Barriers and enablers to implementation of COVID-19 vaccine programs in a rural and regional Queensland: A provider perspective.

INTRODUCTION: Vaccines formed the core of Australia's National COVID-19 Plan in combination with other public health measures. Vaccine rates varied geographically, and lower uptake was seen in some regional and remote areas. OBJECTIVE: Explore barriers and enablers to implementing COVID-19 vaccine programs and recommendations for improvement from a vaccine provider perspective in rural and regional Queensland (QLD). DESIGN: Participants included eleven healthcare personnel (HCP) from rural (45%) and regional (55%) settings in the Wide Bay region, QLD, Australia. Semi-structured interviews were conducted to identify barriers and enabling factors HCP experienced implementing COVID-19 programs, in addition to their recommendations to optimise ongoing implementation of vaccine programs. Braun and Clarke's reflexive thematic analysis of interview transcripts was performed, and over-arching themes were identified. FINDINGS: Four barrier themes were identified: 1. operational barriers, 2. communication issues, 3. financial constraints, and 4. leadership and coordination. Four enabler themes were also identified: 1. adaptability; 2. prior experience and knowledge; 3. collaboration and teamwork; and 4. community engagement. Recommendations for optimising ongoing vaccine rollout included reducing the administrative burden on providers, increasing involvement of primary care and the private sector in planning and decision making, improving communication methods, reviewing financial remuneration for private providers, and decentralising decision-making. DISCUSSION: There were multiple barriers and enablers to implementation of COVID-19 programs experienced by rural and regional HCP in the Wide Bay region of QLD which were consistent with existing literature. CONCLUSION: A range of actionable recommendations were identified that could optimise the COVID-19 vaccine program and future vaccine programs in rural and regional areas.

Did the coronavirus vaccination program in a rural and regional area work? Health outcomes of the vaccination program in Wide Bay.

The objective of this case study is to evaluate the effectiveness of the Wide Bay region coronavirus vaccination program in preventing hospitalisation for coronavirus disease 2019 (COVID-19). Population vaccination data and the vaccination status of patients hospitalised with confirmed COVID-19 have been used to evaluate preventable hospitalisations and risk reduction during and after a 2 month period following the outbreak of COVID-19 in Wide Bay after removal of public health measures in Queensland in December 2021. Wide Bay is a rural region of Queensland including K'Gari (formerly Fraser Island) to the east, the North Burnett farming region in the west and extending from the Fraser Coast to the Discovery Coast. Two local regional hospitals received and managed hospitalised COVID-19 patients. The region had, at this time, 171 365 people 20 years and older eligible for coronavirus vaccination. The risk reduction for hospitalisation of those receiving fewer than two vaccinations, two vaccinations and three vaccinations was calculated to determine the vaccination program effectiveness. The program achieved 90% effectiveness for people with two or more vaccinations (those with two vaccinations and those receiving boosters of third or more vaccination), and 97% effectiveness for those having received three vaccinations, in preventing hospitalisation for COVID-19 during the period. This translated into a significant risk reduction for hospitalisation for those receiving two or more vaccinations, preserving capacity to enable the health service to manage all cases locally.

Post COVID-19 vaccination: AusVaxSafety survey participation and adverse events - a community-based regional Queensland study.

OBJECTIVE: To describe adverse events following COVID-19 immunisation (AEFI) and participation in AusVaxSafety surveillance in a Queensland regional community. METHODS: Participants presenting for second dose COVID-19 vaccine at the Hervey Bay Wide Bay Hospital and Health Service (WBHHS) vaccine clinic in July 2021 completed a survey pertaining to their first COVID-19 vaccine. Data collected included participation in AusVaxSafety surveillance, vaccine type (BNT162b2 (Pfizer/BioNTech) or ChAdOx1-S(Oxford/AstraZeneca), AEFI experienced and impact on work/routine activities. Multivariable logistic regression related demographic factors to odds of surveillance participation and AEFI occurrence. RESULTS: Of 1,148 participants, 37.6% participated in AusVaxSafety surveillance and 44.8% reported an AEFI. Participation in surveillance was higher in older (≥50 vs <50 years: OR 1.36, 95%CI:1.04-1.78) and less-educated participants (university vs. high school/below: OR 0.68, 95%CI:0.48-0.95). Reporting an AEFI was higher in younger (≥50 years vs. <50 years: BNT162b2: OR 0.69, 95%CI:0.51-0.93; ChAdOx1-S: OR 0.42, 95%CI:0.10-1.89), female (female vs. male: BNT162b2: OR 2.28, 95%CI:1.67-3.12; ChAdOx1-S: OR 1.85, 95%CI:1.17-2.94) and more educated participants (university vs. high school/below: BNT162b2:OR 1.63, 95%CI: 1.08-2.45; ChAdOx1-S: OR 3.98, 95%CI:2.03-7.79). Of participants with an AEFI, 15% reported missing work/routine activities. CONCLUSIONS: Participation in surveillance was modest in this regional population, despite AEFI being frequent, and impacts of absenteeism in this setting warrants further research. IMPLICATIONS FOR PUBLIC HEALTH: The findings can inform strategies to improve surveillance participation and inform workforce planning in regional areas.

COVID-19 Vaccination: An Exploratory Study of the Motivations and Concerns Detailed in the Medical Records of a Regional Australian Population.

Understanding motivations and concerns surrounding COVID-19 vaccine uptake is important to reduce vaccine hesitancy and inform strategies to mitigate concerns and increase vaccine uptake. This study aimed to explore motivations and concerns associated with COVID-19 vaccination among adults seeking their first COVID-19 vaccine in a regional Australian community with low prevalence of COVID-19, who received a medical consult prior to vaccination. Medical records from consults were audited and the modified Framework Method was used to conduct qualitative content analysis of data, generating themes and overall core concepts related to motivations for COVID-19 vaccination and associated concerns. There were 102 people included in the study, 81% of whom were aged ≥60 years. Concerns surrounding COVID-19 vaccination included five core concepts: 1. Perceived vaccine risks, 2. Perceived vaccine performance, 3. Uncertainty, 4. Autonomy, and 5. Fairness in access; and a further five core concepts were generated from motivations to seek vaccination: 1. Protection, 2. Occupational or facility responsibility or requirement, 3. Trust in primary healthcare physician, 4. Autonomy, and 5. Civic duty. These motivating factors and concerns can be used to inform strategies and education to increase vaccine uptake in ongoing and future vaccine rollouts.

Queensland Rural Generalist Pathway: why do trainees separate without achieving a Rural Generalist end point?

The aim of this study was to learn from trainees separating from the Queensland Rural Generalist Pathway (QRGP) the reasons and circumstances around their decision so as to improve the efficiency of the program and experience of trainees. Forty-one QRGP trainees who separated without achieving a Rural Generalist (RG) end point to training were interviewed regarding their reasons for separation and thoughts on improving the program. The mean period of time enrolled in the QRGP was 2.87 years. Broadly, the cohort divided into those separating for specialist training, those moving into non-RG general practice and those undecided. Separation for specialist training tended to occur during prevocational years and that to general practice later in the program before trainees had completed advanced skill training. Female trainees were over-represented among trainees separating without completing training. This cohort provided their opinions on the strengths of the QRGP and possible improvements. Understanding and addressing the reasons for early separation suggested several strategies to improve the efficiency of the QRGP in selecting and retaining trainees. Lessons learned included the value of employer-provided coordinated prevocational placements and training, potential benefits of guiding rural-interested medical graduates who ultimately enter other specialist training and the need for greater liaison with external Australian General Practice Training administration organisations to coordinate transition of trainees. There is a need to further address accessibility of advanced training for all trainees.

Local and regional workforce return on investment from sponsoring rural generalist-based training for medical students.

The objective of this case study was to examine and evaluate the retention of medical graduates for a hospital and health service partnering with a university to deliver a rural medical program. Eight cohorts of the Griffith Rural Medical Longlook program were followed for workforce outcomes, including both rural and local workforce outcomes for the Darling Downs Hospital and Health Service (DDHHS) and the region. The DDHHS partnered with Griffith Health for capital investment in the region, creating three main campuses in rural generalist hospitals and augmented resources in other rural health facilities. Most (60%) medical graduates placed for a year or more on the Longlook program chose regional internships in Queensland, including 31% who chose internship in the DDHHS. Students spending 2 years on the program in the DDHHS were more likely to remain for local internship (odds ratio (OR) 5.7) and to be practicing locally after internship (OR 3.3). Local retention of medical graduates from the partnership between the Faculty of Health at Griffith University and the DDHHS to establish and conduct the Rural Medical Longlook Program includes resourcing and utilisation of spare training capacity in rural generalist hospitals and in addressing junior medical workforce recruitment.

A cross-sectional study of skin cancer secondary prevention in rural general practice.

BACKGROUND AND OBJECTIVES: As a result of the lack of evidence of reduction in mortality, secondary prevention of melanoma and keratinocyte skin cancers (KSCs) with active screening is not recommended except for individuals at high risk. Limited access to medical professionals for diagnosis and specialised treatment of skin cancers are related to poorer health outcomes for Australians living in rural areas. The aim of this study was to evaluate the secondary prevention of skin cancer in general practice. METHOD: A clinical audit of 317 melanomas and 5463 KSCs was conducted, examining the nature of consultation and stage of cancer at diagnosis. RESULTS: It was more common for an uncomplicated melanoma ≤1 mm in size to be identified by a general practitioner (GP) during a planned whole-body skin examination than to be the presenting complaint found by the patient (χ2 = 4.2, P <0.05). Half (49%) of KSCs found were the presenting complaint, with 21% an incidental diagnosis during another presentation and 30% found during whole-body skin examinations. Half of all squamous cell carcinomas found were at the intra-epidermal stage. DISCUSSION: Secondary prevention of skin cancer by GPs is a value proposition for rural populations.

Local regional workforce returns on investment of a locally governed and delivered general practice vocational training program.

This study evaluated a program arising from the Commonwealth policy of regionalised training for general practice with regard to the outcomes for the region investing in the training program. A complete operational audit was performed of the outcomes of a training provider of the Commonwealth program, evaluating workforce contribution and retention in the region during and after training, stratified for the effects of locally contextualising, advanced skill training and origin of trainee. The local regional workforce contribution during training peaked at 130 full-time equivalents in 2015. Cumulatively, 53% of alumni remained in the region, but over 40% moved to practice in metropolitan south-east Queensland and other Australian capital cities. Local contextualising of training, completing additional advanced skills training and being an Australian graduate were associated with increased retention in the region. A regional training program is a significant local asset introducing potential general practitioners (GPs) to the region. However, this regional area has become a 'rural' training ground for GPs into metropolitan practice rather than local investment translating as comprehensively as possible into long-term local workforce. The Commonwealth program should focus on local workforce outcomes as an evaluation metric rather than the proportion of trainees in rural training.

Epidemiology of melanoma in rural southern Queensland.

OBJECTIVE: The objective of this study is to define the epidemiology of melanoma in rural communities in southern Queensland. DESIGN: The design used was a 6-year clinical record audit of melanoma cases identified by billing records and electronic clinical records, confirmed and typed with histology. SETTING AND PARTICIPANTS: This study was based on seven agricultural communities on the Darling Downs with patients presenting to local primary care clinics. MAIN OUTCOME MEASURES: Outcomes measured were confirmed type, depth and anatomic distribution of melanoma identified at these practices during the study period. RESULTS: The results from 317 cases of melanoma found anatomic distribution was significantly different (χ2  = 9.6, P < 0.05) to that reported previously from the Queensland Cancer Registry. A high proportion (87%) of melanoma diagnosed by these general practitioners were 1 mm or less when treated. CONCLUSIONS: Conclusions drawn from these findings are that melanoma risk is not so much lesser in rural, inland communities compared with coastal and metropolitan regions, but different. Differences may relate to comprehensive data capture available in rural community studies and to different sun exposure and protection behaviours. The higher proportion of melanoma identified at early stages suggests rural primary care is an effective method of secondary prevention.

Prevalence and outcomes of overweight and obesity among pregnant women in rural Queensland.

OBJECTIVE: To assess the prevalence of overweight and obese women in the antenatal and perinatal periods, in rural hospitals; and to evaluate neonatal and maternal outcomes, including transfer to larger birthing centres. DESIGN: A retrospective clinical chart audit. SETTING: Rural maternity services in five Queensland rural hospitals. PARTICIPANTS: Data were collected from 250 women presenting to participating rural hospitals, with an estimated due date in 2016. MAIN OUTCOME MEASURES: Obstetric and neonatal data, whether transfer occurred, mode of delivery and any complications, and neonatal outcomes including birth weight and complications were collected. Demographic information collected included maternal age, gravidity and parity, race, smoking status and pre-pregnancy body mass index. The main outcome measures of interest were birth weight, Caesarean rate, transfer rate and diagnosis of gestational diabetes in relation to the body mass index. RESULTS: Over 50% of women were overweight or obese while entering pregnancy, with 5.2% of mothers in the morbidly obese category. There was an increase in the birth weight of mothers with a body mass index of more than 25. The increasing body mass index was associated with an increased likelihood of transfer, diagnosis of gestational diabetes, elective and, especially, emergency Caesareans performed at the hospital. Twenty-four percent of women continued to smoke throughout pregnancy. CONCLUSION: A high prevalence of obesity was found in the rural obstetric population. As the body mass index increases, so too does birth weight, gestational diabetes, transfer rate and Caesarean section rate. The rates of smoking throughout pregnancy were higher than the average metropolitan rates. These findings have implications not just for rural hospital operation and resources, but also for preventive health activities in rural communities.

Analysis of agriculture-related life-threatening injuries presenting to emergency departments of rural generalist hospitals in Southern Queensland.

OBJECTIVE: Agricultural industries are among the most dangerous in Australia posing significant public health risks. This study analyses the nature and management of agriculture-related injuries presenting to EDs in selected hospitals in Southern Queensland. METHODS: Data on agricultural injury presentations over a 6 month period was collected at four rural hospitals by a dedicated onsite hospital data coordinator. Additionally, in two of the participating hospitals all injury presentations over the same 6 month period were recorded. A pre-tested survey instrument, modified for rural settings and designed and developed to export the abstracted data using an iPad application was used as the survey tool. RESULTS: The incidence of agriculture-related injuries was 11% of all injuries, most were males (73%), averaging 40 years. On presentation, 66.5% (n = 234) were categorised as imminently or potentially life threatening with 44% of those patients presenting to hospital ED >3 h after the injury. Large animals were more commonly reported as involved in the aetiology of the presenting injury, particularly using horses and handling cattle. CONCLUSIONS: Agricultural injuries are a significant group of primary care presentations to rural hospitals and training and resourcing for rural hospitals should reflect this. A better understanding of common injury types can lead to efficient allocation of available resources in rural hospitals and potentially improve ED practices. The delay in presentation must be considered in response planning both by farmers and hospital EDs.

Chronic Disease and Health Risk Behaviors Among Rural Agricultural Workforce in Queensland.

INTRODUCTION: Little is known of the lifestyle behaviors and prevalence of chronic disease in the Australian agricultural workforce. This study aimed to assess behavioral risk factors and the prevalence of chronic disease among attendees of agricultural events in rural Queensland. METHODS: Data on lifestyle risk factors and prevalence of diabetes and cardiovascular diseases were collected from participants in four separate cross-sectional studies in rural southern Queensland. Anthropometric measures, blood pressure, serum cholesterol, and glucose levels of consenting participants were assessed by trained medical students under the supervision of rural clinicians. Data were analyzed using SPSS 22 statistical software package and t-tests and chi-square tests were used to compare differences between groups. RESULTS: A total of 702 attendees participated; the majority were agricultural workers (n = 393). Greater psychological distress was reported among participants from these rural communities (42%) than in the Australian population (31%); however, levels of psychological distress was similar between agricultural workers and others in the sample. Fewer people in these agricultural communities reported smoking (10%), and they reported being more active (86%) than the average Australian, but a greater proportion reported high-risk alcohol consumption (53%) and were found to be hypertensive (31%). These findings were accentuated among agricultural workers. CONCLUSION: This method of investigation both raises awareness in the community and identifies health risks for further management in a group that has otherwise been poorly defined. Resident agricultural workers have different health risks and behaviors, though psychological distress appears to be borne across these communities.

Longlook: initial outcomes of a longitudinal integrated rural clinical placement program.

OBJECTIVE: To assess outcomes in terms of academic performance and subsequent career choice in medical students undertaking a longitudinal integrated rural clinical placement. DESIGN: This was a retrospective, observational, cohort study. SETTING: The 'Longlook' program is a longitudinal integrated rural clinical placement run collaboratively by Griffith University, Queensland Rural Medical Education and Queensland Health as part of the Griffith medical program. PARTICIPANTS: Participants in this study were students completing years 3 and 4 in the Griffith medical program between 2010 and 2013. Assessment data were available for 683 participants, and internship location was available for all 472 students allocated within Queensland (87% of graduated students). INTERVENTIONS: Introduction of Longlook program. MAIN OUTCOME MEASURES: The primary outcome measures were performance in overall and clinical assessments, and intern location (rural versus urban). RESULTS: When performance in prior year was taken into account, there were no statistically significant differences in academic performance in year 3 or 4 for rural and urban students. Of Longlook students who have graduated, 31/46 (67%) have undertaken internship at a rural location compared with 63/426 (15%) for urban hospital-based students (odds ratio 11.91; 95% confidence interval 6.08-23.32). CONCLUSIONS: We have demonstrated that it is feasible to implement a parallel longitudinal integrated rural clinical placement in an established conventional postgraduate medical program and provide similar learning outcomes. Initial findings suggest that this experience is translating into positive outcomes in terms of future careers in rural settings. There is a need to reappraise the structure of initiatives aimed at promoting rural careers in medicine.

Learning styles in vertically integrated teaching.

BACKGROUND: With vertical integration, registrars and medical students attend the same educational workshops. It is not known whether these learners have similar or different learning styles related to their level of education within the medical training schema. This study aims to collect information about learning styles with a view to changing teaching strategies. If a significant difference is demonstrated this will impact on required approaches to teaching. METHODS: The VARK learning inventory questionnaire was administered to 36 general practice registrars and 20 medical students. The learning styles were compared as individuals and then related to their level of education within the medical training schema. RESULTS: Students had a greater preference for multimodal learning compared with registrars (62.5 per cent versus 33.3 per cent, respectively). More than half of the registrars preferred uni or bimodal learning modalities, compared with one-third of the medical students. DISCUSSION: The present workshop format based on visual and aural material will not match the learning needs of most learners. This small study has shown that the majority of medical students and registrars could have their learning preferences better met by the addition of written material to the workshop series. Surprisingly, a significantly larger number of medical students than registrars appeared to be broadly multimodal in their learning style, and this warrants further research.

Rural generalism and the Queensland Health pathway--implications for rural clinical supervisors, placements and rural medical education providers.

The lifeline for country medicine' was the description by the Rural Doctors Association of Australia of the Queensland Health Rural Generalist Pathway (RGP). The program promises to redress rural medical workforce issues in Queensland. It may fulfil these promises, but only with the support of rural clinical supervisors and medical educators adapting to new expectations of competencies, of training structure and endpoints of training. These adaptations will be a key element of the RGP success, particularly as other states adopt the approach. This article outlines the lessons learnt and adaptations made by clinical supervisors and medical educators in the Queensland Rural Medical Education group, to deliver the Rural Pathway of the Australian General Practice Training program since the first registrars identifying as RGP appeared in this program in 2006.

Training Australian Defence Force Medical Officers to civilian general practice training standards--reflections on military medicine and its links to general practice education and training.

This article examines military medicine and its links to civilian general practice education and training, drawing attention to the variations and difficulties in, and successful approaches for, training Australian Defence Force (ADF) Medical Officers. Military medicine has been an area of change over the 10 years of the Australian General Practice Training (AGPT) program. Crisis situations like those in Timor Leste and Afghanistan have focused attention and recognition on the importance of primary health care in the work of the ADF. To train doctors in military medicine, there are several different models at different locations around Australia, as well as large variations in military course and experience recognition and approvals between AGPT regional training providers. At times, the lack of standardisation in training delays the progress of ADF registrars moving through the AGPT program and becoming independently deployable Medical Officers.