Context: In the Gambia, West Africa, Malaria is a major cause of death among children in rural areas. It has been estimated that in one division in the country malaria accounts for 40% of all deaths in children aged between one and 4 years. Most malaria cases are managed at home assisted by primary healthcare workers. The strategic plan of Gambia's National Malaria Control Programme includes improved training and supervision of all health care providers, at all levels, and increased community awareness in order to reduce the malaria burden by 50% before 2007. Issue: A malaria in-service training program for Community Health Nurses (CHNs) working at village level was piloted in 2004. The program includes a computerbased training (CBT) package, the first of its kind for health professionals in Gambia. The education program is part of a larger initiative, funded by the Gates Malaria Partnership, that aims to increase community involvement in malaria control. The objective of the course is to enable CHNs to facilitate the change process. The curriculum was informed by a reference group and stakeholder input. Interviews and evaluation forms were used to gather information about learner experience and learning preferences. Analysis: The CBT package was well received. Learners reported wanting more computer instruction, but felt they had gained confidence. There was resistance from other health professionals regarding the development of information technology skills in CHNs. This related to the perceived role and status of CHNs, as well as confidence in their ability. Some modifications of the CBT package were necessary, including the reworking of some activities and language. Lessons learned: There are issues related to sustainability and resource implications that need to be addressed. Opportunities exist to expand e-learning in the Gambia for preservice CHNs and other professionals. An investigation into the viability of reproducing this module as a generic planning tool for allied health workers and other extension workers at community level will be undertaken.

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Introduction: This article documents a number of rural medical education initiatives in Australia, Canada and the United States. A typology is created reflecting the centrality the rural mandate and characterizing different features of each school's program. Interviews with school officials are drawn on to reflect the challenges these schools face. Method: Seven schools noted for their rural programs were selected from the three countries and interviews were conducted with senior officials. The interview data was supplemented by published material on the schools. Results: The Typology: Three kinds of school are distinguished: Mixed Urban/Rural Schools (University of Washington, US, the University of British Columbia, Canada and Flinders University, Australia); DeFacto Rural Schools (University of New Mexico, US and Memorial University, Canada) and Stand Alone Rural Schools (James Cook University, Australia and the Northern Ontario School of Medicine, Canada). The Pipeline Approach: All of the schools adopted in varying degrees a pipeline approach to meeting the need for rural doctors focusing on: (a) early recruitment; (b) admissions; (c) locating clinical education in rural settings; (d) rural health focus to curriculum; and (e) support for rural practice. Conclusion: The analysis does not strongly favor one model over others, although the Stand-Alone Rural schools had more opportunities to adopt innovative curricula reflecting rural health issues and to foster positive views of rural practice. Government funding targeting rural health needs will remain critical in the development of all these programs.

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Introduction: The need for health professionals is acute throughout rural communities worldwide. The Rural Health Interdisciplinary Program (RHIP) successfully trains health professional students for practice in rural USA. Student-developed problembased learning (PBL) cases are a central feature of the RHIP and an important educational focus of learning. Methods: This retrospective study was designed to describe 222 PBL cases developed by health professional students in the RHIP. The analysis focused on the extent to which student-developed cases reflect demographics and health conditions of rural New Mexico, as well as how successfully cases reflect rural interdisciplinary healthcare issues and practices. Results: The PBL cases do reflect rural New Mexico in terms of population demographics, certain health problems and complexity of health issues. The cases appear to address interdisciplinary, rural clinical concerns. However, the cases are less effective at raising issues related to public health, financial, legal and ethical issues, and other nonmedical health topics. Conclusions: In order to strengthen attention to non-medical issues, PBL groups should have broad interdisciplinary membership, special case development training, and faculty encouragement to address a wide variety of health-related topics. Student-developed PBL cases appear to be an interesting way for health professional students to learn about rural healthcare issues and could be used in a variety of different educational settings.

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Context: Many medical schools would like to provide students with opportunities to learn and perform practical research and to have positive rural learning experiences. Rural physicians often have research ideas, but may lack the skills or assistance to perform the research. Program description: The unique Rural Summer Studentship Program (RSSP) at The University of Western Ontario (Western) places students with preceptors in small and mid-sized communities throughout Southwestern Ontario where they have an opportunity to perform rural health research, combined with clinical learning, for 8 weeks in the summer after the first or second year of medical school. Secretarial coordination, research assistant support and senior faculty supervision were provided. Outcomes: From 1999 - 2003 inclusive, 44 students have participated including eight who participated over two summers. Projects were carried out in more than 20 communities with over 30 preceptors. Already, two students have had their research published in peerreviewed journals and six have presented at major conferences. Participating students indicated an increase in interest in rural and regional medicine and in their knowledge of rural and regional medicine and patient care. They rated the value of RSSP highly as part of their medical education, even compared with other electives/selectives. Conclusion: The RSSP model developed at Western provides a highly rated, successful combination of supported medical student research and clinical learning with preceptors in small and mid-sized communities.

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Context: Changing medical education to realign it with societal needs has become a renewed priority in many countries. Advanced training in rural settings to prepare physicians to better serve rural areas has received particular attention around the world. Such initiatives are usually targeted at primary care practitioners. Few initiatives have been designed to enhance specialist training in a rural setting, let alone adapt specialist competency frameworks such as the CanMEDS™ roles of the Royal College of Physicians and Surgeons of Canada to non-urban medical education. Issue: We describe an innovation in medical training for rural competence for specialist physicians using the CanMEDS framework near London, Ontario, Canada. Since 1997, the University of Western Ontario has established its Multi-Specialty Community Training Network (MSCTN) to provide rural and regional training opportunities for specialty residents in anaesthesia, general surgery, internal medicine, paediatrics, obstetrics and psychiatry. It became the first program in Canada to fully adapt the new CanMEDS roles into learning objectives and evaluations. Lessons learned: Competency-based frameworks like CanMEDS are important because they provide a comprehensive tool to organize outcome-based curricula. The CanMEDS roles framework has been very useful in developing educational goals for rural/regional specialty resident rotations as well as forming a constructive basis for resident, preceptor, and program evaluations. Our experiences with this program may provide lessons for others planning training for specialists in rural settings, and those adopting the CanMEDS competency framework.

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Introduction: A shortage of healthcare providers in West Virginia led to the creation of a statewide, community-based program with a required three-month rural experience for most state-sponsored health professions students. Project Description: Initiated using funding from the W. K. Kellogg Foundation and expanded using both state funds and Area Health Education Center support, the West Virginia Rural Health Education Partnerships (WVRHEP) program impacts institutions of higher learning, 50 counties, and 332 training sites, and all students in state-funded health professions schools. A longitudinal database has been constructed to study program effects on students' reported attitudes, service orientation, and career intents. Methods: Baseline data are collected from medical students, and students in all disciplines provide feedback on rotations and information about career intents, social responsibility, and attitudes towards rural practice. Results: Data indicate an association between perceived quality of the rural experience and increased interest in rural health, social responsibility and confidence in becoming part of the community. Medical students may tend to rate social responsibility higher after completion of the first rural rotation. Students who anticipate practice in smaller towns also tend to rate the quality of the rotation higher, to anticipate careers in primary care, and to acknowledge social responsibility. Conclusion: As WVRHEP program graduates who have completed these surveys enter practice, both personal and community-specific program characteristics may be identified which strengthen interest in rural practice. The predictive validity of intermediate outcomes of attitudes and career intents in forecasting the ultimate outcomes of recruitment and retention may be studied.

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The Rural Physician Associate Program (RPAP) has 34 years experience in training 1097 medical students as independent distance learners in a 36-week, community-based continuity primary care experience. This program has been successful in preparing competitive students who select primary care residencies and return to rural practice. The RPAP program has been based on traditional apprenticestyle clinical teaching with the support of computer-based resources to enhance distance learning. However while the clinical exposure and development of medical skills was strong, there were weaknesses in evidence-based medicine and managing healthcare, and inconsistencies in community or population health learning. New directions in the educational program for RPAP are described that have been or are being developed to address the competencies as outlined by the Accreditation Council on Graduate Medical Education. They include online and other resources, preceptor education and support, interactive journaling and cases, electronic portfolios, community projects, observed structured clinical exams and examinations. Ongoing challenges to competency-based education include developing meaningful measures and tools to assess competence for areas such as professionalism or systems-based practice; providing faculty development toward being able to practice, teach and evaluate students with an understanding of the competencies; and to build in ways of practicing, learning and improving care that involve effective teams of health-care professionals.

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Background: Access to comprehensive and quality health care services is difficult for socioeonomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. Health Needs of Rural Areas: The Case of Walhalla, SC: The town of Walhalla, South Carolina is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. Designing a Program to Fit the Community-the ''Walhalla Experience'': The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisciplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as Promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural health care initiatives targeting minority groups. This paper reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.

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Introduction: As universities rely more heavily on rural GPs to precept medical students, the formation of symbiotic partnerships benefiting students, universities and GPs, becomes imperative. In order to develop and consolidate these partnerships universities must understand who their rural GP preceptors are and how precepting impacts on them. Methods: A review of the literature was undertaken to determine the significant themes of student impacts from articles where conclusions were clearly based on empirical findings. Results: Forty-three articles were included in the final review, but only nine specifically looked at impacts on rural GPs. Impacts were categorized into six domains: personal; time; patient care; professional relationships and professional development; business and infrastructure; and recognition and remuneration. Conclusions: Literature specifically addressing the impact of precepting on rural GPs is scarce. Further studies are required to evaluate the relationship between the quality of teaching delivered to students, the type and length of student attachments and the likely impacts on rural GPs.

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