Rural health in Aotearoa New Zealand: current state and future challenges

Just over a year ago Aotearoa New Zealand (NZ) launched its first ever Rural Health Strategy¹ with a vision that all people living in rural communities should live long and healthy lives, supported by a health system that meets the varied needs of these communities and draws on the strengths and knowledge of rural communities to achieve pae ora – healthy futures for all.² A major challenge, though, for the strategy’s implementation will be to ensure that it is driven by rural communities for rural communities, and not be led by urban voices. The elephant in the room is ‘geographical narcissism,’ where rural experience is both devalued and ‘othered’ by the urban world.³ Putting it in plain English: urban always knows best, and those living and working rurally feel they need to defer to their betters.

Both our two guest editorials use the concept of geographical narcissism to help understand and address the challenges facing rural health. Nixon⁴ addresses the current state and future direction of academic rural health. His argument is that successful academic rural health requires its practitioners to both practice and research in rural communities. He notes that we only need to look across the ditch to see the benefits that have accrued from Australian government investment in health professional education and research in rural and regional communities. He ends with a question: is it possible to properly deliver health professional education and research in rural NZ without first addressing funding models? Eggleton,⁵ in contrast, uses an urban norm-critical approach in his reframing of rural health inequities. He argues that this reframing requires a focus on urban privilege and power, the discourse of representation needs to be challenged – there is no ‘one’ rural voice – and that rural needs to be centred as ‘normal.’ Rural health also specifically features as a research paper in this issue. Ram and colleagues⁶ explored community views on the role of their rural hospital with a high Māori and Pacific population. A key finding was that the local contextual knowledge of rural hospital providers facilitates personalised, family-centred and culturally responsive care.

Rural health remains a priority for the current coalition government with the launch of a number of initiatives, notably a national rural telehealth service.⁷ It is therefore timely that Reid and Moerenhout^8,9 have conducted two linked studies addressing how virtual consultation services, such as telehealth, can be assessed from an ethical perspective. In the first study,⁸ they conducted a scoping review of academic and policy documents to determine the core ethical challenges arising from virtual consultations. They then conducted a qualitative analysis to translate the main ethical themes and subthemes into a practical ethical checklist to assess virtual general practice services. In the second study,⁹ they applied the checklist to direct-to-consumer NZ virtual primary care consultation services. They conclude by highlighting that the application of this framework raises fundamental questions on how the core values of primary health care – continuity of care, equity, and comprehensive care – can be protected when virtual care becomes commonplace. In an accompanying letter to the editor,¹⁰ the Norwegian bioethicist Bjørn Hofmann points out that such checklists are very useful in identifying and addressing ethical issues with health technologies and services such as telehealth. Moving on from online consultations to online health information, Wells and colleagues¹¹ surveyed adults attending cardiology outpatients regarding their internet use for health information, preferred format and what factors helped them to trust the source. They found that found that most participants had searched for online health information after visiting a health provider and often to check side-effects of medications.

Sexual health-related issues are broad in scope, as reflected by the three papers presented in this issue. Carroll and colleagues¹² focus on the needs of transgender and non-binary young people who start gender-affirming hormone therapy in primary and secondary care. Ludlam and colleagues¹³ note that sexual orientation minorities have worse health outcomes than the heterosexual majority, but that it is not known if members of these minority groups wish to have their sexual orientation recorded on official databases. They sought to answer this question using a sample of gay and bisexual men and found that the majority of participants reported comfort with having their sexual orientation recorded confidentially on official databases. The perspectives of Māori and Pacific rangatahi on testing for sexually transmitted infections by an online service was explored by Rose and colleagues.¹⁴ They found that perceptions of online testing were mixed, and discussion about concerns outweighed perceived benefits. They conclude that for online testing to be an accessible alternative to clinic-based testing for priority populations barriers in the testing pathway need addressing, in particular cost and low awareness. Pacific voices are also the focus of Holt and colleagues’¹⁵ qualitative study exploring the worldviews, knowledge and beliefs held by Pacific peoples regarding hearing health. They conclude that Pacific peoples value the sense of hearing as it allows connection to their communities, environment, and ancestry. Hearing services can be more responsive to their needs by ensuring strong, trusting relationships are built between healthcare provider and families, ensuring physical access needs are met, and being more visible within the community setting.

The final research paper in this issue by Maddela and colleagues¹⁶ addresses the questions of who uses yoga, and who teaches yoga, in NZ. To date the answers to these questions in NZ are unknown, in contrast to other comparable countries. They found that yoga users in NZ are disproportionately NZ European, female, middle-aged and tertiary educated. They use yoga to help manage a range of long-term conditions. Likewise, most yoga instructors are female.

We regularly publish quality improvement reports and Theadom and colleagues¹⁷ present the implementation of a supported primary health care pathway for mild traumatic brain injury (mTBI), a very common condition in NZ. The pathway includes a decision support tool, funded follow-up appointments, clinician training and a patient education resource. They found that the pathway increased follow up of mTBI by health professionals and reduced the time interval between the accident occurring and assessment by concussion services. The issue is rounded off by a Cochrane Corner on whether SSRIs can help women suffering with PMS¹⁸ and Charms and Harms assesses milk thistle, a member of the daisy and sunflower family.¹⁹