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From a broom cupboard: 20 years of rural health at Monash University

Ch 06. Research

Community relevance

Emeritus Professor John S Humphreys

Research has long been acknowledged as the hallmark that distinguishes universities from many other educational institutions. From research comes the knowledge to understand the complexity of human life and the evidence upon which to formulate appropriate policies and programs designed to bring about improvement in the health and wellbeing of people.

Compared with the more established areas of medical and health research, the field of rural health research is still in its infancy both in Australia and overseas. Consequently, the scope for innovation and new discoveries (from which we are better able to understand the pattern of health and wellbeing in rural and remote areas globally) is enormous. In this regard, the Monash School of Rural Health has played a significant role in generating new knowledge relating to overcoming the rural health workforce shortage, developing innovative rural models of health care and understanding the risk determinants that underpin current rural health disadvantage.

Today, Monash University is one of the leading institutions of research and higher learning in Australia and the world. Within Monash University, the School of Rural Health has pioneered rural Australian health research aimed at bringing about improvements in the health and wellbeing of residents of rural, remote and regional communities, and is now acknowledged as a world leader in this field. Since its inception, too, the research program of the school has assisted to build the research capacity of rural health practitioners and stakeholders.

This chapter outlines the growth of rural health research within the school. Highlights include some of the main outcomes; individuals who have been instrumental in the international recognition of the research program; keys to success; and the challenges which the school will have to confront in the future.

Research development in the School of Rural Health

The need for a dedicated rural health research program emanates from the activities of key stakeholder groups such as the Rural Doctors Association of Australia, the New South Wales Rural Doctors Network, the Association of Australian Rural Nurses and the Council of Remote Area Nurses during the 1980s and early 1990s.1 These groups advocated strongly for the need to address outstanding rural health issues that had been highlighted as early as 1976 in the Hospitals and Health Commission report. It specifically featured the following: the difficulties faced by many country people in obtaining adequate health care; the shortage of doctors, dentists and other health personnel; difficulties in maintaining health facilities in many communities; and the appalling plight of Aboriginal health.2 The debate highlighted not only the comparative neglect of rural health by governments, but also the lack of understanding of these problems and why residents of rural and remote areas were characterised by a significantly poorer health status than that of their metropolitan counterparts.

The development of rural health research in the School of Rural Health was oriented towards redressing this knowledge gap and falls broadly into three phases, each of which is discussed below.

1992–2002: Establishing the Centre for Rural Health

During this period, most research activity was linked with project funding from the Commonwealth and Victorian Departments of Health and fell within four broad areas: rural health as a specific discipline; collaborative clinical research; rural health workforce recruitment and retention; and development of models of health service delivery in rural communities. Research highlights included the National Rural General Practice Study and Sustainable Models of Rural and Remote General Practice Services. Much of this research activity was closely related to the lead role assumed in government consultancies and national reviews of general practice. Research leaders at Monash during this period included Roger Strasser, Jo Wainer, Elaine Duffy, Claire Rickard, Gil Soo-Han and Peter O’Meara.

In addition to the specific research undertaken by individual staff, the Centre for Rural Health played a vitally important role in research capacity building and the dissemination of key resources for rural health research. In the early 1990s, national competitive funding was awarded to the Centre for Rural Health to lead in developing a National Rural Health Unit – later renamed the Australian Rural Health Research Institute. This unit was a collaboration between Monash University, Menzies School of Health Research Northern Territory, Charles Sturt University, the University of Western Australia and the University of South Australia, and was mandated to assume a clearing house role for rural health research, training, education and data.

Prior to the ‘take-off’ of electronic literature searches, the Centre for Rural Health also maintained a leading role in supporting and servicing the information and research needs of rural community practitioners through Literature Information Service for Australian Rural and Remote Health and the Rural Health Research Register which increased the dissemination of, and access to, publications relevant to rural health. This period also saw the development of Echidna: Health Service Profiles for Victorian Rural Regions – an electronic database of information relating to localities, health services, demographics and other health-related indicators for communities across rural Victoria.

During its early years, research staff from the Centre for Rural Health were well represented at national conferences and symposia in the dissemination of research project findings; the apogee was perhaps the centre’s representation at the invitation-only Regional Australia Summit at Parliament House Canberra, auspiced by the Deputy Prime Minister and the Department of Transport and Regional Services.

2002–2007: Research ‘take-off’ phase

In 2002, following a faculty restructure, the Centre for Rural Health became the School of Rural Health and set up a dedicated research office in Bendigo, which I led as newly appointed Professor of Rural Health Research. This development, together with the acquisition of funding to establish a Centre for Multi-Disciplinary Studies in Rural Health in Gippsland under the leadership of Elaine Duffy, enabled the consolidation of research activity around two nodes – Moe-Traralgon in Gippsland and Bendigo in the Loddon Mallee region – and provided a major impetus for research ‘take-off’. These developments paralleled funding to establish a rural clinical school network from East Gippsland to Mildura. In 2006, further funding was received to incorporate the Centre for Multi-Disciplinary Studies in Rural Health into a fully fledged university department of rural health. It was renamed MUDRIH (Monash University Department of Rural and Indigenous Health) under the directorship of Mark Oakley Browne. Under his leadership, and guided by the School of Rural Health research strategy, the rural health research platform has been significantly strengthened in Gippsland.

Research activity gained momentum, with a dramatic increase in both the publication of peer-reviewed journal articles and the acquisition of nationally competitive grants from funding bodies such as the Australian Research Council, National Health and Medical Research Council (NHMRC), and Australian Primary Health Care Research Institute. During this period the School of Rural Health was accorded a change of research status within the faculty from ‘an area targeted for development’ to that of ‘a recognised area of strength competitive with the best domestic equivalents’. The Viable Models of Rural Practice study, undertaken in conjunction with the Rural Doctors Association of Australia, exemplified the important workforce research being undertaken within the school.

During this phase, the successful development of a postgraduate research program in Traralgon by Gil Soo-Han led to the graduation of the school’s first PhD candidates, thereby increasing rural health research capacity in the region. During this time too, the school took pride in the appointment of two of its leading researchers to senior academic posts. Claire Rickard went to Tasmania and subsequently Queensland, and Gil Soo-Han to Monash Malaysia and subsequently Clayton.

At the same time, the appointment of a new professoriate in Bendigo – Professors Fiona Judd, Gordon Whyte and Peter Disler – contributed immensely to the development of a strong research culture in the region. It had strong links between researchers from the school and the newly established Centre for Rural Mental Health, a joint activity of Bendigo Health and Monash, based on the Bendigo Hospital campus and led by Professor Fiona Judd. The research team also welcomed its first epidemiologist, Dr Geetha Ranmuthagala, from the National Centre for Epidemiology and Population Health at the Australian National University.

So significant was the school’s education, training and research program that, in 2005, 40 leading medical workforce academics, policy makers and educators from the UK, Canada and USA were hosted in Bendigo at the invitation of the International Medical Workforce Collaborative. In addition, research staff from the school were instrumental in working closely with the Committee of Deans of Australian Medical Schools to set up the national Medical Students Outcomes Database and longitudinal tracking study, one of the recommendations emanating from the review of the Australian Government Rural Undergraduate Support and Coordination program.


Conference, Bendigo 2005: International medical workforce academics, policy makers and educators from the UK, Canada and USA.

2007–2012: National and international pre-eminence

The establishment of the graduate entry Gippsland Medical School and the Northern Victoria Rural Medical Education Network in 2007 were important developments that boosted research within the school. Newly appointed research leaders at the Gippsland Medical School, including Elmer Villanueva and Debra Nestel, helped consolidate the research status of the School of Rural Health in Gippsland. During this period the research reputation of the school grew to one of national and international pre-eminence. This reputation was endorsed by the Research Quality Framework assessment undertaken by the Australian Government in 2008, an evaluation process which morphed into the current Excellence of Research in Australia evaluation process.

Consistent with the University’s mandate of excellence in research, this phase also saw the consolidation of school-wide research culture – exemplified in the regular research newsletters and by a highly successful journal club that brings research staff together monthly – with a greater orientation for evidence-based research to inform policy and practice. The school’s strong presence in the policy arena was typified by invited presentations to parliamentarians in Canberra in 2010 and 2011 in relation to the rural medical workforce crisis, and the launch in Parliament House Canberra of the Australian Primary Health Care Research Institute-funded Workforce Retention study by the Minister for Rural Remote and Aboriginal Affairs, Warren Snowden.

Nationally acclaimed research achievements included the work of Marlene Drysdale who led both the Footprints Forwards: Better Strategies for the Recruitment, Retention and Support of Indigenous Students Project and the Rural Chronic Disease Initiative. The jewel in the crown was the award, in late 2010, of $3 million research funding to lead the Centre of Research Excellence in Rural and Remote Primary Health Care – a collaboration of staff from the School of Rural Health, the Flinders and Charles Darwin Universities Centre for Remote Health in Alice Springs, and the University of Sydney Department of Rural Health in Broken Hill.3 The Centre of Research Excellence was launched on 20 September 2011 in Parliament House Canberra by the Minister for Mental Health and Ageing, Mark Butler.


Launch of the Centre of Research Excellence 2011: John Humphreys (left) and the Minister for Mental Health and Ageing, Mark Butler (right).

During this phase, significant activity focused on building research capacity. Workshop support provided by staff from the Faculty of Medicine, Nursing and Health Sciences Research Office, and the promotion of opportunities for postgraduate research, paid off. Several early career researchers had increased success in obtaining research grants and the award of two International Travelling Research Fellowships. During this time, the appointment of new researchers also helped to increase the critical mass of research active staff. Research from the school established a greater international presence with research staff invited to present their findings at major national and international conferences in Scotland, Sweden, Germany and Canada.

In short, after 20 years in the making, it is clear that research within the School of Rural Health has come of age.

Significant research achievements

Research within the school has covered a very broad spectrum of issues, including studies investigating specific topics such as rural pharmacy; urgent care; telemedicine; gender issues; mental health; health service complaints; treatment and care of people with developmental disability in rural and remote communities; rural medical education; clinical studies relating to intravenous devices; stroke and osteoporosis; and numerous health policy and program evaluations.

Rural health workforce research

Researchers from the school have been actively engaged in all aspects of the rural health workforce, particularly through investigations on two key issues:

  • What aspects of medical and health education and training increase the likelihood of graduates taking up rural practice, thereby increasing the rural health workforce supply?

  • What aspects of recruitment and retention require specific policy intervention in order to ensure an adequate rural health workforce?

Several notable national studies were undertaken on rural medical education and training, factors influencing the intention of medical students to practise in rural Australia, recruitment and retention issues, international medical graduates, the roles and functions of health practitioners, and gender issues. Of particular note is the research undertaken by Dr Matthew McGrail in developing an improved ‘index of access’ to guide workforce planning in rural and remote areas.4 This innovative research has already received international acclaim.

In addition, staff have played a leading role in the development and conduct of the landmark Medical Student Outcomes Data and Longitudinal Tracking Study which is currently auspiced by the Medical Deans Australia and New Zealand and engages all Australian and New Zealand medical schools.5 This project has become a critical part of the national agenda to provide evidence for assessing which aspects of medical education and training are most influential in persuading people to take up rural practice – it is being watched with interest by international medical educators. In addition, Marlene Drysdale has led national research investigating opportunities for, and barriers to, Aboriginal student entry to medical education, with a view to developing better approaches that progress recruitment, retention and support for Aboriginal students in medicine.

The school was also a joint partner in a $2 million, five-year collaborative NHMRC grant with the University of Melbourne to undertake the Medicine in Australia: Balancing Employment and Life national longitudinal study of work–life balance for doctors.6 In 2011 this study received a further five years of funding from the NHMRC as a Centre for Research Excellence in Medical Workforce Dynamics. The research aims to improve the understanding of the determinants of decisions made by doctors on how many hours to work, where to work in terms of sector, geographic location and specialty, when to stop work temporarily or permanently, and productivity. These decisions are, in turn, a key influence on access to health care by the population, health care costs, and ultimately population health.

As a result of this workforce research, School of Rural Health researchers have played a key role in advising government on measures to improve rural health workforce recruitment and retention. Staff have contributed to several key Commonwealth Government workforce program committees that provide advice for national workforce policy development and program implementation, and their expertise has been used by the Australian Government both to undertake program evaluation and to facilitate several national workshops. One notable workshop was the Regional Australia Summit (convened by the Deputy Prime Minister) which was so instrumental in influencing the direction of government measures announced in the landmark 2000–2001 budget that delivered more than $500 million for rural health.7

Rural health services research

The demise of health care services in many rural and remote communities through health service rationalisation and centralisation has left many small communities without access to adequate health care despite their great need for it.8 Over two decades, researchers from the school have pioneered research into alternative, sustainable, innovative models of service delivery for residents of small rural and remote communities.


The longitudinal Elmore Primary Health Service study examined primary health care in a small rural community. The research team in 2008: left to right – Lisa Lavey, Karly Smith, Rachel Tham, Dr Adel Asaid, Judith Jones, Leigh Kinsman, Kathy Tuohey.

Building on several studies undertaken in small communities, the most comprehensive systematic synthesis and typology of rural health service models was published. This research has formed the basis for health service research throughout Australia and helped to set the research agenda about the requirements for sustainable rural health services. Moreover, research staff undertook the Viable Models project – one of the most comprehensive and detailed Australian investigations ever made into the economic, professional and organisation aspects underpinning the viability of rural and remote practice. More recently, in conjunction with researchers from Flinders University in Alice Springs and the Australian National University in Canberra, a comprehensive systematic review of sustainable models of primary care for small rural and remote communities was undertaken to inform policy makers about how best to deliver comprehensive primary health care to areas that currently experience significant problems accessing such services.9

Rural Australians are also disadvantaged by lack of access to comprehensive coordinated health care services. At times of emergency in particular, patients are required to undertake extensive travel to access care only available in distant regional centres, often at great personal cost. It is critically important to ensure efficient and effective pathways of care within the health system as the basis for smooth transition between primary and secondary emergency treatment, and subsequent rehabilitative care. Leigh Kinsman’s innovative research on clinical pathways and the provision of timely and appropriate emergency care in regional centres has been widely received and utilised nationally and internationally.10

Rural health risk determinants research

The explosion of chronic diseases – such as Type 2 diabetes, asthma, heart disease, lung disease, stroke, hypertension, osteoporosis, certain cancers, depression associated with chronic disease, and disabilities caused by preventable injuries – is one of the most pressing problems confronting health services throughout Australia. Chronic diseases present huge costs to the health system, significantly reduce individual quality of life, and reduce economic participation and productivity.

Rural and remote Australians experience higher rates of chronic illness and injury than metropolitan counterparts, with consequent higher morbidity and mortality. The need for effective health promotion, ill-health prevention and early intervention programs for residents of small rural and remote communities, many of which are among Australia’s most educationally and socioeconomically disadvantaged groups, is a major challenge for governments, health authorities and communities alike. Research led by Marlene Drysdale and other School of Rural Health researchers has provided the most significant platform for people in small rural communities who want to try new ways to make a difference to chronic disease at a local level.

Investigation of national priority diseases requires complex and proven methodologies in order to accurately identify their incidence, prevalence and aetiology as the basis for policy response. Significant research has been undertaken by Oakley Browne, Ranmuthugala, Villanueva, Ristevski and Mayberry, particularly in the areas of mental health, rural community epidemiological and population cohort studies, and evidence-based planning. Rickard and McGrail have also taken a lead role in examining the efficacy of interventions designed to bring about improved practice in rural health services.

Landmark research projects

Many landmark research projects have been undertaken by research staff. The studies described below all had a significant impact on national rural health policies and programs, and exemplify the importance of research in providing the evidence base upon which to formulate polices designed to overcome problems or assist in improving the health outcomes of rural and remote Australians.

National Rural General Practice study

The purpose of this study was to examine factors influencing the decisions of general practitioners in relation to undertaking general practice. Its specific objectives were to describe the nature of rural and remote area general practice, to investigate rural doctor experience and perceptions of recent initiatives aimed at improving recruitment, training and retention of rural doctors, and to explore the attitudes of rural doctors to changing rural health services.11

Viable Models project

Funded by a $2 million Commonwealth Government grant, Monash University researchers collaborated with the Rural Doctors Association to undertake the most detailed study of the determinants of viability of rural and remote practice in Australia. This project undertook a detailed analysis of the complexity and costs of general practice in different rural and remote environments. The research provided the most comprehensive empirical evidence differentiating rural from urban general practice in Australia, and set the benchmarks for practice viability in rural and remote locations. The final report was launched by Minister for Health, Tony Abbot, in November 2003 and the study had a significant impact on government policy, rural doctors and their communities.12

Elmore Primary Health Service project

The problem of ensuring sustainable, equitable and quality primary health care services for rural and remote communities is an international issue. The longitudinal Elmore Primary Health Service study – funded by Australian Rotary Health and the Australian Government Department of Health and Ageing – examines the performance, sustainability and impact of a comprehensive primary health care service in a small rural community. The evaluation framework developed has been widely adopted as the basis for informing future rural health service policies.13

Footprints Forwards: Better Strategies for the Recruitment, Retention and Support of Indigenous Medical Students

This project investigated opportunities for, and barriers to, Indigenous student entry to medical education with a view to designing suitable resources for use in secondary schools. The three key objectives were to:

  • examine existing information relating to Indigenous recruitment and support strategies of Australian Medical Schools

  • identify reasons for low Indigenous recruitment, enrolment and completion in medical schools and

  • review existing promotional materials, and develop and pilot an interactive multimedia product designed to facilitate flexible and sustainable models of recruitment.

The team produced a promotional DVD titled You Can Do It!, and undertook widespread dissemination with key stakeholders to develop approaches to achieve better recruitment, retention and support for Indigenous students in medicine.

Rural Chronic Disease Initiative – Building Healthy Communities Resource Kit

The Rural Chronic Disease Initiative was funded by the Australian Government Department of Health and Ageing to improve what people know about chronic disease, to encourage community members to adopt a healthier lifestyle, and provide better ways to help people with chronic disease. Monash University School of Rural Health researched small rural and remote communities throughout Australia as the basis for developing and distributing high quality information on chronic disease and injury, and supporting and developing skills and leadership in people in small rural communities. This research resulted in a major publication, Building Healthy Communities – A Guide for Community Projects, that has become a critically important training resource to guide people in small rural communities who want to try new ways to make a difference to chronic disease at a local level.14

Centre of Research Excellence in Rural and Remote Primary Health Care (CRE)

This centre is a collaboration between Monash University School of Rural Health, the Flinders University and Charles Darwin University Centre for Remote Health in Alice Springs, and the University of Sydney Department of Rural Health in Broken Hill.15 The centre aims to develop:

  • a better understanding of health behaviour relating to primary health care service use in rural and remote Australia

  • better measures of access to guide resource allocation relating to primary health care in small rural and remote communities

  • a comprehensive framework for evaluating the impact of rural and remote primary health care services on access and equity of health outcomes

  • evidence-based models of sustainable primary health care for different rural and remote contexts.

Indicators of success

Over the 20-year period, research staff have achieved widespread success in gaining competitive research funding and in publishing extensively in peer-reviewed journals (see table: Research performance indicators 1992-2012). Publications have increased significantly over the 20-year period, accompanied by an increase in articles published in high-impact rural health journals. The increasing importance and impact of the contribution of rural health publications and expertise is seen in journal citations, keynote presentations at national and international conferences, invited addresses, reviewer status and membership of government rural health advisory committees. In terms of research funding, most grants in the early years of the Centre of Rural Health fell into Category 2, Other Public Sector Research Income, and emanated mostly from federal and state government sources. Most recently, an increased proportion of research funding has come from nationally competitive granting bodies such as the National Health and Medical Research Council, Australian Research Council and other national competitive grants such as the Australian Primary Health Care Research Institute and Rotary Health. The school is now leading one Centre of Research Excellence and is a joint partner with another. Compared with equivalent rural health research organisations – such as university departments of rural health – Monash University School of Rural Health now rates highly on all research indicators.

Research performance indicators 1992–2012

Year
Number of peer-reviewed publications
Competitive research funding

1992

9a

na

1997

32b

na

2002

20c

$608,607c

2007

51d

$2,137,000e

2012

93f

$4,635,300e

a 1993/94 Annual Report

b 1997/98 Centre for Rural Health Year in Review

c 2002 Monash University School of Rural Health Year in Review

d 2007 Monash University School of Rural Health Report to Department of Education Science and Training

e Based on Office of Research Records 2007 and 2012

f 2012 Monash University School of Rural Health Report to Department of Industry, Innovation,
Science, Research and Tertiary Education.

Importantly too, research undertaken by the school has had a significant impact on rural health policy development. This strong linkage and exchange between rural health researchers and policy decision makers is the result of close collaborations with, and involvement of, key rural health policy makers in reference groups. Such groups have been established to help guide major research projects, and are an important catalyst for ensuring research uptake so that policy and practice are evidence-based. Rural health researchers have also engaged actively in knowledge translation through:

  • ensuring research findings are published in a broad range of public outlets – such as in summaries and reports specifically targeting consumer, practitioner and policy audiences – as well as peer-reviewed academic publications

  • public research presentations, professional workshops, and community consultation and feedback

  • membership and significant involvement in several key government advisory and reference groups

  • strong collaborations with health service providers and peak organisations

  • media broadcasts

  • program monitoring and evaluation research.

The strong research culture and activity that has been developed within the school has had a significant impact on rural health research capacity building. With the advent of postgraduate education in the school, higher degree research students continue to assume an increasingly important role in the school’s research program. Moreover, research staff have played a key role in assisting other rural health groups to gain research funding through critical evaluation of grants, mentoring, grant reviews, presentations about research quality, membership of external research funding bodies, and through submissions to national bodies – Australian Rural Health Education Network, NHMRC – for more strategic rural health research funding. The school has ‘grown’ and ‘exported’ research leaders who made valuable contributions to its research program, with early career researchers being promoted to senior academic positions – Dr Leigh Kinsman and Dr Gil Soo-Han to associate professorships, and Dr Claire Rickard and Dr Elaine Duffy to professorships at other Australian universities.

Factors contributing to research success

With rural health research in general still in its infancy in many universities, it is timely to reflect on the factors which have contributed to its success within Monash University. These include vision and leadership, faculty and school support, strong stakeholder relationships, a strategic approach, international exposure, mentoring, capacity building and the fostering of a research culture in the School of Rural Health.

Vision and leadership

Undoubtedly the early vision of Roger Strasser, in pioneering the establishment of the Centre of Rural Health in Moe, recognised the need for a strong research presence to parallel government activity designed to address outstanding rural health workforce problems. Roger’s decision, strongly supported by then dean of the faculty, Professor Nick Saunders, to appoint Australia’s first dedicated Professor of Rural Health Research ensured that the school was characterised by strong research leadership. Through the strategic vision of its early leaders, the school has played a lead role in identifying priority research issues and themes for rural and remote Australia. Many of them have been adopted as the basis for rural health research programs elsewhere in the country.

Faculty and school support

Instrumental in facilitating research success was the strong support from the faculty deans (Professors Porter, Saunders, Byrne, Wesselingh, and Mitchell), deputy deans of research (Professors Michael Berndt, Ian Smith, and Ross Coppel), and heads of school (Professors Roger Strasser, Elaine Duffy, Geoff Solarsh, Gordon Whyte and Judi Walker). Under the school headship of Geoff Solarsh and Gordon Whyte and, more recently, its current head, Judi Walker, research activity received further endorsement. A decision was made to build up research nodes, with sufficient critical mass through geographic consolidation of activity, to foster early career researchers and develop a more viable postgraduate program.

Much of the research success is also attributable to the excellent support provided by the Office of Research staff. In particular, the school’s research program owes much to the first-class administrative support provided by the manager of the Office of Research in Bendigo, Lisa Lavey. Testimony to the exemplary role she played were the recognition awards presented to her: the Monash University Vice-Chancellors Award for exceptional performance, and the special individual recognition award for her role as a Research Office Professional from the Australian Institute of Office Professionals Provincial Victorian Office. Lisa’s role has been assisted immensely by the strong support she received from Sandra Paschkow and Cathy Ward in Bendigo, while Janelle McGrail provided excellent support in the Gippsland region.

Strong research stakeholder relationships

Central to the strong, successful policy orientation and relevance of much of the research within the school have been the extensive, long-standing and close collaborations with a wide range of rural stakeholders. The school has an established track record of working closely with state and federal governments, universities, a broad range of health service providers, professional organisations and community stakeholder groups, rural workforce agencies, and university departments of rural health. The development of the regional clinical schools provided the opportunity to further establish close research links with clinicians, regional service providers, divisions of general practice and rural communities at local and regional levels. Additionally, the school works closely with researchers from other departments within the faculty, including nursing, primary health care, epidemiology and preventive medicine. Without the support and involvement of these stakeholders, the research undertaken by the school would not have been adopted in the policy and practice arenas to the extent that it has.

Strategic approach to priority research issues

Building on its comparative advantage of geographical locations stretching from Mildura to East Gippsland, staff within the school undertook research on key rural health issues impacting locally, nationally and internationally. The school developed a research strategy targeting the priority goals promoted by the Australian Government, and undertaking evidence-based research to inform government policy. As has been outlined above, major research themes included:

  • rural health workforce, including rural medical education and training, factors influencing the intention of medical students to practise in rural Australia, recruitment and retention issues, international medical graduates, the roles and functions of health practitioners, and gender issues

  • the development of sustainable models of service delivery in rural and remote areas of Australia

  • epidemiological studies designed to better understand the distribution of priority health conditions and the specific effect of health service interventions on health outcomes.

Over the years, strategic planning meetings for research were held regularly at the following places: Phillip Island in 2000; Clayton in 2004; Moe in 2006; Traralgon in 2001 and 2002; and Bendigo in 2005, 2007, 2009, and 2011.

National and international visitors

Since its founding, the school has welcomed some of the world’s leading figures in rural and remote health, and their presentations and presence have assisted in fostering a strong research culture. Visitors have included Professors Raymond Pong and Roger Pitblado from the Centre for Remote and Northern Health Research, Laurentian University Ontario Canada; Professor Ivar Aaraas, National Centre of Rural Medicine, University of Tromso; Professor John Wakerman, the Flinders University and Charles Darwin University Centre for Remote Health, Alice Springs; Associate Professor Lisa Bourke, University of Melbourne Department of Rural Health; Professor Jane Farmer, University of Aberdeen; Associate Professor Mike Jones, Macquarie University; Professor David Lyle and Associate Professor David Perkins, University of Sydney Department of Rural Health; Professors Ian Smith, Michael Berndt, Robin Bell, and Ross Coppell, Monash University; Professor Stephen Campbell, University of Manchester; Professor Joachim Kugler, University of Dresden; Professor Rod Hooker, University of Texas; Professor Gary Hart, University of Washington; Professor Jim Rourke, University of Western Ontario; Dr John Wynn Jones, Institute of Rural Health, Wales; Professor Ruth Endacott, University of Plymouth, England; Professor Ian Couper, University of Witswatersrand, Johannesburg; and Dr John Wootton, Ontario, Canada.

Research mentoring and capacity building

A significant advance in 2001 was the introduction of a full-time postgraduate research program to complement the existing masters and graduate diploma programs in rural health. The school’s first two PhD students graduated in 2005, and there is now a robust program for training higher degree research students. A number of other specific measures to increase research skills and productivity were also undertaken, including a week-long Write-way workshop designed to provide inexperienced researchers with the opportunity to participate in a group activity. The aim was to maximise the acceptance of publications by peer-reviewed journals, and foster relationships with research mentors.

Research culture

Developing a strong research culture does not happen overnight, but rather reflects the combination of a commitment to enquiry and new knowledge, support for early career researchers, success in grants and publications and, above all, a clear strategic focus to guide activity. The School of Rural Health has been successful in integrating research into all aspects of its mandate; its success is reflected in the large number of invitations to participate in both national and international conferences and workshops.

Future challenges

The current research environment is highly competitive and the emphasis on strong national and international collaborations will require the School of Rural Health to continue to broaden its outlook and process of engagement. In order to maintain leadership in rural health research, the school will need to build on the factors that have led to its present success and to address some new challenges. Aside from the inherent complexity of many issues that rural health researchers are required to address, new challenges include the following needs: to build stronger research relationships across all nodes of the school; to respond to the requirements of governments and policy makers rapidly; to overcome the ‘metro-centric corporatist’ paradigm by which rural health research is being governed; to develop a better pipeline into research for persons from health science backgrounds; and to strengthen research methodologies that are appropriate for investigating rural health issues; and to refine the process by which research findings are disseminated and adopted in the policy arena.

Research consolidation

One of the biggest problems confronting rural health researchers is their relative isolation in nodes that lack critical mass and research expertise in areas such as bio-statistics, epidemiology and health economics. The key to overcoming such isolation is consolidation, something which can be achieved through developing strong relationships between the individual sites and the efficient use of IT to support research. Access to a robust and reliable IT system is crucial since it has the ability to transcend distance through instant access to library resources, rapid movement of data, and both visual and aural communication. Videoconferencing now enables access over wide areas to seminars, workshops, journal clubs, and participation in all manner of reference groups and meetings relevant to the research.

Knowledge transfer

Ensuring relevance to all stakeholders, but particularly to governments, is of increasing importance in research. It requires a sound understanding of government, health service, practitioner and consumer needs, and a well-developed strategy for disseminating research evidence and new knowledge. The ongoing involvement of rural health researchers on government advisory committees and health organisation boards is critical in this regard, as is the participation of bureaucrats, service providers and consumers in formulating and conducting the research.

Research governance

Increasing demands of reporting on research outcomes and the growth of the corporatist paradigm in universities has fostered a ‘one-coat-fits-all’ approach to research. Such an approach works against the flexibility required by rural health researchers who need to adapt their investigations and methodologies to the context in which they are working. An inflexible system alienates key stakeholders because it fails to work with them as equal partners and unnecessarily complicates the way in which research is conducted at the local level.

Research capacity

Most university pipelines into research are very traditional and fail to recognise that many health practitioners interested in undertaking research in conjunction with their practice do not easily fulfil the pre-requisites for postgraduate research. Nor does their heavy workload enable them to leave the workforce and take on research full-time. What is required is the development of innovative pathways which facilitate entry into research without devaluing its standards and rigour.

Research methodology and knowledge translation

Rural health issues are ‘wicked problems’.16 As such, adherence to traditional scientific methods, such as randomised control trials, are often not appropriate or cannot be used, thereby requiring the development of alternative robust methodologies. The effective use of mixed methods, both quantitative and qualitative, in the best rural health studies, exemplifies the importance of establishing timely, appropriate relationships with all persons involved with, and affected by, the research being undertaken. The process is time-consuming and demands great expertise, understanding and sensitivity on the part of the researcher; nowhere is this more important than in working with Aboriginal Australians. Moreover, the research findings must be shared and disseminated in diverse ways for different audiences.

A critical role in the future

Over its first 20 years, research activity at the School of Rural Health has matured into a program that has national and international significance. Its current high status reflects the enormous work undertaken by everyone associated with research in the school. The strategic research undertaken by the researchers from the school has had a very significant impact on the development of new knowledge as well as on national policies and programs designed to address rural health problems of workforce shortage, health service provision and poor health status that characterise rural and remote Australia. This high impact and take-up of research from the school reflects the applied nature of the investigations and the close engagement and collaboration the school maintains with rural hospitals, rural workforce agencies, divisions of general practice, rural doctors associations, Commonwealth and state governments, and numerous professional and community organisations. Guided by the Monash University research strategy imperatives of excellence, relevance and impact, there is no doubt that the research program within the school will continue to play a critical role over the next 20 years.

Endnotes

1 Chater, A. 1993. ‘The role of the National Rural Health Alliance’. Australian Journal of Rural Health 1 (2): 5–12.

2 Hospitals and Health Services Commission. 1976. ‘Rural health in Australia: A report’. Canberra: Australian Government Publishing Service.

3 See the centre’s website: http://www.crerrphc.org.au.

4 McGrail, M; Humphreys, J. 2009. ‘A new index of access to primary care services in rural areas’. Australian and New Zealand Journal of Public Health 33 (5): 418–423.

5 See the medical deans’ website: http://www.medicaldeans.org.au/projects-activities/msod.

6 See the Medicine in Australia: Balancing Employment and Life website:
https://mabel.org.au/.

7 Department of Infrastructure and Transport. 2008. ‘The Regional Australia Summit’[Internet]. Australian Government. Accessed July 2012. Available from: http://www.infrastructure.gov.au/department/annual_report/1999_2000/RegionalAustraliaSummit.aspx.

8 Humphreys, J; Dixon, J. 2004. ‘Access and equity in Australian rural health services’. In Accessing Health Care: Responding to Diversity, edited by Healy, J.; & McKee, M. Oxford: Oxford University Press: 89–107.

9 Wakerman, J; Humphreys, J; Wells, R; Kuipers, P; Entwistle, P; Jones, J. 2006. ‘A systematic review of primary health care delivery models in rural and remote Australia 1993-2006’. Canberra: Australian Primary Health Care Research Institute. Available from http://aphcri.anu.edu.au/research-program/aphcri-network-research-completed/stream-four-translating-evidence-policy/systematic-review-primary.

10 Kinsman, L; Champion, R; Lee, G; Martin, M; Masman, K; May, E; Mills, T; Taylor, M; Thomas, P; Williams, R; Zalstein, S. 2008. ‘Assessing the impact of streaming in a regional emergency department’. Emergency Medicine Australasia 20: 221–222.

Rotter, T; Kinsman, L; Kugler, J; Gothe, H; James, E; Snow, P; Willis, J; Machotta, A. 2010. ‘Clinical pathways: Effects on professional practice, patient outcomes, length of stay and hospital costs (systematic review)’. Cochrane Database of Systematic Reviews 3:CD006632.

11 School of Rural Health, Office of Research. 2008. ‘National Rural General Practice Study (NRGPS) – Executive Summary & Final Report’. [Internet]. Monash University. Accessed June 2012. Available from: http://www.med.monash.edu.au/srh/research/nrgps/.

12 Viable Models Management Committee. 2003. ‘Viable models of rural and remote practice: Stage 1 and stage 2 reports’. [Internet]. Rural Doctors Association of Australia. Accessed June 2012. Available from: http://www.rdaa.com.au/Uploads/Documents/Stage%201%20and%20Stage%202%20Reports_20110224092844.pdf.

13 Tham, R; Humphreys, J; Kinsman, L; Buykx, P; Asaid, A; Tuohey, K; Riley, K. 2010. ‘Evaluating the impact of sustainable comprehensive primary health care on rural health’. Australian Journal of Rural Health 18 (4): 166–172.

14 Department of Health and Ageing. 2004. ‘Building Healthy Communities’. [Internet]. Australian Government. Accessed August 2012. Available from:
http://www.health.gov.au/internet/main/publishing.nsf/Content/ruralhealth-pubs-BHC.htm.

15 See the Centre of Research Excellence in Rural and Remote Primary Health Care web site: http://www.crerrphc.org.au.

16 Humphreys, J; Kuipers, P; Wakerman, J; Wells, R; Jones, J; Kinsman, L. 2009. ‘How far can systematic reviews inform the policy development for “wicked” rural health service problems?’. Australian Health Review 33 (4): 592–600.

Humphreys, John S. 2012. ‘Research: Community relevance’, in From a Broom Cupboard: 20 Years of Rural Health at Monash University, edited by Clough, Robert. Melbourne: Monash University Publishing. Pp. 90–111.

From a broom cupboard: 20 years of rural health at Monash University

   by Robert Clough, editor