Introduction: Rural and remote communities in Australia continue to face challenges in attracting and retaining doctors, highlighting the need for medical graduates who feel confident and motivated to practise rurally. This study explored medical students' emotional responses to future rural practice after completing a rural clinical school (RCS) placement, and identified demographic and placement factors associated with both anxiety and positive attitudes.Methods: This retrospective, cross-sectional study analysed data from 6371 medical students who completed RCS placements between 2013 and 2022, using responses from the Federation of Rural Australian Medical Educators survey. Feelings were assessed using Likert scale responses to statements about experiencing anxiety (a 'sinking feeling') and positive attitudes towards rural work. Associations with sociodemographic characteristics and placement experiences were examined using χ2 tests and multinomial logistic regression.Results: Most students (76%) did not report anxious feelings, while 68% expressed positive feelings about future rural practice. Males were more likely than females to report neutral feelings towards rural practice regarding anxiety (odds ratio (OR)=1.23, 95%CI 1.04-1.45). International fee-paying students had significantly higher odds of reporting both neutral (OR=1.95, 95%CI 1.28-2.98) and anxious feelings (OR=2.41, 95%CI 1.46-3.98). Students with rural backgrounds were less likely to report neutral feelings (OR=0.75, 95%CI 0.60-0.94) and more likely to express positive feelings. Having a rural-based mentor was associated with lower odds of anxiety and higher odds of positive feelings. Students who identified rural generalism as a career aspiration were more likely to report positive feelings than those who preferred a specialist career.Conclusion: RCS placements were associated with positive feelings and confidence in rural practice among medical students. However, specific student groups, such as international students, remained more apprehensive. Mentorship was identified as a significant modifiable factor associated with reduced anxiety and higher rural positivity, suggesting that structured mentorship programs could nurture a commitment to rural practice. In addition, a rural background was strongly associated with positive sentiment towards rural practice. Targeted recruitment and supported pathways to expand the proportion of rural-origin students in medical programs could therefore foster rural intent in the pipeline.

OBJECTIVE:To investigate the trends in the perceived social isolation and improved wellbeing of Australian medical students over a 6-year period (2017-2022) during their rural clinical school (RCS) placements. METHODS:Data were analysed using descriptive statistics and multinomial logistic regressions to identify the trends and factors contributing to perceived social isolation and improved wellbeing during RCS placements. DESIGN:This is a retrospective, cross-sectional study of the 2017-2022 FRAME (Federation of Rural Australian Medical Educators) dataset. PARTICIPANTS:Data were collected from 2915 Australian medical students who completed RCS placements. SETTING:Respondents were located at RCS placements across 19 Australian universities. MAIN OUTCOME MEASURES:The main outcomes were self-reported social isolation and improvement in wellbeing. RESULTS:Over 30% of respondents reported experiencing social isolation. Factors contributing to social isolation were preference to practice in a capital city and lack of financial or overall support from the RCS, while lack of academic isolation was protective. More than 80% of respondents perceived the RCS placement had a positive impact on their wellbeing. Positive influences on wellbeing were associated with active role-modelling of self-care, support services and mentorship by a rural-based clinician. The COVID-19 years did not significantly impact perceived social isolation or improved wellbeing. CONCLUSIONS:Most medical students on RCS placements reported positive impacts on their wellbeing, while over 30% experienced social isolation. Targeted support strategies that reduce social isolation and enhance student wellbeing on rural placements may help improve rural workforce retention and address healthcare shortages.

INTRODUCTION:Rural and remote communities in Australia continue to face challenges in attracting and retaining doctors, highlighting the need for medical graduates who feel confident and motivated to practise rurally. This study explored medical students' emotional responses to future rural practice after completing a rural clinical school (RCS) placement, and identified demographic and placement factors associated with both anxiety and positive attitudes. METHODS:This retrospective, cross-sectional study analysed data from 6371 medical students who completed RCS placements between 2013 and 2022, using responses from the Federation of Rural Australian Medical Educators survey. Feelings were assessed using Likert scale responses to statements about experiencing anxiety (a 'sinking feeling') and positive attitudes towards rural work. Associations with sociodemographic characteristics and placement experiences were examined using χ2 tests and multinomial logistic regression. RESULTS:Most students (76%) did not report anxious feelings, while 68% expressed positive feelings about future rural practice. Males were more likely than females to report neutral feelings towards rural practice regarding anxiety (odds ratio (OR)=1.23, 95%CI 1.04-1.45). International fee-paying students had significantly higher odds of reporting both neutral (OR=1.95, 95%CI 1.28-2.98) and anxious feelings (OR=2.41, 95%CI 1.46-3.98). Students with rural backgrounds were less likely to report neutral feelings (OR=0.75, 95%CI 0.60-0.94) and more likely to express positive feelings. Having a rural-based mentor was associated with lower odds of anxiety and higher odds of positive feelings. Students who identified rural generalism as a career aspiration were more likely to report positive feelings than those who preferred a specialist career. CONCLUSION:RCS placements were associated with positive feelings and confidence in rural practice among medical students. However, specific student groups, such as international students, remained more apprehensive. Mentorship was identified as a significant modifiable factor associated with reduced anxiety and higher rural positivity, suggesting that structured mentorship programs could nurture a commitment to rural practice. In addition, a rural background was strongly associated with positive sentiment towards rural practice. Targeted recruitment and supported pathways to expand the proportion of rural-origin students in medical programs could therefore foster rural intent in the pipeline.

ObjectiveThe impact of COVID-19 on medical students has predominantly been assessed by one-off survey studies at the pandemic onset. This national study investigated the sustained impacts of the COVID-19 pandemic on medical students’ rural clinical placement learning and well-being.DesignRepeated cross-sectional survey design.SettingAnnual Federation of Rural Australian Medical Educators (FRAME) survey across 2020 to 2022.ParticipantsMedical students completing an extended (mostly 12 months) rural placement.Outcome measureA mixed-methods survey with closed-ended and open-ended question. Quantitative data were analysed using χ2and Kruskal-Wallis tests. Qualitative responses were analysed through content analysis.ResultsQuantitative findings: in 2022 (43%), respondents were more likely to interact with COVID-19 patients in a clinical capacity compared with 2020 (26%) and 2021 (23%; p<0.001). Respondents were more likely to be concerned about missed clinical learning in 2020 (58%) than in 2021 (40%) and 2022 (44%; p<0.001). Respondents in 2020 (41%) and 2022 (39%) were more likely to feel that their performance on assessments was affected by COVID-19 compared with 2021 respondents (28%; p<0.001). Respondents in 2022 (38%) and 2021 (31%) were more likely to report being exposed to an increased breadth of cases than 2020 respondents (13%; p<0.001) and also reported more exposure to community-based placements (2022: 38%, 2021: 31%, 2020: 19%; p<0.001).Qualitative findings: three categories were developed from the data—mental health and well-being impacts, learning preferences at play, and concerns about flow-on effects.ConclusionsWhile the pandemic has now become the ‘new normal’, the mental well-being and learning concerns raised by students in rural Australia, and their concerns about sustained impacts into their internship cannot be ignored. Healthcare organisations need to ensure that when impacted students enter the workforce the practice context is supportive, with mechanisms such as effective clinical supervision in place.

INTRODUCTION:Currently, no reporting guidelines exist for observational and qualitative study protocols. In an effort to enhance the quality of research protocols, we introduce two study protocol reporting checklists that we have developed. MAIN RECOMMENDATIONS:These checklists include educational components and examples intended to assist novice researchers. Through the analysis of 333 study protocols submitted for ethical review, our checklists have been developed and validated, demonstrating their applicability across various observational and qualitative study designs. CHANGES IN MANAGEMENT:We provide insights into the systematic implementation of these checklists alongside complementary elements that support their effectiveness. We recommend longitudinal monitoring and evaluation of checklist utilization.

Background The geographical remoteness of rural clinical school (RCS) placements presents unique challenges to medical students, detrimentally impacting their well-being and potentially leading to social isolation. Understanding these challenges is essential for medical institutions to implement effective support mechanisms. Objective This study investigated the perceptions of rural medical students regarding well-being and social isolation during a five-year period (2017 to 2022) during their RCS placements. Methods Data from approximately 600 medical students (mostly females n = 2025, 57.7%) collected annually across 17 Australian universities, through self-administered FRAME (Federation of Rural Australian Medical Educators) surveys were extracted. Sociodemographic variables, their feelings of academic isolation and support, and the effect of COVID during their RCS were assessed. The main outcomes were social isolation and well-being which were derived from students’ responses to the statement, ‘ I felt socially isolated during my RCS placement’ , and ‘Overall, my RCS placement impacted positively on my well-being’, respectively. Data was analyzed using descriptive statistics and binomial logistic regressions to identify factors associated with their perception of social isolation and well-being during RCS placement. Results Over half of Australian rural medical students reported experiencing social isolation, with one-fifth expressing that rural placement had no positive impact on their wellbeing. Although the majority perceived a positive impact, this proportion decreased by 11.0% from 2017 to 2019, before rising again in subsequent years. Factors contributing to social isolation and negative impacts on well-being included academic isolation, non-rural background, preference to practice in a capital or major urban city upon entry to the RCS, and lack of academic, financial, or general support from the RCS. Positive influences were associated with active self-care role modeling and informal information regarding rural career options Notably, the years affected by the COVID-19 pandemic did not significantly alter perceived social isolation and well-being. Conclusions Addressing the challenges faced by medical students in rural placements is imperative to foster positive well-being and combat social isolation. These findings underscore the importance of tailored support mechanisms and educational programs to enhance resilience among future healthcare professionals. Moreover, improving the experiences of medical students in RCS placements may contribute to increased retention of doctors in rural and remote areas, thereby alleviating the nationwide shortage in these regions.

These data collectively build a portrait of candidates who are more likely to work rurally. The portrait suggests that a very convincing set of known factors are at play: rural background, lower socio-economic status, locally-born, quarantined rural pathway … entering with rural intent, Medical Rural Bonded Scholarship holders.4 Selection and support of rural students, rural placement immersions and development of comprehensive rural medical programs are within the control of medical schools and supported by Australian evidence. The pathways to rural practice are rich and varied. Successful approaches tailor these elements to local resources, needs and priorities (Box 1). In this article, we describe the elements of a comprehensive approach for medical schools. The Aristotelian notion that “the whole is greater than the sum of its parts” is important and medical schools need to apply a comprehensive approach to deliver more graduates who will work rurally. Select for rural workforce outcomes Highlight rural medicine in medical school curricula Invest in rural training pathways Social accountability obliges medical schools to focus their own research, service and education undertakings specifically on addressing the health needs of their local community, region and/or nation. Priority health needs are to be identified jointly by local communities, health care organisations, health professionals and the government.5 As the majority of medical schools remain centred in large metropolitan areas, it is essential that these medical schools adopt a rural social mission statement as a way of expressing their commitment. Overt commitment enables the medical schools to put in place the strategies outlined below to produce more rural doctors, and build a supportive environment to fulfil this mission.6 Graduates from rural backgrounds are more likely to work in rural practice (odds ratio, 2.6 to 3.9).7-11 This “rural background effect” is independent of rural clinical training, but is augmented by it.7-9, 12 The effect endures throughout postgraduate career stages,8, 13 and has been found in some studies to increase over time.14 Rural background graduates are more likely to commence in rural practice, move to rural practice and remain in rural practice.13 Since 1995, in an effort to meet equity-of-access goals, the Commonwealth Government has mandated that 25% of medical student Commonwealth-supported places are allocated to students with a rural background.15 With 28% of Australians living in rural areas,16 more recently funded rural programs, such as the Murray–Darling Medical Schools Network, have higher mandated proportions of rural background places (up to 100%).17 Medical school selections traditionally use university entrance examinations, which are expensive and less easily accessed from rural areas.18 Admitting more students from a rural background has been achieved in different ways across Australia. Equity adjustments have been used by many universities, such as adjusting academic and entrance exam scores, or keeping selection methods consistent and creating specific rural quotas. Other medical programs have adopted specific rural selection tools, including written personal statements and interviews, using community members to understand candidates’ rural interests.19-22 Despite these adjustments to admissions, rural background students demonstrate the same academic outcomes in medical school as other student cohorts admitted with higher entry scores.23 The Modified Monash Model (MMM) categorises the rurality of Australian communities using a scale from 1 for metropolitan to 7 for very remote.24 Including MMM2 communities (regional, population > 50 000) in selection targets risks displacing students from more isolated locations. Applying a sub-quota to MMM3–MMM7 communities ensures that students from smaller communities and remote Australia enter medical school. This focus is an important step forward in rural selection. Targeting selection of MMM3–MMM7 students from a specific geographic region within a university's regional footprint is a promising emerging strategy — it is informed by evidence that rural students are more likely to return to their own or a similar rural community.12, 25 Many students in rural schools, particularly those from higher rurality areas, do not see medicine as an achievable career. Geographical, financial, social and self-efficacy barriers prevent many potential rural applicants from considering medicine. Medical schools can play a key role in leading community-engaged recruitment and support programs for high school students and other people living in rural areas who are eligible to access graduate-entry medical schools. The impact of these recruitment programs can increase applications from students in rural areas.26 Strongly coercive interventions, such as bonded medical places, are associated with comparatively lower rural retention than interventions that involve less coercion.27 Currently about 25% of all Commonwealth-supported medical students are bonded to areas of workforce need (including rural areas) for 3 years.28 Medical student bonding arrangements have reduced over time, due to limited evidence of long term success. Bonding conveys messages at the start of medical school that rural is less attractive, and it perpetuates inappropriate deficit discourse around rural practice. The current policy initiative of reducing Higher Education Loan Program debt for rural doctors is likely to have a much more positive impact.29 Promoting this financial support to students will assist with their choices to move to and stay in rural areas, but more needs to be done to overcome financial pressures for students from disadvantaged backgrounds during medical school. Rural students are a heterogeneous group, with potentially vast differences in rurality of background, socio-economic status, and personal agency. When available, generous scholarships targeting rural students enable those experiencing financial hardship to participate in medical training. Access to safe, student-friendly and affordable accommodation is invaluable for student success and rural retention. University-owned and subsidised housing allows students to transition into medical school and access clinical placements in a range of locations. Few medical courses are wholly based outside of capital cities in Australia.21 In 2019, the Commonwealth Government recognised the value of comprehensive rurally based programs that are more accessible for rural students by introducing legislation to reallocate 2% of medical school Commonwealth-supported places from urban medical schools to rural end-to-end programs every 3 years. This redistribution of medical school training places, which commenced in 2020, facilitated the recent establishment of medical programs in regional areas of New South Wales and Victoria.17 Before the COVID-19 pandemic began, this redistribution of medical places to rural programs may have been enough to provide an adequate rural medical workforce. Recent significantly reduced inward immigration of international medical graduates means that this policy needs to be reviewed. An expansion of Commonwealth-supported medical student places is required in rurally located end-to-end medical school programs, rather than a reliance solely on redistribution, to ensure that each state has at least one rural medical school program that provides remote or rural training from the start to the completion of the medical degree. A national collaboration could share medical education and remote teaching resources to support this initiative, with the Federation of Rural Australian Medical Educators well placed to facilitate this (https://ausframe.org/). Medical curricula and assessments shape students’ views of rural career options.30 Traditional medical school teaching is predominantly metropolitan focused and specialist led. Medical students report that denigration of both rural doctors and general practice is still commonplace in Australia.31 Attitudes which fail to recognise the expertise of generalists influence students’ career choices away from rural practice. Medical schools with strong academic engagement by rural clinicians illustrate the value of rural doctors. Integrating rural clinical cases and management plans for rural practice within the formal curriculum can reinforce positive and realistic messages about rural medicine in Australia.30 Australian medical schools with MD programs require students to undertake research, providing an opportunity for students to undertake rural projects that contribute to rural communities, which in turn can draw students to rural careers. As generalists, rural doctors deal with high levels of complexity and uncertainty in clinical practice. Students who are ill prepared for clinical complexity can avoid specialties that have high loads of uncertainty. Modern curricula need to prepare students explicitly for uncertainty, multimorbidity, shared decision making and communication across clinical settings. Clinical cases set in rural contexts provide opportunities to build medical students’ generalist approaches to clinical care. Having rural doctors teach core medical content will encourage a broader scope of practice for all students. In addition, medical students need to learn to work in multidisciplinary teams. Ensuring that a broad range of rural health practitioners teach medical students alongside nursing and allied health students will promote good foundations for future work practices. These changes in the curriculum will ensure all medical students have the skills for 21st century health care. Immersive rural training remains a cornerstone for producing more rural doctors. Australian rural clinical schools have provided a generation of medical students with a year or more of rural clinical experience.32 Placement types vary from traditional hospital rotations in regional centres, with arguably less rural context, to placements based in general practices in small rural communities where students interleave general practice and hospital experience, often supervised by rural generalists.33 Rural placements enable students to build connections with rural clinicians and communities. Their influence can range from cementing intent for students already interested in rural practice to changing intent of students primarily interested in metropolitan practice.9, 34 Longitudinal integrated rural clinical placements demonstrate consistently excellent academic outcomes and increased rural medical workforce outcomes by up to seven times those of metropolitan medical student clinical training.8, 35 These programs, when situated in small rural towns, result in graduates who are up to five times more likely to work in small rural towns.36 This workforce outcome takes time, particularly in communities that are not big enough to provide prevocational training. Many rural clinical school graduates who have to leave rural areas for their postgraduate training come back 5–10 years after graduation.37 Students who become rural doctors often spend longer than their peers being undecided about their specialty intentions, highlighting the importance of regular positive rural experiences to promote the uptake of general practice and rural practice.38 Longer duration (18–24 versus 12 months) of rural training is associated with a threefold increase in returning to practise in the same rural region after training.7, 39 Incrementally stronger associations exist for longer duration, a combination of regional hospital and general practice experience, greater remoteness and multiple placements.7, 10, 32 Apart from duration, there may be specific place-based effects. For example, the Rural Clinical School of Western Australia distributes rural medical workforce in a clearly geographically patterned way, with Broome acting as a bridge to the remote north of Australia.40 In Victoria, those selected from a specific region and having greater than one year of rural training in that region had a 17.4 times increased chance of working in that same rural region compared with urban background students who had completed fewer than 12 weeks of training in the region.25 In rural communities, students make an authentic contribution to the clinical care of patients.41 They are seen by local people as contributing members of the community, and these meaningful relationships shape their learning and professional identity.41 As students on full year rural placements engage in community social activities, such as participation in sport, choir or church, they develop individual informal relationships with community members. Adopting a community-engaged approach to training also includes facilitating rural communities to engage in the selection and education of students as patient-experts and simulated patients. Prolonged rural placement experiences trigger aspirational, intellectual and emotional responses, particularly in students who have a strong motivation to help others and who value teamwork.42 Accordingly, students are drawn in and bound to their “own” town.43 For many students choosing a rural career, this requires simultaneous choices of rural location and specialty discipline, while urban medical careers tend to be shaped first by chosen specialty and later by location of practice.38 A medical school's social and cultural context shapes who students become (eg, rural community member), not solely what they practise (ie, discipline interest).33, 44 This highlights the importance of fostering rural self-identity during medical school. Rural practice self-efficacy is an individual's sense of self-confidence to thrive working in rural practice.45 It correlates with medical student rural practice intent and increased remoteness of location of practice after graduation.45-47 Rural doctors describe their practice as involving connection with their communities, comfort with clinical uncertainties and preparedness to undertake clinical activities at the edge of their scope.48 Students on rural placements are immersed in this culture of rural medicine, see others like them in rural practice, and thereby develop rural practice self-efficacy.45 Students’ aspirations and expectations are strongly influenced by peers. Rural health clubs at universities celebrate and support students’ interests and facilitate contact with like-minded peers. Students who undertake a rural stream in medical school develop strong ties, before and during rural placements, with each other and with mentors.49 Extended rural placements help students build firm friendships in the student group on location and between students in other similar rural sites. In rural areas, a strong community of practice is essential for developing and sustaining clinicians who thrive.50 An apprenticeship-style mentoring model between rural medical practitioners and rural students enables students to feel supported and trained appropriately for rural and remote practice.51 Close working relationships between learners and their rural clinical supervisors enable rural professional identity formation over time.41, 52 Mentors have a key influence on graduates’ career choices and practice locations.53 The John Flynn Placement Program, which previously supported medical students to undertake extracurricular rural placements (2 weeks annually for 4 years), demonstrated positive effects of mentorship on rural practice intent.11 The rural medical workforce is under stress. Maintaining and developing training capacity is vital for all rural programs and Australia's future rural medical workforce. Junior doctors, registrars and international medical graduates compete for limited supervisor time and clinical space. Rural clinical schools play an important role in developing educationally supportive communities of practice for rural doctors. Schools also advocate for increased resources for rural areas, including financial remuneration for teaching and research, and clinical training infrastructure in rural general practices and hospitals. With proposed expansion of rural medical training pathways at all levels, the importance of appropriate support for rural clinical teachers, to ensure high quality clinical supervision, cannot be underestimated. Rural academic positions provide career diversity in rural Australia. Rural medical programs develop and support rural doctors to have blended roles, including clinician–teacher and clinical academic. Medical schools that include rural academics in curriculum design and delivery, assessment, research projects and wider opportunities within the university can improve advancement and longevity of engagement of rural staff.54 Having rural academics in senior medical school management teams secures rural oversight of rural missions. Rural clinical schools can provide academic skills for general practitioner and specialist registrars, enabling them to complete their training rurally. Many of these registrars will stay on or come back to the rural centre that provided this academic environment.32 Developing and sustaining rural and regional postgraduate training pathways is critical for supporting doctors to stay in rural areas.55 The Commonwealth Government's regional training hubs initiative funds rural clinical schools to develop, promote and sustain intern and vocational training opportunities in rural and remote Australia. Importantly, rural clinical schools connect students and junior doctors to vertically integrated training opportunities. Through regional training hubs, medical schools are increasingly engaging with other stakeholders contributing to workforce outcomes to maximise return on government investment and collaborate to address Australia's rural workforce needs. Several specialist training programs have now adopted a rural health equity strategy which sees rural background graduates privileged in college selection processes, particularly for rural training positions.56 The Australian College of Rural and Remote Medicine has recognised the value of rural connection and has incorporated a demonstrated connection with rural communities into its selection process for all candidates.57 Ongoing research into medical school influences on rural career choice will continue to influence medical school policy. Small changes in admissions policies can effect significant changes in terms of rural students entering medical school. Reporting on outcomes of rural pathways within the medical course must hold medical schools to account, ensure appropriate participation of students from under-represented rural communities, and enable continuous quality improvement of rural training pathways. Tracking rural student progress throughout the course can facilitate access to social and academic supports when required to retain these students. Finally, the Australian Health Practitioner Regulation Agency collects data on location of practice, which enables universities to track their graduates to understand the impact on the end goal — more rural doctors. The rural workforce outcomes of medical school interventions can take many years to eventuate and will remain dependent on other factors such as specialty choice, rural postgraduate training opportunities, and individual, family and partner commitments. Rural clinical schools in Australia have demonstrated the compounding effect of rural background, generalist intent, rural immersion, rural curricula, rural practice self-efficacy and rural identity on rural practice outcomes (Box 2). Medical schools have an obligation to direct their activities to addressing priority health needs in rural areas. Incorporating a comprehensive approach to all the elements of selection, rural immersion and rural curriculum, based on a defined social mission and geographic binding to the communities they serve, will enable students to develop their skills and careers in rural areas across Australia. PG = postgraduate. Australian rural clinical schools are funded through the Australian Government Rural Health Multidisciplinary Training program. The funder had no role in the preparation of this article. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. We all work within Australian rural clinical schools or rural medical programs and have leadership roles in rural medical undergraduate training or rural research. Commissioned; externally peer reviewed.

Background Cervical cancer (CC) is the second leading cause of cancer among women in the Philippines, mainly caused by a persistent human papillomavirus infection (HPV). We aimed to determine the prevalence of HPV and compare screening methods within a socio-economically deprived rural community in the Philippines. Methods We conducted a retrospective audit of the medical records of 872 women from the free Women’s clinic in a regional Philippines community over the period, 2013-2019. All participants were screened for CC using the VIA/VILI method, with only 284 women tested for HPV using the HPV-polymerase chain reaction (HPV-PCR) method. For the 284, we compared their HPV-PCR and VIA/VILI results. Data was de-identified and descriptively analysed. Results Thirteen different HPV subtypes, all oncogenic, exist in the community. HPV was detected in 32 (11%) of the 284 women tested. Of note, 28 patients who had an oncogenic HPV infection had a normal VIA/VILI inspection result. The bivalent vaccine protects only 6% of the HPV-positive cases in the clinic. Conclusions This study suggests HPV-PCR testing is superior at detecting HPV before cervical changes occur. The different oncogenic HPV strains reflect the low coverage of the bivalent HPV vaccination in the community – a key area for practice and policy reforms. Further studies on the prevalence of oncogenic HPV strains will be vital in designing suitable preventive care programs for CC.

BACKGROUND AND OBJECTIVES:Hepatitis C virus treatment uptake varies by geographic area in Australia; however, analysis has not been conducted on variations in treatment completion. This study investigated treatment completion according to remoteness, as well as demographic and clinical characteristics.METHOD:A retrospective analysis was conducted on all Pharmaceutical Benefits Scheme claim data from March 2016 to June 2019. Treatment was considered completed if all prescriptions required to complete the course were dispensed. Treatment completion was compared by remoteness of residence, sex, age, state or territory, treatment duration and prescriber type.RESULTS:Of 68,940 patients, 85.6% completed treatment, although the completion rate decreased over time. Residents living in very remote areas had the lowest treatment completion rate (74.3%; odds ratio [OR] 0.52; 95% confidence interval [CI]: 0.39, 0.7; P < 0.005), particularly those treated by general practitioners (GPs; 66.7%; OR 0.47; 95% CI: 0.22, 0.97; P = 0.042).DISCUSSION:This analysis suggests that people in very remote areas of Australia have the lowest hepatitis C treatment completion rate, particularly those accessing treatment through GPs. Further investigation into predictors of low treatment completion within these populations is required.

Introduction: Previous studies have shown that patient-centredness may become eroded as students progress through medical training. The primary objective of this study was to explore the differences in patient-centred attitudes between first- and final-year students in the context of an Australian medical school. The secondary objective was to determine whether student factors such as age, gender, background (rural/urban), discipline of previous degree and specialty of interest were associated with patient-centred attitudes. Methods: This cross-sectional study surveyed 214 first-year and 141 final-year Australian medical students in 2016 and 2017 (total n = 355). Score on the Patient–Practitioner Orientation Scale (PPOS) was the main outcome measure. Results: Anonymous questionnaires were completed by 355 students (76.2%). Mean PPOS score was 4.51 (SD 0.46). Although there was no difference in mean PPOS between first-year and fourth-year students, female respondents were significantly more patient-centred than male respondents (4.58 vs 4.42, p = 0.002). Students with an interest in a surgical specialty had significantly lower patient-centredness than students with a non-surgical specialty of interest (4.36 vs 4.55, p = 0.002). Having general practice intentions was not associated with higher patient-centredness. Students with a previous humanities-based degree had higher patient-centredness than students with previous degrees in different areas (4.67 vs 4.49, p = 0.025). Conclusions: There appears to be no erosion of patient-centredness between first-year and fourth/final-year students. Medical student selection and university culture may have influenced this finding.

Background The aim of this national study was to explore the learning experiences of Australia’s medical students who trained rurally during the COVID-19 pandemic in 2020. Methods A cross-sectional, national multi-centre survey was conducted in 2020, through the Federation of Rural Australian Medical Educators (FRAME). Participants were medical students who had completed an extended Rural Clinical School (RCS) training placement (≥ 12 months). A bespoke set of COVID-19 impact questions were incorporated into the annual FRAME survey, to capture COVID-19-related student experiences in 2020. Pre-pandemic (2019 FRAME survey data) comparisons were also explored. Results FRAME survey data were obtained from 464 students in 2020 (51.7% response rate), compared with available data from 668 students in 2019 (75.6% response rate). Most students expressed concern regarding the pandemic’s impact on the quality of their learning (80%) or missed clinical learning (58%); however, students reported being well-supported by the various learning and support strategies implemented by the RCSs across Australia. Notably, comparisons to pre-pandemic (2019) participants of the general RCS experience found higher levels of student support (strongly agree 58.9% vs 42.4%, p < 0.001) and wellbeing (strongly agree 49.6% vs 42.4%, p = 0.008) amongst the 2020 participants. Students with more than one year of RCS experience compared to one RCS year felt better supported with clinical skills learning opportunities ( p = 0.015) and less affected by COVID-19 in their exam performance ( p = 0.009). Conclusions This study has provided evidence of both the level of concern relating to learning quality as well as the positive impact of the various learning and support strategies implemented by the RCSs during the pandemic in 2020. RCSs should further evaluate the strategies implemented to identify those that are worth sustaining into the post-pandemic period.

OBJECTIVE:Demoralization is prevalent in patients with life-limiting chronic illnesses, many of whom reside in rural areas. These patients also have an increased risk of disease-related psychosocial burden due to the unique health barriers in this population. However, the factors affecting demoralization in this cohort are currently unknown. This study aimed to examine demoralization amongst the chronically ill in Lithgow, a town in rural New South Wales, Australia, and identify any correlated demographic, physical, and psychosocial factors in this population.METHOD:A cross-sectional survey of 73 participants drawn from Lithgow Hospital, the adjoining retirement village and nursing home, assessing correlating demographic, physical, psychiatric, and psychosocial factors.RESULTS:The total mean score of the DS-II was 7.8 (SD 26.4), and high demoralization scores were associated with the level of education (p = 0.01), comorbid condition (p = 0.04), severity of symptom burden (p = <0.001), depression (p = <0.001), and psychological distress (p = <0.001). Prevalence of serious demoralization in this population was 27.4% according to a cutoff of a DS-II score ≥11. Of those, 11 (15%) met the criteria for clinical depression, leaving 9 (12.3%) of the cohort demoralized but not depressed.SIGNIFICANCE OF RESULTS:Prevalence of demoralization was high in this population. In line with the existing literature, demoralization was associated with the level of education, symptom burden, and psychological distress, demonstrating that demoralization is a relevant psychometric factor in rural populations. Further stratification of the unique biopsychosocial factors at play in this population would contribute to better understanding the burdens experienced by people with chronic illness in this population and the nature of demoralization.

Australasian Journal of DermatologyVolume 60, Issue 3 p. 251-253 Letter to the Editors A qualitative discourse analysis of safe sun exposure and vitamin D in Australian print media Stephanie Clare Blake, orcid.org/0000-0002-1550-168X Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia St. George Department of Dermatology, Sydney, New South Wales, AustraliaSearch for more papers by this authorCatherine Jane Harding, School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, AustraliaSearch for more papers by this authorZelda Doyle, orcid.org/0000-0001-8648-1383 School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, AustraliaSearch for more papers by this author Stephanie Clare Blake, orcid.org/0000-0002-1550-168X Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia St. George Department of Dermatology, Sydney, New South Wales, AustraliaSearch for more papers by this authorCatherine Jane Harding, School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, AustraliaSearch for more papers by this authorZelda Doyle, orcid.org/0000-0001-8648-1383 School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 07 January 2019 https://doi.org/10.1111/ajd.12984Citations: 1 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Citing Literature Volume60, Issue3August 2019Pages 251-253 RelatedInformation

Purpose The purpose of this paper is to investigate if any exposure to segregation minimal association in a single male prison population had any association with an increased risk of vitamin D deficiency. Design/methodology/approach A retrospective case study was undertaken with all inmates who had a 25-hyrdoxy-vitamin D test taken during the study period deemed eligible. Hand searching of the medical records by an independent party identified eligible participants whose data were recorded for analysis. Findings In total, 124 prisoners were deemed eligible for inclusion; 67 were vitamin D sufficient and 57 were vitamin D deficient by Australian standards. Time in segregation minimal association was shown not to be significant, however, smoking (OR 2.93, 95% CI 1.27-6.81, p=0.012) and having Asian ethnicity (OR 4.16, 95% CI 1.56-11.10, p=0.004) independently significantly increased the risk of vitamin D deficiency. Research limitations/implications This research is limited by its study design, small sample size and single location. Originality/value This paper presents the first published research into vitamin D levels in a prison population in Australia, and provides a basis for a larger prospective cohort study.

The concept of femoral neck preservation in total hip replacement (THR) was introduced in 1993. It is postulated that retaining cortical bone of the femoral neck offers triplanar stability, uniform stress distribution, and accommodates physiological anteversion. However, data on safety, efficacy and learning curve are lacking. We prospectively assessed all patients who were operated for a THR with a short neck preserving stem (MiniHip) between 2012 and 2014. The safety and learning curve were assessed by recording operative time; stem size; and adverse events including periprosthetic fracture; paresthesia; and limb length discrepancy (LLD). The cohort was divided into equal groups to assess the learning curve effect, and the cumulative sums (CUSUM) test was performed to monitor intraoperative neck fractures. For assessment of efficacy, Oxford Hip Score (OHS) and Short Form-36 (SF-36) scores were compared preoperatively and postoperatively. 138 patients with median age 62 years (range 35–82 years) were included with a median followup of 42 months (range 30–56 months). The minimum followup was 2.5 years. The OHS, SF-36 (physical and mental component) scores improved by a mean score of 26, 28, and 27 points, respectively. All patients had LLD of <10 mm (1.9 mm ± 1.3). Adverse events included intraoperative neck fracture (n = 6), subsidence (n = 1), periprosthetic fracture (n = 1), paresthesia (n = 12), and trochanteric bursitis (n = 2). After early modification of the technique to use a smaller finishing broach, the CUSUM test demonstrated acceptable intraoperative neck fracture risk. The second surgery group had a reduced risk of intraoperative neck fracture (5/69 vs. 1/69 P = 0.2), reduced operative time (66 vs. 61 min, P = 0.06), and increased stem size (5 vs. 6, P = 0.09) although these differences were not statistically significant. The MiniHip stem is safe alternative to standard THR with good functional outcomes but with a learning curve for the surgical technique, implants sizing, and the risk of intraoperative neck fractures.

Background The concept of femoral neck preservation in total hip replacement (THR) was introduced in 1993. It is postulated that retaining cortical bone of the femoral neck offers triplanar stability, uniform stress distribution, and accommodates physiological anteversion. However, data on safety, efficacy and learning curve are lacking. Materials and Methods We prospectively assessed all patients who were operated for a THR with a short neck preserving stem (MiniHip) between 2012 and 2014. The safety and learning curve were assessed by recording operative time; stem size; and adverse events including periprosthetic fracture; paresthesia; and limb length discrepancy (LLD). The cohort was divided into equal groups to assess the learning curve effect, and the cumulative sums (CUSUM) test was performed to monitor intraoperative neck fractures. For assessment of efficacy, Oxford Hip Score (OHS) and Short Form-36 (SF-36) scores were compared preoperatively and postoperatively. Results 138 patients with median age 62 years (range 35–82 years) were included with a median followup of 42 months (range 30–56 months). The minimum followup was 2.5 years. The OHS, SF-36 (physical and mental component) scores improved by a mean score of 26, 28, and 27 points, respectively. All patients had LLD of <10 mm (1.9 mm ± 1.3). Adverse events included intraoperative neck fracture (n = 6), subsidence (n = 1), periprosthetic fracture (n = 1), paresthesia (n = 12), and trochanteric bursitis (n = 2). After early modification of the technique to use a smaller finishing broach, the CUSUM test demonstrated acceptable intraoperative neck fracture risk. The second surgery group had a reduced risk of intraoperative neck fracture (5/69 vs. 1/69 P = 0.2), reduced operative time (66 vs. 61 min, P = 0.06), and increased stem size (5 vs. 6, P = 0.09) although these differences were not statistically significant. Conclusions The MiniHip stem is safe alternative to standard THR with good functional outcomes but with a learning curve for the surgical technique, implants sizing, and the risk of intraoperative neck fractures.

Objective: Clinical guidelines recommend that patients who sustain a minimal trauma fracture (MTF) should receive a bone mineral density (BMD) scan and bisphosphonate (or equivalent) therapy if diagnosed with osteoporosis. A pilot fracture liaison service (FLS) was implemented in regional NSW to improve adherence to the guidelines. Design: Prospective cohort study with an historical control. Setting: Primary care. Participants: Control (n = 47) and cohort (n = 93) groups comprised patients consenting to interview who presented with a MTF to the major referral hospital 4 months before and 12 months after FLS implementation respectively. Main outcome measures: Primary outcome measures were the rates of BMD scans and anti-osteoporotic medication initiation/review after MTF. Hospital admission data were also examined to determine death and refracture rates for all patients presenting during the study period with a primary diagnosis of MTF within 3 years of their initial fracture. Results: Although there was no improvement in BMD scanning rates, the reported rate of medication initiation/review after fracture was significantly higher (P < 0.05) in the FLS cohort. However, once adjusted for age, this association was not significant (P = 0.086). There was a lower refracture rate during the cohort period (P = 0.013), however, there were significantly more deaths (P = 0.035) within 3 years of initial fracture. When deaths were taken into account via competing risk regression, patients in the cohort period were significantly less likely to refracture than those in the control period (Hazard ratio = 0.576, P = 0.032). Conclusions: A rurally based nurse-led FLS was associated with modest improvement after MTF. Consideration should be given to ways to strengthen the model of care to improve outcomes.