a local level. It concludes that while plantation forestry may bring benefits to the national economy, these benefits may not be apparent at a local level especially if the industry operates in competition with a viable alternative.

Reconstructing violent rural masculinities : responding to fractures in the rural gender order in Australia

Men's violence against women is higher in rural communities compared to urban areas and many writers have identified the increased vulnerability of women in rural areas when addressing men's violence. This article will explore the implications of the emerging scholarship on rural masculinities for understanding how rurality invokes different modes of masculinity associated with men's violence in the context of rural restructuring. While the socio-cultural aspects of rural areas generate stronger enforcement of gender roles that perpetuate gender inequality, rural restructuring challenges dominant forms of masculinity, and this has contradictory consequences for reconstructing masculinities. Consequently, while many rural men are endeavouring to preserve traditional masculinity in the face of the rural crisis, other men are exploring alternative masculinities that are incompatible with men's violence against women.

Implementation of diabetes prevention programs in rural areas : Montana and south-eastern Australia compared

Objective: To identify the key elements that enabled the Greater Green Triangle Diabetes Prevention Project (GGT DPP) and the Montana Cardiovascular Disease and Diabetes Prevention (CDDP) programs successful establishment and implementation in rural areas, as well as identifying specific challenges or barriers for implementation in rural communities.
Methods: Focus groups were held with the facilitators who delivered the GGT DPP in Australia and the Montana CDDP programs in the USA. Interview questions covered the facilitators’ experiences with recruitment, establishing the program, the components and influence of rurality on the program, barriers and challenges to delivering the program, attributes of successful participants, and the influence of community resources and partnerships on the programs.
Results: Four main themes emerged from the focus groups: establishing and implementing the diabetes prevention program in the community; strategies for recruitment and retention of participants; what works in lifestyle intervention programs; and rural-centred issues.
Conclusions: The results from this study have assisted in determining the factors that contribute to developing, establishing and implementing successful diabetes prevention programs in two rural areas. Recommendations to increase the likelihood of success of programs in rural communities include: securing funding early for the program; establishing support from community leaders and developing positive relationships with health care providers; creating a professional team with passion for the program; encouraging participants to celebrate their small and big successes; and developing procedures for providing post-intervention support to help participants maintain their success.

Extending the paramedic role in rural Australia : a story of flexibility and innovation

Introduction: This article identifies trends in the evolving practice of rural paramedics and describes key characteristics, roles and expected outcomes for a Rural Expanded Scope of Practice (RESP) model.

Methods: A multiple case study methodology was employed to examine the evolution of rural paramedic practice. Paramedics, volunteer ambulance officers and other health professionals were interviewed in four rural regions of south-eastern Australia where innovative models of rural paramedic practice were claimed to exist. The research team collected and thematically analysed the data using the filter of a sociological framework throughout 2005 and 2006.

Results: The study found that paramedics are increasingly becoming first line primary healthcare providers in small rural communities and developing additional professional responsibilities throughout the cycle of care.

Conclusions: Adoption of the RESP model would mean that paramedics undertake four broad activities as core components of their new role: (1) rural community engagement; (2) emergency response; (3) situated practice; and (4) primary health care. The model’s key feature is a capacity to integrate existing paramedic models with other health agencies and health professionals to ensure that paramedic care is part of a seamless system that provides patients with well-organized and high quality care. This expansion of paramedics’ scope of practice offers the potential to improve patient care and the general health of rural communities.

Healthy-lifestyle behaviors associated with overweight and obesity in US rural children

Background

There are disproportionately higher rates of overweight and obesity in poor rural communities but studies exploring children’s health-related behaviors that may assist in designing effective interventions are limited. We examined the association between overweight and obesity prevalence of 401 ethnically/racially diverse, rural school-aged children and healthy-lifestyle behaviors: improving diet quality, obtaining adequate sleep, limiting screen-time viewing, and consulting a physician about a child’s weight.
Methods

A cross-sectional analysis was conducted on a sample of school-aged children (6–11 years) in rural regions of California, Kentucky, Mississippi, and South Carolina participating in CHANGE (Creating Healthy, Active, and Nurturing Growing-up Environments) Program, created by Save the Children, an independent organization that works with communities to improve overall child health, with the objective to reduce unhealthy weight gain in these school-aged children (grades 1–6) in rural America. After measuring children’s height and weight, we17 assessed overweight and obesity (BMI ≥ 85th percentile) associations with these behaviors: improving diet quality18 (≥ 2 servings of fruits and vegetables/day), reducing whole milk, sweetened beverage consumption/day; obtaining19 adequate night-time sleep on weekdays (≥ 10 hours/night); limiting screen-time (i.e., television, video, computer,20 videogame) viewing on weekdays (≤ 2 hours/day); and consulting a physician about weight. Analyses were adjusted 21 for state of residence, children's race/ethnicity, gender, age, and government assistance.
Results

Overweight or obesity prevalence was 37 percent in Mississippi and nearly 60 percent in Kentucky. Adjusting for covariates, obese children were twice as likely to eat ≥ 2 servings of vegetables per day (OR=2.0,95% CI 1.1-3.4), less likely to consume whole milk (OR=0.4,95% CI 0.2-0.70), Their parents are more likely to be told by their doctor that their child was obese (OR=108.0,95% CI 21.9-541.6), and less likely to report talking to their child about fruits and vegetables a lot/sometimes vs. not very much/never (OR=0.4, 95%CI 0.2-0.98) compared to the parents of healthy-weight children.
Conclusions

Rural children are not meeting recommendations to improve diet, reduce screen time and obtain adequate sleep. Although we expected obese children to be more likely to engage in unhealthy behaviors, we found the opposite to be true. It is possible that these groups of respondent parents were highly aware of their weight status and have been advised to change their children’s health behaviors. Perhaps given the opportunity to participate in an intervention study in combination with a physician recommendation could have resulted in actual behavior change.

Actively disadvantaged : a foucauldian perspective of rural adolescent girls' participation in sport and physical activity

The illustriousness of sport to Australian culture has often been discussed and in rural communities it could be argued that community sporting clubs are integral, and often unparalleled, in the development of collective community identities and individual subjectivities (Tonts, 2005). Sport is considered a way of life for many rural Australians, yet social, climatic and economic factors have resulted in vast changes to the sporting landscape in rural communities, particularly for adolescent females. With the amalgamation of many community sporting clubs due to declining populations and the rationalisation of Government funding, fewer opportunities for participation in organised physical activity now exist for rural adolescent girls (Tonts & Atherley, 2005). Compounding this lack of opportunity, are questions around the types of physical activity experiences available to rural adolescent females and the impact this has on the way that rural adolescent females construct ideas around being physically active. This paper is concerned with the ways in which prevalent cultural and institutional discourses mediated through community sport and school-based physical activity impact the construction of female physically active subjectivities in rural communities.

As if the future matters : teaching design for sustainable communities

Between 2007 and 2010 a series of intensive annual field trips took around 100 predominantly city-based Australian and international students from The University of Adelaide into rural communities (numbers ranged from 82 in 2007 to 105 in 2009). Country areas/towns (rather than the city) were chosen because in them issues of sustainability are ‘in your face’ and much clearer for students to comprehend than in the city. The trips required co-operation between the respective communities, the School and the students. The organization required for this number of students was time-consuming and prone to disruption, and the series ended when the principal organisers moved on to new positions and the School reverted to less time-costly modes of teaching. This paper provides a retrospective insight into the series of field trips and examines their educational and professional value for the participants – students, staff and communities. We begin by describing the aims of the course and argument for an immersive educational approach, then present the logistics and process for the field trips, discuss the outcomes for the stakeholders, and finally present some conclusions.

Rural living and health-related quality of life in Australians with Parkinson's disease

Introduction: The motor and non-motor symptoms associated with idiopathic Parkinson’s disease (PD) may compromise the health-related quality of life (HRQOL) of some individuals living with this debilitating condition. Although growing evidence suggests that PD may be more prevalent in rural communities, there is little information about the life quality of these individuals. This study examines whether HRQOL ratings vary in relation to rural and metropolitan life settings.
Methods: An analytic cross-sectional study was conducted to compare the HRQOL of two separate samples of people with PD living in metropolitan Melbourne and rural Victoria. The metropolitan sample consisted of 210 individuals who had participated in the baseline assessment for an existing clinical trial. The rural sample comprised 24 participants who attended community-based rehabilitation programs and support groups in rural Victoria. Health-related quality of life was quantified using the Parkinson’s Disease Questionnaire-39 (PDQ-39).
Results: The HRQOL of participants in rural Australia differed from individuals living in a large metropolitan city (p=0.025). Participants in rural Australia reported worse overall HRQOL, after controlling for differences in disease duration. Their overall HRQOL was lower than for city dwellers. Rural living was also found to be a significant negative predictor of HRQOL (β=0.14; 95% CI -1.27 to -0.08; _p=0.027).
Conclusion: The findings of this study suggest that some people with PD living in rural Victoria perceive their HRQOL to be relatively poor. In order to minimise the debilitating consequences of this disease, further studies examining the factors that may contribute to the HRQOL of individuals living in rural and remote areas are required.