Global health education for medical undergraduates.

CONTEXT: The Rural Undergraduate Support and Coordination (RUSC) program has stimulated teaching in remote indigenous health, primary health care and international health for Australian students prior to their placements. Medical students have traditionally taken electives in the developing world, although these electives are of variable use to the communities hosting them and to the students. Calls for development of a curriculum in international or global health have resulted in some attempts to define a curriculum. An International Health (IH) course at the University of Adelaide Medical School, South Australia, has evolved since 1999. ISSUES: The IH course has functioned both as an introduction to the social determinants of health and as a pre-departure course for student electives. The sequence progresses from general information to disease specific information and service provision for refugees and returning travellers. Experienced presenters deliver the content; student assessment is via a group development program proposal. LESSONS LEARNT: The current course aligns with international thinking on 3 structural themes for global health: the burden of global disease, travellers' medicine and immigrant/refugee health. Student opinion expressed in qualitative evaluation has been largely positive and consistent with the debate about whether this content should be a core unit or an elective part of the curriculum. From 2011 the course will be known as 'Global Health' and ongoing content development is expected.

Vitamin D insufficiency in Aboriginal Australians.

OBJECTIVE: To investigate the adequacy of vitamin D status in a South Australian Aboriginal population, and to examine the relationship between serum 25-hydroxyvitamin D (25-OHD) levels and biochemical variables of calcium and bone mineral homeostasis, as well as other factors which may influence vitamin D synthesis, storage and metabolism. DESIGN, SETTING AND PARTICIPANTS: A single-visit, observational study of 58 adults from two Aboriginal community-controlled health services in Adelaide and Yalata, South Australia. Participants were recruited between May 2008 and December 2009. MAIN OUTCOME MEASURES: Serum levels of 25-OHD, parathyroid hormone (PTH), fasting glucose and fasting C-terminal telopeptides of type I collagen (ß-CTx). RESULTS: Serum 25-OHD levels showed clear seasonal variation, being higher in summer (P < 0.001). The overall mean level was 56.8 nmol/L (SD, 22.1), which is below the recommended target level of 60 nmol/L. Serum 25-OHD levels correlated significantly with ß-CTx (P = 0.03), but not with age, body mass index (BMI), PTH levels or levels of fasting glucose. A significant association was found between BMI and PTH levels (P = 0.001). A significant inverse association between serum 25-OHD levels and BMI, observed in other studies, was not found in our study. CONCLUSIONS: Vitamin D insufficiency is highly prevalent in this population of adult Aboriginal Australians, with low mean values found in all seasons other than summer.

Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: cross-sectional study.

OBJECTIVE: The aim of this research was to assess tertiary student distress levels with regards to (i) comparisons with normative population data, and (ii) the effects of discipline, year level, and student characteristics. Self-reported treatment rates and level of concern regarding perceived distress were also collected. METHOD: Students from all six years of an undergraduate medical course were compared with samples from Psychology, Law and Mechanical Engineering courses at the University of Adelaide, Australia. Students participated in one of three studies that were either web-based or paper-based. All studies included Kessler's Measure of Psychological Distress (K10), and questions pertaining to treatment for any mental health problems and concern regarding distress experienced. RESULTS: Of the 955 tertiary students who completed the K10, 48% were psychologically distressed (a K10 score > or = 22) which equated to a rate 4.4 times that of age-matched peers. The non-health disciplines were significantly more distressed than the health disciplines. Distress levels were statistically equivalent across all six years of the medical degree. Of tertiary students, 11% had been treated for a mental health problem. Levels of concern correlated with the K10 score. CONCLUSION: The results from this research suggest that high distress levels among the tertiary student body may be a phenomenon more widely spread than first thought. Low treatment rates suggest that traditional models of support may be inadequate or not appropriate for tertiary cohorts.

Rural student entry into a medical course: a South Australian rural high school perspective.

INTRODUCTION: Rural background is an acknowledged predictor of later rural medical practice. This study aimed to explore why only small numbers of high school students from rural South Australia seek entry to the University of Adelaide Medical School. METHOD: Questionnaires were designed to explore the interest in, knowledge of and attitudes about studying medicine of rural high school students, their parents and their careers counsellors. A stratified sample of 15 high schools in rural South Australia was selected. Data were collected from all participants on perceptions and knowledge of the entry processes and subject requirements for studying medicine. Student participants were also asked about their interest in studying medicine and becoming a doctor. RESULTS: Four hundred and sixty-one rural year 11 and 12 students, 512 parents of rural year 11 and 12 students, and 12 rural high school careers advisors returned useable data. Students, parents and career advisors were found to hold inaccurate perceptions of the minimum Tertiary Entrance Rank, and they incorrectly believed prerequisite subjects were required in order to study medicine at the University of Adelaide. Analysis identified a group of students interested in a career as a doctor but who had never considered studying medicine. The majority of students who had seriously considered studying medicine reported a lack of knowledge of admission processes and the requirements for studying medicine. Among students who found becoming a doctor appealing, those who had never considered medicine had less confidence regarding and knowledge of requirements and entry processes into medical courses than those who had. CONCLUSION: Some keen rural students have inadequate or inaccurate information about medical courses and admissions processes, which will deter them from applying to study medicine. Another group of students were identified who were attracted to a medical career but had not sought information on entry to a university undergraduate medical course. Both groups might be encouraged to progress their application to a medical school through 'academic detailing visits' to rural high schools, targeting medical careers promotion and provision of accurate and timely information on applying for and studying medicine.

Education to improve cancer care in rural South Australia.

INTRODUCTION: Cancer management follows the overall trend of rural health disparities, with higher incidence rates of preventable cancers and lower survival rates in rural Australia. Cancer prevention and management has been identified as a priority area and Cancer Australia has funded a variety of innovations throughout Australia. The Rural Chemotherapy Mentoring Program (RCMP) forms part of this drive to improve access to chemotherapy for rural based cancer sufferers in South Australia (SA). The key strategy of this program was the provision of opportunities for rural health clinicians (nurses and GPs) to enhance their knowledge and skills in the delivery of chemotherapy and cancer care through clinical placements at metropolitan oncology units. The RCMP enrolled 43 current SA rural clinicians (five GPs and 38 nurses). This evaluation was undertaken at the end of RCMP's initial 18 months. It considered how those involved in the RCMP perceived development and delivery of the RCMP, identifying key aspects of the program that were successful. This report emphasises lessons learnt which may be of relevance more widely in the development of other rural health professional education. METHODS: The evaluation used a mixed method approach, designed to accommodate different perspectives from the health professionals with different roles in the program. Quantitative and qualitative questionnaire data from clinician participants, their employers, and providers of education at metropolitan cancer units, were supplemented with qualitative interview data from these sample groups and from the program's steering committee. The analysis used interpretative methods to examine the key strengths, limitations and the potential for future development of the program. RESULTS: The vast majority of participants, employers, providers of training and the steering committee representatives expressed high levels of overall satisfaction about their involvement in RCMP. A clear identifiable need for increased knowledge and skills in cancer care was expressed by rural clinical participants pre-clinical placement. Technical aspects of the delivery of some chemotherapy protocols and the steps in safely preparing patients to receive chemotherapy were key areas where respondents lacked confidence prior to their clinical placement. Post-placement self-evaluation data highlighted improvements in participants' understandings and confidence about chemotherapy, and cancer care knowledge. Participants and their employers identified change in specific work activities resulting from their new knowledge. The program's limitations were identified. CONCLUSIONS: Knowledge acquisition was a key to the success of the program, and the transfer of experience between rural and urban based clinicians was an important aspect of this. Generalisable recommendations for further improvement of the RCMP include: (1) clearly define and articulate a precise learning objective of the program; (2) involve staff who will directly deliver mentoring in planning of the program; (3) allow time in the planning phase to resolve complex indemnity issues across workplaces; and (4) provide funding for a dedicated trainer (preferably a staff member within the unit) to supervise placements in busy urban oncology clinics.

Rural clinician opinion on being a preceptor.

INTRODUCTION: This article reports the evaluation of the motivation and experiences of preceptors of health professional students in the Spencer Gulf Rural Health School (SGRHS) in South Australia. The aims for this evaluation were to establish: (1) What factors influenced the professional's decision to precept students? (2) Did preceptors report having adequate skills and preparation for preceptoring? (3) What were the variations in professional streams with regards to the factors and skills of the staff involved? (4) What were preceptors' overall perceptions of their role? Heeding the opinions of preceptors involved in such initiatives is an important part of ensuring the sustainability of the rural workforce initiatives such as SGRHS. METHODS: A preceptor questionnaire was developed from the literature in 2002 and pilot tested twice. At the end of 2004, all 255 preceptors who had been involved with SGRHS placement programs were sent a paper questionnaire. 145 valid responses were received (58%). The data were analysed using SPSS, Excel and Xpro. RESULTS: Respondent preceptors were drawn from medicine (n = 70), nursing (37), allied health (24), and other (14) backgrounds and had generally preceptored previously (133). Respondents had preceptored a total of 1007 students from medicine, nursing, allied health and other fields of study. Respondents had worked for either a very long time (> 15 years) or a short time (< 5 years) in rural areas. Respondents reported the factors which influenced their decision to precept were (in order): (1) I value my contribution to the growth in student's knowledge and skills; (2) Teaching allows me to promote rural health as a career option; (3) I enjoy the teaching/preceptor role; (4) Being a preceptor enhances my desire to keep up with recent health developments/literature; (5) I increase my time reviewing the basics of my clinical knowledge. There was significant interdisciplinary difference with nurses valuing their professional contribution more highly than doctors or allied health professionals. Preceptors' reports of their rural placement experiences reveal high agreement (99%) with the statement about the purposefulness of rural placements for providing students with the opportunity to see careers in rural practice in action, and most (93%) believed that they had adequate skills to precept and (91%) that the placement was an overall positive experience for the practice. Open-ended answers were coded and analysed to further understand these findings. Medical preceptors delighted in sharing youthful students' enthusiasm for learning while nurses most enjoyed encouraging students' understanding of rural health care. The principal preceptor problems related to time and associated issues, while doctors more than nurses and allied health professionals reported these issues. CONCLUSIONS AND RECOMMENDATIONS: The SGRHS findings are consistent with world preceptor literature. To ensure sustainability of preceptors a number of areas need to be improved--notably recognition of loss of productivity; improvements to communication between sending institution and placement site; maintaining a multi-disciplinary approach to selecting preceptors based on the different 'world view' of the respondents; and, last, persisting with rural placements in acknowledgement that preceptors themselves agree that short observational placements allow students to see rural careers in action, which is the fundamental goal for rural placements.

Development of 'rural week' for medical students: impact and quality report.

INTRODUCTION: The Rural Undergraduate Support and Coordination program funds medical schools to provide all medical students some time in rural Australia throughout their course. The University of Adelaide has developed a rural week program for both first and second year students to fulfill part of this objective. METHODS: First year students' rural week is an introduction to a range of rural health issues, Indigenous culture and rural lifestyle issues. Second year students choose either a clinical rural week with a general practitioner or a week of Indigenous cultural learning with the Adnyamathanha people in the Flinders ranges, South Australia. Evaluation data were collected from students, practitioners and university staff during rural weeks in 2003 and 2004 using quantitative and qualitative methods. RESULTS: First year students increased their knowledge of and interest in rural medicine and enjoyed their (limited) clinical interaction with patients. Second year students appreciated the clinical experience and valued the welcome they received from doctors and practice staff. Those who chose Indigenous cultural programs appreciated the opportunity to interact with and learn from Indigenous people. General practitioners valued contributing to student knowledge and skills and the opportunity to promote rural practice. Volunteer community members were very enthusiastic about meeting the students and their generosity had a significant impact on the students' ideas about rural lifestyle. University academic and administrative staff found rural week very intensive work but experience and thorough preparation now ensures that few problems occur. CONCLUSION: Rural weeks are now an established part of the first year and second year curriculum at the University of Adelaide Medical School. The ability to provide small groups of students with an intense introduction to rural practice and/or Indigenous culture results in a positive change in opinion about this aspect of medical education. Students now have first-hand experience to positively influence their choice of rural education or Indigenous health options in the medical course. Problems do occur with students being away from the traditional classroom, and protocols have been put in place for behaviour of all parties. Despite the rural weeks program being very demanding on staff energy, financial resources, general practices and rural communities, we feel that this program is valuable and sustainable. Further experience will determine if rural weeks function effectively as a recruitment strategy for the long rural placements offered by the Rural Clinical School.

Health assessment of elderly patients.

BACKGROUND: Comprehensive health assessment of the elderly in primary care will become a more important element of general practice as population aging proceeds and evidence of efficacy emerges. OBJECTIVE: This article describes approaches to provision of health assessment in primary care based on the best available evidence. DISCUSSION: Current best practice includes the use of structured health assessment protocols, an integrated multidisciplinary approach, targeting patient groups with intermediate levels of disability and handicap, in-home assessments and carefully structured follow up mechanisms.

Malnutrition in older people--screening and management strategies.

BACKGROUND: Malnutrition in older people is not only common, but frequently overlooked. It can result in multiple medical complications, hospitalisation and even death. OBJECTIVE: This article focusses on the consequences, pathophysiology, diagnosis and management of this clinical syndrome. DISCUSSION: Nonphysiological causes of malnutrition include social, psychological, medical and medication related factors. With vigilance, early screening and the institution of simple therapeutic measures of correcting nonphysiological causes and following dietary guidelines for older people, the adverse effects of malnutrition may be minimised.

Randomised controlled trial of health assessments for older Australian veterans and war widows.

OBJECTIVE: To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death. DESIGN: Randomised controlled trial of the effect of health assessments over 3 years. PARTICIPANTS AND SETTING: 1569 community-living veterans and war widows receiving full benefits from the Department of Veterans' Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942). INTERVENTION: Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner. MAIN OUTCOME MEASURES: Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up. RESULTS: 3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05-1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40-2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01). CONCLUSIONS: Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.