In some rural and remote locations in New South Wales and elsewhere in Australia, a limited range of radiographic examinations may be performed by nurses and general practitioners if there is no radiographer available. These so called remote x-ray operators are licensed under the New South Wales Radiation Control Act 1990. This study aimed to investigate the experiences and perceptions of remote x-ray operator radiography and examine the role of remote operators in New South Wales from the perspective of a cohort of rural radiographers and nurse and GP remote x-ray operators involved in frontline delivery of rural radiographic services. Methodology Semi-structured in-depth interviews were performed with twenty rural radiographers, ten rural nurses and seven rural general practitioners from various rural communities in New South Wales. Interview questions explored the informants’ knowledge, opinions and values, experience and behaviour, and attitudes and feelings in relation to remote x-ray operator radiography. Interviews were tape-recorded and transcribed. Data analysis was subsequently performed using an iterative process based on a modified grounded theory methodology. Data labelling and comparative analysis were carried out in parallel with data collection, allowing progressive modification of the interview theme list to ensure that theoretical saturation was achieved. Results Data analysis led to the emergence of three key concepts, together with their relevant themes and sub-themes. The primary key concept, ‘Dimensions of Practice’, was inclusive of the central precepts of remote x-ray operator radiography. It includes themes titled ‘Licence Conditions and Limitations’, ‘Competency Requirements’ and ‘Image Quality and Practice Standards’. The key concept of ‘Service Provision and Equity of Access’, represents the realities of clinical practice in the rural and remote health care setting. It includes themes of ‘Clinical Management and Decision Making’, ‘Access and Availability’, ‘Patient Expectations’ and ‘Commitment to Service’. The third key concept is ‘Professional Roles and Relationships’, which deals with the interactions that take place between individual practitioners and the factors that influence them. It encompasses the xii themes of ‘Boundary Delineation’, ‘Professional Status and Esteem’ and ‘Interprofessional Conflict and Collaboration’. Relationships between the key concepts, via their themes and sub-themes were also explored. Conclusions Analysis of the data led to the development of a conceptual model and a single story line that represent the perspectives of the study informants. Remote x-ray operator radiography takes place at the intersection of the occupational worlds of rural radiographers, nurses and general practitioners. Remote operators provide a valuable service that prevents rural residents having to travel to access minor radiographic examinations. However, the quality of the radiography they perform is below the standard expected of radiographers. Improvements in collaborative teamwork could improve the quality of service, although interprofessional communication is stifled by status and hierarchical relationships. The remote x-ray operator experience may inform the development of future models of health care. / PhD Doctorate

This study was conducted in the context of health service planning in an environment of changing government strategies for regional, rural and remote area health care and telecommunications infrastructure planning in Western Australia. The study provides an account of the State Government of Western Australia’s planning for the implementation of a telecommunications network infrastructure, and specifically the Telehealth Project, conducted between 1998 and 2002. The purpose of this study was to examine influences on community participation in planning within the dynamic political, economic and social forces that impact on the development of regional, rural and remote area health services. Specifically, the study outlines the issues and barriers in providing for significant local participation in projects that are centrally initiated and controlled. It examines the influences in planning for projects that incorporate local community based beliefs and needs, the requirements of collaborating with multiple state and national government departments, and the private sector. This study was situated within the interpretive paradigm, and is conceptualised within Donabedian’s (1969) framework for assessing and assuring quality in health care. The methodological approach is bound within a case study and consists of a participatory action research approach. The research method uses the single case to undertake in-depth interviews, observations and a survey to collect data from community, government and industry members as a basis for reflection and action. The findings of the study clearly indicated that there was consensus between all rural, remote and metropolitan area participants that telecommunications did offer the opportunity to provide increased, improved or alternative health services. However, there were a number of obstacles to the success of the planning process, including a lack of local community inclusion in planning committees, poor communication within central government agencies, overuse of external consultants, a bias toward the medical view, a limited scope of invitation to contribute, and local information being overlooked in the final implementation plan. Analysis of planning for the Telehealth Project reveals the implications of organisational and political stakeholders making final decisions about outcomes; and provides a reminder of the importance of engaging communities authentically when planning for health and telecommunications services which involve the public and private sectors. The originality and significance of this study stems from understanding how technology can advance community health; through measures such as the use of community participation strategies, through authentic community based leadership, truly representative participants, decentralised decision making, a focus on community based health needs and change management strategies that include all of these. Consequently, the study advances knowledge of community participation in planning, and the evidence suggests implications for practice, education and further research.

Introduction The Northwest Territories as a rural and remote region of Canada has higher colorectal cancer rates and lower uptake of colorectal cancer screening compared to the rest of the country. Understanding the complex health system processes involved in screening is necessary to develop informed solutions to improve screening access amongst marginalized populations. A systems approach to describe and understand the health care processes and system-level factors influencing colorectal cancer screening access was undertaken. Methods Semi-structured interviews with health care providers (N=29) involved in colorectal cancer screening in all health authorities within the Northwest Territories (N=8) were performed from September to December 2015. Interview transcripts were analyzed using qualitative content analysis methods within a Collaborative Information Behaviour (CIB) and Continuity of Care framework. Exploratory models of colorectal cancer screening processes were developed and translated into quantitative parameters for simulation modelling. Results Colorectal cancer screening access was defined by patient health care interactions supported by foundational information processes. Eighteen models of colorectal cancer screening access within the territory were identified, with varying complexity in care access seen across communities. Screening access problems included screening initiation, colonoscopy scheduling, screening recall and information silos, and were influenced by multiple contextual factors including a transient health work force, social health determinants, and patient travel. Qualitative models were translated into a system dynamics (SD) design framework for development of further quantitative modeling. Conclusions Colorectal cancer screening access in the Northwest Territories is a complex process comprising patient interactions and information processes linking primary care and hospital care processes, which are influenced by challenging contextual factors in the rural and remote health care environment. In developing screening access solutions the foundational role of information support and the need for system trade-offs in restructuring health system processes are necessary considerations. Optimizing information processes through the utilization of health informatics tools such as standardized referral forms and EMRs may also support health system transformation to improve screening access across the Northwest Territories. Understanding and evaluating system trade-offs may be best achieved using a combination of qualitative and quantitative modeling through future application of SD modeling research.

The Sachigo Lake Wilderness Emergency Response Education Initiative represented a partnership between Sachigo Lake First Nation in northern Ontario Canada, and medical professionals and university researchers from outside the community. This study was one component of a larger community-based participatory research program to develop locally relevant first response training to address the isolation from emergency healthcare in Sachigo Lake. The aim of this qualitative study was to complete a formative evaluation to understand how a five-day comprehensive training course implemented in May 2012: (a) met the local needs of Sachigo Lake; and (b) fostered resilience and community capacity. The results of this study describe the unique features of delivering first aid training in a remote context and illustrate the intrapersonal and interpersonal impacts of the program. Health promotion through community based first aid education is a model with potential to improve emergency care in the absence of formal emergency medical services.

Applications of Telehealth in the practice, upgrading of knowledge, and communication of physicians with their colleagues and patients in Canada was explored in this study. The research used exploratory-grounded theory to investigate the opinions of practicing clinicians regarding the use of Telehealth. The study involved conducting semi-structured interviews with physicians who were using or might in the future use Telehealth in their practice. This study was designed to assess the major advantages and shortcomings that Telehealth has to offer in the field of medicine. The research found that clinicians predominantly had a very positive view of Telehealth, although some minor concerns were expressed with respect to the use of Telehealth in private offices and the home (rather than in the hospital). The data indicated that Telehealth can improve overall patient care by bettering the speed and accuracy of communication and diagnosis and the subsequent treatment of patients, saving physicians and patients time and money, reducing waiting lists, aiding the environment, reducing emergency visits and hospitalizations, addressing shortages of physicians (particularly in rural areas), increasing access to specialists, and enabling convenient distance education. These are just some of the many benefits of Telehealth which outweigh its disadvantages. This study also was designed to extract clinicians’ opinions on avenues for improving Telehealth, which thus led to implications for future research. Barriers to the use of Telehealth were found to include concerns about security and IT support, lack of public knowledge of Telehealth’s existence, and installation and maintenance costs for the necessary equipment in the private sector. The study suggests that Telehealth will become more widely available and accessible to the general public. The study also proposes that, through increased governmental support and funding, Telehealth should be advertised and promoted, researched in more depth (in part, to discourage misconceptions regarding Telehealth), collaborated on by stakeholders, and expanded. / Graduate

Maldistribution of healthcare professionals persists in remote and rural communities throughout the world. Adoption of a Community Paramedic (CP) program could improve access to quality healthcare for rural communities. The conceptual framework defined rural communities by their distinct characteristics — community efficacy, weaknesses, attitudes, assets, deficits, local culture, and the driving and restraining forces — and not defined by their small populations or distances to cities. The theoretical foundation was a synthesis of theories of Bandura, Rogers, and Lewin. This study assessed community characteristics that may influence the likelihood of success, sustainability, or program failure of the Australian CP model in a single remote Texas border community. In this qualitative formative bounded case study, 3 bounded groups were examined; data collection was by in-person interviews. Group members were purposively selected: 5 residents and 3 EMS members. The 3rd group consisted of 4 randomly self-selected resident interviews, field observations, news articles, and local social media. Data transcripts were coded using theoretical coding based on the conceptual framework and theoretical foundation. Strong individual and group efficacy, efficacy resilience, adaptability, strong communications, overlapping groups, and a strong sense of community program ownership were evident in this study. The probability of establishing an effective CP program based on the Australian model is high based on study findings. Improved access to quality healthcare in remote and rural communities could result in improved health of community members and significant social change.

Rural and remote areas of Australia remain the last bastion of health disadvantage in a developed nation with an enviable health score-card. During the last ten years, rural and remote health has emerged as a significant issue in the media and the political arena. This thesis examines print media, policy documents and interviews from selected informants to ascertain how they represent medical practitioners and health services in rural and remote areas of Australia, why they do so, and the consequences of such positions. In many of these representations, rural and remote medical practitioners are aligned with national and cultural mythologies, while health services are characterised as dysfunctional and at crisis point. Ostensibly, the representations and identity formulations are aimed at redressing the health inequities in remote rural and Australia. They define and elaborate debates and contestations about needs and claims and how they should be addressed; a process that is crucial in the development of professional identity and power (Fraser; 1989). The research involves an analysis and critical reading of the entwined discourses of culture, power, and the politics of need. Following Wodak and others (1999), these dynamics are explored by examining documents that are part of the discursive constitution of the field. In particular, the research examines how prevailing cultural concepts are used to configure the Australian rural and remote medical practitioner in ways that reflect and advance socio-cultural hegemony. The conceptual tools used to explore these dynamics are drawn from critical and post-structural theory, and draw upon the work of Nancy Fraser (1989; 1997) and Ruth Wodak (1999). Both theorists developed approaches that enable investigation into the effects of language use in order to understand how the cultural framing of particular work can influence power relations in a professional field. The research follows a cultural studies approach, focussing on texts as objects of research and acknowledging the importance of discourse in the development of cultural meaning (Nightingale, 1993). The methodological approach employs Critical Discourse Analysis, specifically the Discourse Historical Method (Wodak, 1999). It is used to explore the linguistic hallmarks of social and cultural processes and structures, and to identify the ways in which political control and dominance are advanced through language-based strategies. An analytical tool developed by Ruth Wodak, Rudolf de Cillia, Martin Reisigl and Karin Leibhart (1999) was adapted and used to identify nationalistic identity formulations and related linguistic manoeuvres in the texts. The dissertation argues that the textual linguistic manoeuvres and identity formulations produce and privilege a particular identity for rural and remote medical practitioners, and that cultural myth is used to popularise, shore up and advance the goals of rural doctors during a period of crisis and change. Important in this process is the differentiation of rural and remote medicine from other disciplines in order to define and advance its political needs and claims (Fraser, 1989). This activity has unexpected legacies for the rural and remote health sector. In developing a strong identity for rural doctors, discursive rules have been established by the discipline regarding roles, personal and professional characteristics, and practice style; rules which hold confounding factors for the sustainability of remote and rural medical practice and health care generally. These factors include: the professional fragmentation of the discipline of primary medical care into general practice and rural medicine; and identity formulations that do not accommodate an ageing workforce characterised by cultural diversity, decreasing engagement in full time work, and a higher proportion of women participants. Both of these factors have repercussions for the recruitment and retention of rural and remote health professionals and the maintenance of a sustainable health workforce. The dissertation argues that the formulated identities of rural and remote medical practitioners in the texts maintain and reproduce relationships of cultural, political and social power. They have also influenced the ways in which rural and remote health services have been developed and funded. They selectively represent and value particular roles and approaches to health care. In doing so, they misrepresent the breadth and complexities of rural and remote health issues, and reinforce a reputational economy built on differential professional and cultural respect, and political and economic advantage. This disadvantages the community, professions and interest groups of lower value and esteem, and other groups whose voices are often not heard. Thus, regardless of their altruistic motivations, the politics of identity and differentiation employed in the formulated identities in the texts are based on an approach that undermines the redistributive goals of justice and equity (Fraser 1997), and works primarily to develop and advantage the discipline of rural medicine.

<p dir="ltr">Digital Health technologies have revolutionized healthcare delivery, offering innovative solutions that enhance access, improve patient outcomes, and optimize the use of resources. Despite this advancement, health outcomes remain disparate across different social groups, with underprivileged populations at an increased risk of poor health outcomes due to inadequate access to care. Digital Health technologies serve as a critical intervention in mitigating these disparities, particularly for groups affected by geographical, economic, and infrastructural barriers.<br><br>The purpose of this study was to conduct a review of the current state of Digital Health technologies, including Software as a Medical Device (SaMD), Wearable Health, Portable Diagnostic Devices, and remote care platforms, and their impact on healthcare accessibility. Employing qualitative methodology, this metasynthesis emphasized an important discovery: the need for a paradigm shift among stakeholders in healthcare towards integrated and digitally-driven patient care. This shift requires more than just an understanding of new technologies. It demands a fundamental re-evaluation of patient care methods and the orchestration of the entire healthcare system towards integrated digital practices. Importantly, this study found that the pace of digitalization must be carefully managed and cultural factors must be considered and signals the urgency for a balanced approach to digital integration in healthcare.</p>