Remote Australia Online

Background. Optimising retention of rural and remote primary healthcare (PHC) workers requires workforce planners to understand what constitutes a reasonable length of employment and how this varies. Currently, knowledge of retention patterns is limited and there is an absence of PHC workforce benchmarks that take account of differences in geographic context and profession.Methods. Three broad strategies were employed for proposing benchmarks for reasonable length of stay. They comprised: a comprehensive literature review of PHC workforce-retention indicators and benchmarks; secondary analysis of existing Australian PHC workforce datasets; and a postal survey of 108 rural and remote PHC services, identifying perceived and actual workforce-retention patterns of selected professional groups.Results. The literature review and secondary data analysis revealed little that was useful for establishing retention benchmarks. Analysis of primary data revealed differences in retention by geographic location and profession that took time to emerge and were not sustained indefinitely. Provisional benchmarks for reasonable length of employment were developed for health professional groups in both rural and remote settings.Conclusions. Workforce-retention benchmarks that differ according to geographic location and profession can be empirically derived, facilitating opportunities for managers to improve retention performance and reduce the high costs of staff replacement.What is known about the topic? Health services located in small rural and remote locations are likely to continue to experience workforce shortages and high costs of recruitment. Health workforce retention is therefore crucial. However, effective rural health workforce planning and use of strategies to maximise retention of existing health workers is hindered by inadequate knowledge about baseline employment-retention patterns.What does this paper add? Differences in health worker retention patterns by geographic location and profession are most evident after the first 6 months through until the end of the second year of employment. Health worker-retention benchmarks that differ according to geographic location and profession are proposed.What are the implications for practitioners? Benchmarking workforce retention in comparable health services can enable identification of best practice and the underpinning retention strategies. Workforce planners can use this, together with knowledge of baseline retention patterns and the high cost of staff replacement, to guide the design, timing and implementation of cost-neutral retention strategies.

Introduction Mental health is a national priority in Australia, and the need is greatest where access to specialist care is poorest, in the rural and remote regions of the nation. The Mental Health Emergency Care–Rural Access Project (MHEC) was developed to provide 24-hour access to mental health specialists in rural and remote New South Wales using video conferencing equipment. Method An evaluation of the service activity of MHEC using a concurrent mixed methods approach. Results Use of the service increased from a low base to around 60 video assessments per month at the end of the study period. Use of video assessments was greatest in the remote zone (30.7 video assessments/10,000 population/year). The number of people referred to a mental health inpatient unit declined (50 fewer patients, representing a decrease from 73% to 52% of all admissions between 2008 and 2009). Both patients and providers found the service helpful. Most patients (81%) stated that they would recommend or use the service again. Discussion This service is well positioned to have an increasing effect on emergency nursing and patient outcomes, as well as potentially on transportations. Continued use of MHEC suggests that video conference technology is acceptable and offers responsive specialist emergency mental health care to rural and remote communities.

Health services for Aboriginal and Torres Strait Islander people are expensive. The National Aboriginal Community Controlled Health Organisation reported that government Aboriginal and Torres Strait Islander health and hospital service expenditure per person in 2010-11 was $8190 nationally, and as high as $16 110 in the Northern Territory, compared with $4054 per non-Indigenous person. Increasing expenditure on health services for Aboriginal and Torres Strait Islander people is not closing the gap in health outcomes at the rate to which governments have committed. Gaps in education and employment outcomes between Aboriginal and Torres Strait Islander Australians and other Australians are also not closing, despite significant investment. Overall employment indicators for Aboriginal and Torres Strait Islander Australians are deteriorating. Comprehensive lack of progress in the three key areas of education, employment and health highlights the interplay among these three areas. Transformative changes in our approaches to the health and wellbeing of Aboriginal and Torres Strait Islander people are needed.

Background Indigenous Australians experience high risk of diabetes and cardiovascular disease. On-site pathology data can help identify those at risk. We sought to evaluate point-of-care (POC) analysers in remote Australian communities. Methods Results obtained from population screening (n=76–118) on the DCA2000+® and Cholestech LDX® analysers were compared to laboratory measures. Results were compared using parametric and non-parametric statistical analyses, including the use of conventional cut-off values for pathology markers. Results Agreements (95% CI) between the two methods for categorising results according to the selected cut-off values ranged from 88% (77–94%) for HDL-C to 99% (92–100%) for glucose, and Kappa coefficients ranged from 0.668 for total cholesterol to 0.945 for glucose. Differences in median values were not clinically meaningful but were statistically significant (P<0.05) for urinary albumin (18.8 [inter-quartile range: 7.5–41.7] vs. 18.0 [5.5–43.2] mg/L), creatinine (12.1 [7.9–17.1] vs. 12.4 [8.1–17.0] mmol/L) and albumin:creatinine ratio (ACR; 1.66 [0.70–3.53] vs. 1.27 [0.46–3.03] mg/mmol), HDL cholesterol (HDL-C; 1.05 [0.95–1.25] vs. 1.00 [0.81–1.20] mmol/L), triglycerides (1.65 [1.12–2.19] vs. 1.49 [1.07–2.36] mmol/L) and glucose (5.2 [4.5–6.0] vs. 5.2 [4.7–5.8] mmol/L), respectively, for POC and laboratory methods. Median HbA1c (5.6% [5.3–6.0%] vs. 5.5% [5.3–6.1%]) and total cholesterol (4.4 [3.8–5.0] vs. 4.4 [3.8–5.1] mmol/L) did not differ significantly. Bland–Altman analyses showed statistically significant (but not clinically meaningful) variation in the measurement difference across analyte concentration for all measures except ACR and total cholesterol. Conclusion POC instruments provided a reliable alternative to conventional laboratory methods for screening for chronic disease risk factors in locations remote from urban centres.

Background Early detection of developmental problems is important for facilitating access to targeted intervention and maximising its positive effects. The later problems are identified, the more likely that they will become increasingly difficult to ameliorate. Standardised developmental screening tools are known to improve detection rates of developmental problems compared to clinical judgement alone and are widely recommended for use with all children. The Ages and Stages Questionnaire (ASQ-3) is a tool that is widely used in Australia. However, mainstream screening tools may not be appropriate for remote-dwelling Australian Aboriginal children. While Australian Aboriginal children face multiple developmental risk factors, there are no developmental screening tools that have been validated for use in this population. Aims To determine the concurrent validity of the culturally adapted ASQ-3 – the ASQ-TRAK – for Australian Aboriginal children compared to the Bayley Scales of Infant and Toddler Development (Bayley-III), a standardised, professionally administered developmental assessment. Subjects The ASQ-TRAK and Bayley-III were administered cross-sectionally to 67 Central Australian Aboriginal children between 2 and 36months of age. Results The ASQ-TRAK communication, gross motor, fine motor and problem-solving domains and the corresponding domains on the Bayley-III were moderately correlated. Overall sensitivity for the ASQ-TRAK was 71% (95% CI 29–96) and specificity was 92% (95% CI 88–99). Percentage agreement between the ASQ-TRAK and the Bayley-III was 90%. Conclusions The ASQ-TRAK shows promise as a tool that can be used to improve developmental monitoring for remote dwelling Australian Aboriginal children. Further research is necessary to build on the current findings.

This paper presents findings from the rural and remote road safety study, conducted in Queensland, Australia, from March 2004 till June 2007, and compares fatal crashes and non-fatal but serious crashes in respect of their environmental, vehicle and operator factors. During the study period there were 613 non-fatal crashes resulting in 684 hospitalised casualties and 119 fatal crashes resulting in 130 fatalities. Additional information from police sources was available on 103 fatal and 309 non-fatal serious crashes. Over three quarters of both fatal and hospitalised casualties were male and the median age in both groups was 34 years. Fatal crashes were more likely to involve speed, alcohol and violations of road rules and fatal crash victims were 2½ times more likely to be unrestrained inside the vehicle than non-fatal casualties, consistent with current international evidence. After controlling for human factors, vehicle and road conditions made a minimal contribution to the seriousness of the crash outcome. Targeted interventions to prevent fatalities on rural and remote roads should focus on reducing speed and drink driving and promoting seatbelt wearing.

Direct observation of health professionals is recognised as the ‘gold standard’ for monitoring hand hygiene compliance. Trained and validated auditors directly observe health professionals’ hand hygiene behaviours, and assess their compliance with standard guidelines. In June 2010, a hand hygiene program that coincided with the adoption of the National Hand Hygiene Initiative (NHHI), including the Five Moments for Hand Hygiene, was introduced into a rural health service district in Australia. Infection prevention and control representatives from each inpatient facility within the district attended hand hygiene auditor training during a 2-day face-to-face workshop using standard models and training materials. The district infection control practitioner and a representative from the jurisdiction's infection prevention and control unit conducted the workshop. The success of the program has been variable, particularly at the institutional level. In part, this has been due to a lack of administrative leadership and refusal by Directors of Nursing in some facilities to site the alcohol-based hand hygiene product at the point of care. At the individual level, not all representatives have achieved the benchmark set by the NHHI for validation of auditors, with some reporting difficulty grasping the definitions and methodology of auditing. The subsequent process of re-training auditors has been resource-intensive due to the significant physical distance between facilities and limited on-site resources. These challenges and difficulties have brought into question the sustainability of the NHHI model for a geographically vast health service district. This paper examines the implementation of a nationally sanctioned hand hygiene program in a rural and remote health service district, and proposes a novel model for monitoring hand hygiene compliance in such settings.

A decision-making model was constructed to assist remote Australian Indigenous communities select appropriate climate change mitigation programs. The Resilient Community and Livelihood Asset Integration Model (ReCLAIM) comprises six steps that focus on community assets and aspirations. The second of these steps is to determine the baseline carbon profiles of communities based on six sources of carbon emissions: materials, construction processes, stationary energy, transport, water systems and waste. The methodology employed an annualised lifecycle analysis of housing materials and construction, and an annual inventory of other emission sources. Profiles were calculated for two remote communities and compared to the Australian average and also average electricity consumption by remote communities in the Northern Territory. The results, expressed in tonnes of carbon dioxide equivalent (tCO2-e), showed that average household carbon profiles of the two communities (6.3 and 4.1 tCO2-e/capita/yr) were generally lower than the Australian average (7.3 tCO2-e/capita/yr). The stationary energy results revealed that infrastructure and building design could raise fuel consumption and costs, and therefore carbon emissions, despite modest lifestyles. The carbon emission categories differed between the two communities highlighting the need for an individualised approach to understanding the drivers of carbon emissions and mitigation responses.

This report examines oral health and access issues relating to Australian adults living in rural and remote locations. Findings at the population level are presented from the series of National Dental Telephone Interview Surveys, and the associated Dental Satisfaction Surveys conducted in 1994, 1995 and 1996. These data include adults who have a government concession card (who may be eligible for public-funded dental care), and those who do not. The findings are not restricted by time since last dental visit, and include adults who have not made a recent dental visit. Population estimates are presented on oral health status, access to services, social impact and economic factors, and dental satisfaction. Findings are also presented for Australian adults who reported that they possessed or were covered by a government concession card which would allow them to access public-funded dental care. The same indicators which were used for the general population were also reported in the chapter which is specifically related to card-holders. Also presented are findings related to patients receiving public-funded dental care. These data were obtained from the Prospective Adult Dental Programs Survey in 1995–96. Public-funded dental care may include care provided at public dental clinics as well as care provided by private practitioners to eligible patients that is paid for by public funds. Estimates are presented on the type of care received, oral health status, and services provided.

This paper reviews the role of predominantly nurse-led, multidisciplinary, chronic heart failure management programs as part of the gold-standard management of patients discharged from hospital with this syndrome. It discusses the various options for applying these evidence-based programs and how they apply to the management of those living in rural/remote Australia. Specifically, it describes the challenges of applying CHF management in remote settings and how face-to-face, family based programs of care might be particularly effective from an Indigenous perspective. Finally, it describes ongoing research to determine the best approach to CHF management in remote settings.

Background Rates of overweight and obese Australians are high and continue to rise, putting a large proportion of the population at risk of chronic illness. Examining characteristics associated with preference for a work-based weight-loss program will enable employers to better target programs to increase enrolment and benefit employees' health and fitness for work. Methods A cross-sectional survey was undertaken at two Australian mining sites. The survey collected information on employee demographics, health characteristics, work characteristics, stages of behavior change, and preference for workplace assistance with reaching a healthy weight. Results A total of 897 employees participated; 73.7% were male, and 68% had a body mass index in the overweight or obese range. Employees at risk of developing obesity-related chronic illnesses (based on high body mass index) were more likely to report preference for weight management assistance than lower risk employees. This indicates that, even in the absence of workplace promotion for weight management, some at risk employees want workplace assistance. Employees who were not aware of a need to change their current nutrition or physical activity behaviors were less likely to seek assistance. This indicates that practitioners need to communicate the negative effects of excess weight and promote the benefits of a healthy lifestyle to increase the likelihood of weight management. Conclusion Weight management programs should provide information, motivation. and trouble-shooting assistance to meet the needs of at-risk mining employees, including those who are attempting to change and maintain behaviors to achieve a healthy weight and be suitably fit for work.

Background: Australians living in rural and remote areas experience poorer access to primary health care (PHC) and poorer health outcomes compared to metropolitan populations. Current health reform in Australia aims to ensure all Australians, regardless of where they live, have access to essential PHC services. However, at a national level policy makers and health planners lack an evidence-based set of core PHC services to assist in implementing this goal. Methods: A Delphi method was used to reach consensus on an evidence-based list of core PHC services to which all Australians should have access and their necessary support functions. Experts in rural and remote and/or Indigenous PHC, including policy-makers, academics, clinicians and consumers, were invited to consider a list of core services derived from the literature. Results: Thirty nine experts agreed to participate. After three survey rounds there was a strong consensus (≥80% agreement) on core PHC services namely;‘care of the sick and injured’, ‘mental health’, ‘maternal/child health’, ‘allied health’, ‘sexual/reproductive health’, ‘rehabilitation’, ‘oral/dental health’ and ‘public health/illness prevention’; and on the PHC support functions of; management/governance/leadership’, ‘coordination’, ‘health infrastructure’, ‘quality systems’, ‘data systems’, ‘professional development’ and ‘community participation’. Themes emerging from qualitative data included challenges in providing equitable PHC in rural and remote areas, the importance of service coordination and diverse strategies to overcome access barriers. Conclusion: This study identifies a basket of PHC services that consumers in rural and remote communities can expect to access. It provides rigorously derived evidence that will contribute to a more systematic approach to PHC service planning and availability and will assist policy makers in the allocation of scarce resources necessary to improve the health outcomes of residents of rural and remote areas.

Heart failure (HF) remains a condition with high morbidity and mortality. We tested a telephone support (TS) strategy to reduce major events in rural and remote Australians with HF, who have limited healthcare access. TS comprised an interactive telecommunication software tool (Telewatch) with follow-up by trained cardiac nurses.

Understanding the links between resource dependence and socio-economic wellbeing has long been a subject of interest amongst social scientists in North America. By contrast, relatively few Australian studies exist on this topic. This is despite the significant role of resource industries in shaping Australia's economic and social geography. Where research has been undertaken it tends to focus on the experience of a single town or region. This paper presents a cross-sectional analysis of socio-economic performance across 33 small mining towns in Western Australia. We design and test a number of empirical models that are hypothesised to account for the variability in socio-economic performance across different resource industry contexts. The results of the analysis suggest that socio-economic wellbeing in these towns is highly variable, and contingent on a range of factors including the nature of the particular commodity, company structure, and location.

Objective The aim of this work was to understand the pattern and outcomes for heart failure (HF)–related hospitalization among Indigenous and non-Indigenous patients living in Central Australia. Methods and Results A retrospective analysis of administrative data for patients presenting with a primary or secondary diagnosis of HF to Central Australia's Alice Springs Hospital during 2008–2012 was performed. The population rate of admission and subsequent outcomes (including mortality and readmission) during the 5-year study period were examined. A total of 617 patients, aged 55.8 ± 17.5 years and 302 (49%) female constituted the study cohort. The 446 Indigenous patients (72%) were significantly younger (50.8 ± 15.9 vs 68.7 ± 14.9; P < .001) and clinically more complex compared with the non-Indigenous patients. Annual prevalence of any HF hospitalization was markedly higher in the Indigenous population (1.9%, 95% CI 1.7–2.1) compared with the non-Indigenous population (0.5%, 95% CI 0.4–0.6); the greatest difference being for women. Overall, non-Indigenous patients had poorer outcomes and were significantly more likely to die (P < .0001), but this was largely driven by age differences. Alternatively, Indigenous patients were significantly more likely to have a higher number of hospitalizations, although indigeneity was not a predictor for 30- or 365-day rehospitalization from the index admission. Conclusion The pattern of HF among Indigenous Australians in Central Australia is characterized by a younger population with more clinically complex cases and greater health care utilization.

For a short period in the mid 1970s a conjunction of exceptional circumstances allowed the community of Wirliyajarrayi.

Growing Our Own is an innovative and unique program for Initial Teacher Education (ITE) in the remote Northern Territory. As a partnership between Catholic Education, Northern Territory (CENT) and Charles Darwin University (CDU), lecturers travel to remote Indigenous communities to deliver unit content to local 'Assistant Teachers’ enrolled in the Bachelor of Education: Primary degree. However, it is much more than an effective scheduling exercise; the program has been intentionally established to function under the ‘two way’ pedagogy whereby the pre-service teachers, their mentors and lecturers engage in a process of epistemological dialogue and exchange. There is also a place-based emphasis, with a clear pattern of teaching ‘on country’. Overall, such a process of genuine negotiation to incorporate localised Indigenous Language and Knowledge within the Australian Curriculum is opening up new and exciting possibilities for (school) student learning and a tertiary Indigenous ‘standpoint’. Growing Our Own was established in 2009 and has been refined over the years to meet the increasing demands on Initial Teacher Education and local community desires. This paper is both a report concerning the successes of the program thus far and a critical reflection on some of the key findings that have evolved in regards to such a ‘two way’, place-based, Indigenous andragogic approach.

Wik people on Cape York Peninsula in Queensland, Australia, have been granted native title over 18,500 km2 of customary land. This was seen as a coup by Wik people and it appears that they have a relatively unencumbered right to manage a large proportion of this land, including for commercial timber production. However, economists of the private property rights tradition are of the view that the inalienable and communal nature of native title presents an obstacle to economic development in remote indigenous communities that will prevent the land from being managed in an economically and ecologically efficient manner, and preclude the land from realising its full market value. This negative view has risen to prominence in Australia and privatisation of the indigenous land estate is being debated. In this paper, it is argued that privatising Australian native title land will not suddenly provide conditions where indigenous enterprise will flourish, nor will it necessarily maximise resource use efficiency where cultural and ecological values are important. For the Wik and other indigenous Australians, factors such as their low Western education and skill levels, poor health, limited financial resources, complex social environment, the remoteness and low productive capacity of their land, and the high importance of non-pecuniary land management objectives, are more important impediments to economic development than the broad type of property right held over natural resources.

Adequate health workforce alone will not ensure optimal health service access. We consider what an effective and sustainable health system for rural and remote Australia might look like in 2025, briefly describe some of the barriers to achieving this vision and propose how these challenges may be overcome. More radical change is required on at least four fronts: changing the prevailing ethos about rural and remote health; addressing persistent gaps in workforce education and training; delivery of comprehensive service models; and accountability.

Objective: To describe the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of primary health care (PHC) service delivery in rural and remote Australia. Design: Case-study approach, including review of relevant literature, interviews with key informants, site visits and direct observation. Thematic analysis and template analysis were used with interview transcripts. An expert reference group provided feedback and advice on policy relevance. Setting and participants: Six PHC services in small communities across rural and remote Australia were selected based on results of a previous systematic review; they reflected diverse rural and remote settings and PHC models, and the multidisciplinary nature of PHC. Sites were visited, and 55 individuals associated with the establishment and operation of these services were interviewed between July 2006 and December 2007. Results: Independent and template analysis confirmed the usefulness of a conceptual framework, which identified three key “environmental enablers” — supportive policy; federal and state/territory relations; and community readiness — and five essential service requirements — governance, management and leadership; funding; linkages; infrastructure; and workforce supply. Systematically addressing each of these factors improves effectiveness and lessens the threat to service sustainability. Conclusions: Evidence from existing effective rural and remote PHC services can inform the health care reform agenda, in Australia and other countries. The evidence highlights the need for improved governance, management and community involvement, as well as strong, visionary political leadership to achieve a more responsive and better coordinated health system which could help eliminate existing health status differentials between cities and rural areas. In Australia, establishment of a single national health system, operationalised at a regional level, would obviate much of the current inefficiency and poor coordination.

Introduction A case of life threatening envenoming by a wild specimen of the inland taipan, Oxyuranus microlepidotus, is described. There have been 11 previously well-documented envenomings by O. microlepidotus, but only 2 were inflicted by wild snakes. Envenomed patients have presented predominantly with defibrinating coagulopathy and neurotoxicity. Case report The victim was seeking to observe members of an isolated population of this species and was envenomed while attempting to photograph an approximately 1.5 m specimen. He reported feeling “drowsiness” and blurred vision that progressed to ptosis; he later developed dysphagia and dysarthria. The patient was treated with 1 vial of polyvalent antivenom, which was later followed with an additional two vials of taipan monovalent. He was intubated during retrieval, and recovered after 3 days of intensive care. He had a right ophthalmoplegia that persisted for approximately 1 week post-envenoming. Despite a positive 20-min whole blood clotting test, defibrination coagulopathy was absent, and there was no myotoxicity, or acute kidney injury. Discussion Physicians presented with a patient envenomed by O. microlepidotus should remain cognizant of the possible variability of medically important venom toxins in some populations of this species. Some patients seriously envenomed by this species may develop persistent cranial nerve palsies. When clinically indicated, prompt provision of adequate antivenom is the cornerstone of managing O. microlepidotus envenoming. Rapid application of pressure-bandage immobilization and efficient retrieval of victims envenomed in remote locales, preferably by medically well-equipped aircraft, probably improves the likelihood of a positive outcome.

The technical, economic and environmental aspects of small-scale desalination units powered by renewable energies for remote areas have received considerable attention in recent years. However, social aspects of such units have often been neglected resulting in abandoned and dysfunctional systems. This paper considers the potential of the reverse osmosis solar installation (ROSI) to be integrated at a number of different sites in Central Australia. Performance is evaluated against attributes of social sustainability, such as the unit's capacity to meet community water needs (both quality and quantity), the human resources available to operate and maintain the unit and the community response to the unit. From this preliminary evaluation, a number of operation and management recommendations relating to membrane choice, recovery rate and maintenance provision are made to ensure the potential offered by ROSI is fulfilled in a socially sustainable manner. Areas requiring further research are also identified.

People living in remote areas often experience problems accessing palliative care services, and yet there is a dearth of research examining these problems. A review of the limited literature on this topic highlights the assumption that poor access to services is chiefly a product of remoteness, or geography. This paper will argue, however, that previous studies have reacted to remoteness by focusing on a discourse of ‘needs and deficits’, which draws attention away from developing a body of remote area palliative care knowledge. The suggestion will be made that overemphasis of remoteness as the limiting factor has created a mind-set that extrapolates geographical limitations to people and, that such extrapolations are oppressive. Moreover, an over reliance on a simplistic and binary view of remote cultures, has shifted attention away from an examination of the real capacity of remote communities to aid in developing their own palliative care service. In exposing this as a distraction, this paper highlights the importance of understanding remote communities as heterogeneous entities separate from urban communities, and able to develop and use palliative care services based on the principle of community capacity.

This cross-cultural qualitative study examined the ethical, language and cultural complexities around offering fetal anomaly screening in Australian Aboriginal communities. There were five study sites across the Northern Territory (NT), including urban and remote Aboriginal communities. In-depth interviews were conducted between October 2009 and August 2010, and included 35 interviews with 59 health providers and 33 interviews with 62 Aboriginal women. The findings show that while many providers espoused the importance of achieving equity in access to fetal anomaly screening, their actions were inconsistent with this ideal. Providers reported they often modified their practice depending on the characteristics of their client, including their English skills, the perception of the woman's interest in the tests and assumptions based on their risk profile and cultural background. Health providers were unsure whether it was better to tailor information to the specific needs of their client or to provide the same level of information to all clients. Very few Aboriginal women were aware of fetal anomaly screening. The research revealed they did want to be offered screening and wanted the ‘full story’ about all aspects of the tests. The communication processes advocated by Aboriginal women to improve understanding about screening included community discussions led by elders and educators. These processes promote culturally defined ways of sharing information, rather than the individualised, biomedical approaches to information-giving in the clinical setting. A different and arguably more ethical approach to introducing fetal anomaly screening would be to initiate dialogue with appropriate groups of women in the community, particularly young women, build relationships and utilise Aboriginal health workers. This could accommodate individual choice and broader cultural values and allow women to discuss the moral and philosophical debates surrounding fetal anomaly screening prior to the clinical encounter and within their own cultural space.

Objective: To provide data on the career trajectories of medical students from rural and remote workforce programs at Flinders University (the Parallel Rural Community Curriculum [PRCC] and the Northern Territory Clinical School [NTCS]), comparing them with students at the urban Flinders Medical Centre (FMC). Design: Retrospective postal survey of all 150 graduates who undertook their Year 3 study in the period 1998–2000. Outcome measure: Associations with career preference, assessed using univariate analyses and multivariate regression. Results: PRCC and NTCS graduates were more likely to choose rural career paths than graduates from FMC. The odds ratios were 19.1 (95% CI, 3.4–106.3; P < 0.001) and 4.3 (95% CI, 1.2–14.8; P = 0.026), respectively, after adjusting for age and rural background. There was no difference in the specialty choices of graduates of the three programs. Conclusion: This study provides evidence that clinical attachments designed to increase the rural and remote medical workforce do fulfil this objective.