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Review Article
Rural Healthcare in Light of a Multinational Pandemic: A Global Perspective
Liew TYS1*
and Khoo CY2
1
Emergency Department, Ng Teng Fong General Hospital, National University Health System, Singapore
2
Department of General Surgery, Singapore General Hospital, Singapore
*
Corresponding author:
Liew Yi Song Terence,
Emergency Department, Ng Teng Fong General
Hospital, National University Health System,
Singapore, 1 Jurong East Street 21,
Singapore 609606, Tel: +65 83213015,
E-mail: liew.yisong.terence@gmail.com
Received: 15 May 2021
Accepted: 29 May 2021
Published: 03 Jun 2021
Copyright:
©2021 Liew TYS. This is an open access article distribut-
ed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
build upon your work non-commercially.
Citation:
Liew TYS, Khoo CY. Rural Healthcare in Light of a
Multinational Pandemic: A Global Perspective. Ann Clin
Med Case Rep. 2021; V6(18): 1-4
http://www.acmcasereport.com/ 1
Annals of Clinical and Medical
Case Reports
ISSN 2639-8109 Volume 6
Keywords:
Equity; Healthcare Disparity; Pandemic; Rural
Healthcare; Rural Population
1. Abstract
Rural healthcare recently came into international spotlight, with
recent reported influx of the COVID-19 into rural regions. This ar-
ticle focuses on susceptibilities of the rural population to pandem-
ics and mitigating measures to prevent formation of disease epi-
centre. Rural Healthcare is by far one of the most neglected areas
of medicine. The discrepancies in quality of rural healthcare has
been evident for decades, yet no lasting measures have been able
to bridge this gap till date. Lessons gleaned from the recent SARS
and H1N1 pandemics has once again fallen through the cracks in a
futile attempt to curb urban spread. Adequate provisions and deliv-
ery of healthcare to rural areas, early identification, isolation and
implementation of precautionary measures, re-evaluation of rural
healthcare infrastructure and strategies on rural healthcare work-
er retention are quintessential to equity of healthcare worldwide.
Only robust, sincere and well-tailored measures would result in a
resilient and enduring rural population.
2. Introduction
Rural medicine is the delivery of healthcare to individuals residing
in rural conditions. The needs of the rural population is not just
unique to developing nations. Regardless of nationality, the cov-
erage of and access to rural healthcare remains reprehensible [1].
The deficiency in delivery of quality health services leads to un-
necessary suffering and deaths in the rural population.[1] It must
be acknowledged and recognized that with an increasingly inter-
connected world, the rural community has somewhat benefited
from an increase in healthcare provisions [2]. However, common-
ly preventable mortalities such as under-5 mortality and maternal
deaths remain much higher in rural states compared to the urban
counterparts [2]. Hart JT pointed out in 1971 that the availability
of good medical care tends to vary inversely with the need for it in
the population served [3]. The persistence of the inverse care law
remains regrettable [3].
The COVID-19 global pandemic has infected more than 40 mil-
lion people to date. The urban population took the greatest hit ini-
tially, with more than 90% of COVID-19 cases reported in urban
cities as of June 2020 [4]. This is attributed to the dense and highly
populated cities with high levels of interconnectivity within the
populace [4]. Globalization and urbanization has significant in-
fluence in the spread and containment of a disease [5]. However,
there has been reports of a significant influx of the pandemic into
the rural population [6]. This phenomenon drew parallel to the
2003 SARS pandemic, when countermeasures had been proposed
by world leaders then [7].
3. Why Rural Areas are more Susceptible to a Pandemic
The rural population has limited access to technology and is conse-
quently poorly prepared against a pandemic. They are particularly
susceptible to misinformation which may result in distrust in the
http://www.acmcasereport.com/ 2
Volume 6 Issue 18 -2021 Review Article
local health system. Recent advancement in informative technol-
ogy has allowed for near instantaneous relaying of information.
This has often been manipulated for political, financial or personal
agendas resulting in erosion of public confidence in the healthcare
system [8]. At the same time, those who live in areas with limited
technology may lack access to such information resulting in fail-
ure to take necessary precautions against an impending pandem-
ic. This include personal hygiene and safe distancing measures,
which are primary preventative measures imperative in mitigating
the spread of infection and flattening the epidemiological curve.
Lower healthcare literacy has also been shown to result in poorer
health outcomes in rural populations [9].
The glaring disparity of healthcare services and quality between
urban and rural locales has been well recognized. It is known that
increased primary healthcare physician supply is associated with
improved clinical outcomes of any given population [10]. Over
the decade, the density of primary healthcare physicians have de-
clined, with significantly greater loss in the rural areas [10]. This
may explain the rural-urban mortality disparity across states, ac-
counting for poorer outcomes in rural settings [11,12]. Healthcare
disparity continues to persist, and will become more evident in the
pandemic. With a global pandemic overwhelming healthcare insti-
tutions in urban areas, even less focus will be placed in the rural
setting, contributing to an uncontrollable influx of disease.
Deficiencies in healthcare resources is another contribution to the
increased susceptibility of rural populations to a global pandem-
ic. Since the H1N1 pandemic, it was evident that rural mortality
far exceeds the urban counterparts, with greater lack of healthcare
resource in the rural precincts [13]. Essential medical facilities
and equipment for a predominantly respiratory pandemic includes
Intensive Care Units (ICUs), ventilators, personal protection
equipment for healthcare workers and eventually vaccines when
available. Lack of availability and access to healthcare facilities
and resources will result in a larger population succumbing to the
disease [13].
The livelihood of a significant proportion of the rural population
still lies in agriculture, manufacturing and construction [14]. The
novel “Work-from-Home” culture to maintain productivity during
a pandemic cannot be applied to such activities. Although the scale
of operations may be large (especially within agricultural fields)
with few interactions between co-workers, safe distancing mea-
sures cannot be guaranteed. In large-scale manufacturing and con-
struction, workers who travel huge distances to their workplace are
generally housed in cramped and shared quarters to reduce travel
time, increasing susceptibility to formation of disease clusters/epi-
centres.
Delayed care is also another dominant issue in the rural popula-
tion. Patients with illness generally present later in the course of
disease with advanced disease presentation, which is associated
with a higher mortality [15]. This is commonly attributed to further
travel to healthcare facilities, lack of access to healthcare, lower
healthcare literacy leading to later diagnosis, lack of availability
of disease information and fear of stigmatization associated with
disease. With the relatively high R0 values of respiratory diseases,
these factors can lead to formation of huge clusters and epicentres
long before detection of disease. Mitigating actions at that stage
may already be too late.
4. Approach to Rural Health in a Global Pandemic
Delivery of healthcare and medical resources to rural areas can
potentially mitigate the impact on the pandemic on these popula-
tions in the short term. This can come in the form of ambulatory
clinical services, military medical services, personal protection
and medical equipment, and funding for telehealth to bridge the
distance factor in healthcare delivery to the vast rural land areas.
However, these resources must be customized to fit the rural en-
vironment, where distance and accessibility may limit movement
of such resources. It is thus imperative that health officials identify
in advance specific susceptibilities and vulnerabilities of the rural
population to allow for judicious allocation of resources.
COVID-19 test kits should also be made readily available to rural
areas early, allowing local authorities to identify and isolate cases
and take the necessary precautions to prevent formation of large
disease clusters. Upon identification of an outbreak, measures to
disperse or shelter specific vulnerable communities should be im-
plemented quickly. Efforts to provide these patients with essential
services such as food and personal care must be undertaken. This
has to be done tactfully so as not to alarm the local population.
Many countries have mobilized the military, which can boost the
capacity and capabilities to reach and render assistance to the rural
regions. This can help to temporarily alleviate the critical shortage
of healthcare provision in these areas.
The long term goal should be to improve rural healthcare collec-
tively. This can only be done with adequate support, funding and
endowments from the government and non-profit organizations.
Healthcare infrastructure needs to be revitalized and equipped
with basic capabilities similar to their urban counterparts, while
remaining accessible. This will come in the form of hospital fa-
cilities, primary healthcare clinics and medical posts to deliver
quality healthcare to the population. Similarly, the emotional and
socioeconomic repercussions sustained post pandemic would need
to be addressed in the form of support schemes and counselling
services. In order to build a robust and holistic rural healthcare
system, financial gain cannot be the primary driving force. Assis-
tance must be sought from the governing bodies to incentivise the
movement of healthcare resources to the rural population.
Rural upbringing was the most common predictor of physicians
entering rural practice [16]. Early exposure to rural practice and
personal characteristics of physicians are also common predictors
http://www.acmcasereport.com/ 3
Volume 6 Issue 18 -2021 Review Article
[16,17]. Negating factors include professional isolation and per-
ceived lack of access to amenities in rural practices [18]. Monetary
incentives played a minimal role in long term retention of rural
physicians [19]. Understanding the needs and proper recognition
services provided by rural physicians is paramount to improving
rural healthcare in the long term. This will encourage recruitment
and retention of healthcare workers in the rural setting.
There are many lessons on rural healthcare delivery that can be
further drawn from nations worldwide. Structured clinical prac-
tice guidelines can incorporate evidence based medical treatments,
but rural healthcare physicians must have both the awareness and
ability to practice it in a myriad of clinical settings [20]. Policies
crafted must adequately address the key issues faced by rural phy-
sicians in their practice in rural healthcare settings [21]. Policies
incorporating the multiple dimensions of access will be better
tailored to the needs of rural healthcare [21]. The public health
response strategy incorporated in Australia and Canada provides
insight to the management of a global pandemic in a rural primary
healthcare setting [22]. The elements include risk assessment, pan-
demic resilience and response, which are critical in quickly iden-
tifying the salient differences in the rural healthcare system and
ensuring that needs of the rural population are not overlooked [22].
5. Conclusion
The lack of technology, health care and social services are some
of the non-exhaustive list of issues faced in the rural population.
Instead of channelling a large majority of resources to mitigate
the impact of the pandemic in urban cities alone, perhaps more
efforts should be placed on prevention of spread within the rural
environments where a large majority of the population reside. The
current Covid-19 pandemic will definitely not be the last pandemic
this world will see. It is time for lasting measures to be implement-
ed to minimize the discrepancy in healthcare between urban and
rural areas. Access to healthcare was declared a fundamental hu-
man right in 1948 by the World Health Organization (WHO). The
WHO’s Universal Health Coverage (UHC) necessitated equity in
access to health services, adequate quality of health and protection
against financial risks. To achieve these goals, there must first be
awareness of the persistence of healthcare disparity despite mul-
tiple measures to bridge this gap. The rewards of improving rural
medical care are innumerable, and the time is now.
The authors declare no conflicts of interest.
6. Authors Contribution Statement
Both authors were involved in the literature review, processing,
writing and editing of this manuscript.
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Rural Healthcare in Light of a Multinational Pandemic: A Global Perspective

  • 1. Review Article Rural Healthcare in Light of a Multinational Pandemic: A Global Perspective Liew TYS1* and Khoo CY2 1 Emergency Department, Ng Teng Fong General Hospital, National University Health System, Singapore 2 Department of General Surgery, Singapore General Hospital, Singapore * Corresponding author: Liew Yi Song Terence, Emergency Department, Ng Teng Fong General Hospital, National University Health System, Singapore, 1 Jurong East Street 21, Singapore 609606, Tel: +65 83213015, E-mail: liew.yisong.terence@gmail.com Received: 15 May 2021 Accepted: 29 May 2021 Published: 03 Jun 2021 Copyright: ©2021 Liew TYS. This is an open access article distribut- ed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Citation: Liew TYS, Khoo CY. Rural Healthcare in Light of a Multinational Pandemic: A Global Perspective. Ann Clin Med Case Rep. 2021; V6(18): 1-4 http://www.acmcasereport.com/ 1 Annals of Clinical and Medical Case Reports ISSN 2639-8109 Volume 6 Keywords: Equity; Healthcare Disparity; Pandemic; Rural Healthcare; Rural Population 1. Abstract Rural healthcare recently came into international spotlight, with recent reported influx of the COVID-19 into rural regions. This ar- ticle focuses on susceptibilities of the rural population to pandem- ics and mitigating measures to prevent formation of disease epi- centre. Rural Healthcare is by far one of the most neglected areas of medicine. The discrepancies in quality of rural healthcare has been evident for decades, yet no lasting measures have been able to bridge this gap till date. Lessons gleaned from the recent SARS and H1N1 pandemics has once again fallen through the cracks in a futile attempt to curb urban spread. Adequate provisions and deliv- ery of healthcare to rural areas, early identification, isolation and implementation of precautionary measures, re-evaluation of rural healthcare infrastructure and strategies on rural healthcare work- er retention are quintessential to equity of healthcare worldwide. Only robust, sincere and well-tailored measures would result in a resilient and enduring rural population. 2. Introduction Rural medicine is the delivery of healthcare to individuals residing in rural conditions. The needs of the rural population is not just unique to developing nations. Regardless of nationality, the cov- erage of and access to rural healthcare remains reprehensible [1]. The deficiency in delivery of quality health services leads to un- necessary suffering and deaths in the rural population.[1] It must be acknowledged and recognized that with an increasingly inter- connected world, the rural community has somewhat benefited from an increase in healthcare provisions [2]. However, common- ly preventable mortalities such as under-5 mortality and maternal deaths remain much higher in rural states compared to the urban counterparts [2]. Hart JT pointed out in 1971 that the availability of good medical care tends to vary inversely with the need for it in the population served [3]. The persistence of the inverse care law remains regrettable [3]. The COVID-19 global pandemic has infected more than 40 mil- lion people to date. The urban population took the greatest hit ini- tially, with more than 90% of COVID-19 cases reported in urban cities as of June 2020 [4]. This is attributed to the dense and highly populated cities with high levels of interconnectivity within the populace [4]. Globalization and urbanization has significant in- fluence in the spread and containment of a disease [5]. However, there has been reports of a significant influx of the pandemic into the rural population [6]. This phenomenon drew parallel to the 2003 SARS pandemic, when countermeasures had been proposed by world leaders then [7]. 3. Why Rural Areas are more Susceptible to a Pandemic The rural population has limited access to technology and is conse- quently poorly prepared against a pandemic. They are particularly susceptible to misinformation which may result in distrust in the
  • 2. http://www.acmcasereport.com/ 2 Volume 6 Issue 18 -2021 Review Article local health system. Recent advancement in informative technol- ogy has allowed for near instantaneous relaying of information. This has often been manipulated for political, financial or personal agendas resulting in erosion of public confidence in the healthcare system [8]. At the same time, those who live in areas with limited technology may lack access to such information resulting in fail- ure to take necessary precautions against an impending pandem- ic. This include personal hygiene and safe distancing measures, which are primary preventative measures imperative in mitigating the spread of infection and flattening the epidemiological curve. Lower healthcare literacy has also been shown to result in poorer health outcomes in rural populations [9]. The glaring disparity of healthcare services and quality between urban and rural locales has been well recognized. It is known that increased primary healthcare physician supply is associated with improved clinical outcomes of any given population [10]. Over the decade, the density of primary healthcare physicians have de- clined, with significantly greater loss in the rural areas [10]. This may explain the rural-urban mortality disparity across states, ac- counting for poorer outcomes in rural settings [11,12]. Healthcare disparity continues to persist, and will become more evident in the pandemic. With a global pandemic overwhelming healthcare insti- tutions in urban areas, even less focus will be placed in the rural setting, contributing to an uncontrollable influx of disease. Deficiencies in healthcare resources is another contribution to the increased susceptibility of rural populations to a global pandem- ic. Since the H1N1 pandemic, it was evident that rural mortality far exceeds the urban counterparts, with greater lack of healthcare resource in the rural precincts [13]. Essential medical facilities and equipment for a predominantly respiratory pandemic includes Intensive Care Units (ICUs), ventilators, personal protection equipment for healthcare workers and eventually vaccines when available. Lack of availability and access to healthcare facilities and resources will result in a larger population succumbing to the disease [13]. The livelihood of a significant proportion of the rural population still lies in agriculture, manufacturing and construction [14]. The novel “Work-from-Home” culture to maintain productivity during a pandemic cannot be applied to such activities. Although the scale of operations may be large (especially within agricultural fields) with few interactions between co-workers, safe distancing mea- sures cannot be guaranteed. In large-scale manufacturing and con- struction, workers who travel huge distances to their workplace are generally housed in cramped and shared quarters to reduce travel time, increasing susceptibility to formation of disease clusters/epi- centres. Delayed care is also another dominant issue in the rural popula- tion. Patients with illness generally present later in the course of disease with advanced disease presentation, which is associated with a higher mortality [15]. This is commonly attributed to further travel to healthcare facilities, lack of access to healthcare, lower healthcare literacy leading to later diagnosis, lack of availability of disease information and fear of stigmatization associated with disease. With the relatively high R0 values of respiratory diseases, these factors can lead to formation of huge clusters and epicentres long before detection of disease. Mitigating actions at that stage may already be too late. 4. Approach to Rural Health in a Global Pandemic Delivery of healthcare and medical resources to rural areas can potentially mitigate the impact on the pandemic on these popula- tions in the short term. This can come in the form of ambulatory clinical services, military medical services, personal protection and medical equipment, and funding for telehealth to bridge the distance factor in healthcare delivery to the vast rural land areas. However, these resources must be customized to fit the rural en- vironment, where distance and accessibility may limit movement of such resources. It is thus imperative that health officials identify in advance specific susceptibilities and vulnerabilities of the rural population to allow for judicious allocation of resources. COVID-19 test kits should also be made readily available to rural areas early, allowing local authorities to identify and isolate cases and take the necessary precautions to prevent formation of large disease clusters. Upon identification of an outbreak, measures to disperse or shelter specific vulnerable communities should be im- plemented quickly. Efforts to provide these patients with essential services such as food and personal care must be undertaken. This has to be done tactfully so as not to alarm the local population. Many countries have mobilized the military, which can boost the capacity and capabilities to reach and render assistance to the rural regions. This can help to temporarily alleviate the critical shortage of healthcare provision in these areas. The long term goal should be to improve rural healthcare collec- tively. This can only be done with adequate support, funding and endowments from the government and non-profit organizations. Healthcare infrastructure needs to be revitalized and equipped with basic capabilities similar to their urban counterparts, while remaining accessible. This will come in the form of hospital fa- cilities, primary healthcare clinics and medical posts to deliver quality healthcare to the population. Similarly, the emotional and socioeconomic repercussions sustained post pandemic would need to be addressed in the form of support schemes and counselling services. In order to build a robust and holistic rural healthcare system, financial gain cannot be the primary driving force. Assis- tance must be sought from the governing bodies to incentivise the movement of healthcare resources to the rural population. Rural upbringing was the most common predictor of physicians entering rural practice [16]. Early exposure to rural practice and personal characteristics of physicians are also common predictors
  • 3. http://www.acmcasereport.com/ 3 Volume 6 Issue 18 -2021 Review Article [16,17]. Negating factors include professional isolation and per- ceived lack of access to amenities in rural practices [18]. Monetary incentives played a minimal role in long term retention of rural physicians [19]. Understanding the needs and proper recognition services provided by rural physicians is paramount to improving rural healthcare in the long term. This will encourage recruitment and retention of healthcare workers in the rural setting. There are many lessons on rural healthcare delivery that can be further drawn from nations worldwide. Structured clinical prac- tice guidelines can incorporate evidence based medical treatments, but rural healthcare physicians must have both the awareness and ability to practice it in a myriad of clinical settings [20]. Policies crafted must adequately address the key issues faced by rural phy- sicians in their practice in rural healthcare settings [21]. Policies incorporating the multiple dimensions of access will be better tailored to the needs of rural healthcare [21]. The public health response strategy incorporated in Australia and Canada provides insight to the management of a global pandemic in a rural primary healthcare setting [22]. The elements include risk assessment, pan- demic resilience and response, which are critical in quickly iden- tifying the salient differences in the rural healthcare system and ensuring that needs of the rural population are not overlooked [22]. 5. Conclusion The lack of technology, health care and social services are some of the non-exhaustive list of issues faced in the rural population. Instead of channelling a large majority of resources to mitigate the impact of the pandemic in urban cities alone, perhaps more efforts should be placed on prevention of spread within the rural environments where a large majority of the population reside. The current Covid-19 pandemic will definitely not be the last pandemic this world will see. It is time for lasting measures to be implement- ed to minimize the discrepancy in healthcare between urban and rural areas. Access to healthcare was declared a fundamental hu- man right in 1948 by the World Health Organization (WHO). The WHO’s Universal Health Coverage (UHC) necessitated equity in access to health services, adequate quality of health and protection against financial risks. To achieve these goals, there must first be awareness of the persistence of healthcare disparity despite mul- tiple measures to bridge this gap. The rewards of improving rural medical care are innumerable, and the time is now. The authors declare no conflicts of interest. 6. Authors Contribution Statement Both authors were involved in the literature review, processing, writing and editing of this manuscript. References 1. Scheil-Adlung X. Global evidence on inequities in rural health pro- tection: new data on rural deficits in health coverage for 174 coun- tries. ESS Doc. 47, Int. Labour Organ., Geneva. 2015. 2. World health statistics 2020: monitoring health for the SDGs, sustain- able development goals. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. 3. Hart JT. The inverse care law. Lancet. 1971; 1(7696): 405-412. doi:10.1016/s0140-6736(71)92410-x 4. United Nations Human Settlements Programme (UN-Habitat), “Opinion: COVID-19 demonstrates urgent need for cities to prepare for pandemics”, 15 June 2020, available at https://unhabitat.org/ opinion-covid-19-demonstrates-urgent-need-for-cities-to-prepare- for-pandemics 5. Reyes R, Ahn R, Thurber K, Burke TF. Urbanization and Infectious Diseases: General Principles, Historical Perspectives, and Contem- porary Challenges. In: Fong I. (eds) Challenges in Infectious Dis- eases. Emerging Infectious Diseases of the 21st Century. Springer, New York, NY. 2012; 123-146. https://doi.org/10.1007/978-1-4614- 4496-1_4 6. Stern, D., 2020. Covid-19 Cases Surpass 900,000 In Rural America – 20,000 Deaths - Housing Assistance Council. 2020. 7. Lam, W., 2003. SARS Battle Shifts To Rural China. [online] Edition. cnn.com. 2020 8. Larson HJ. The biggest pandemic risk? Viral misinformation. Nature. 2018; 562(7727): 309. doi:10.1038/d41586-018-07034-4 9. Moser DK, Robinson S, Biddle MJ, et al. Health Literacy Predicts Morbidity and Mortality in Rural Patients With Heart Failure. J Card Fail. 2015; 21(8): 612-618. doi:10.1016/j.cardfail.2015.04.004 10. Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015. JAMA Intern Med. 2019; 179(4): 506-514. doi:10.1001/jamainternmed.2018.7624 11. Hoffman, A. and Holmes, M., 2017. Regional Differences In Rural And Urban Mortality Trends. [online] Findings Brief. 2020. 12. Moy E, Garcia MC, Bastian B, et al. Leading Causes of Death in Non-metropolitan and Metropolitan Areas-United States, 1999– 2014. MMWR Surveill Summ 2017; 66(No. SS-1):1-8. 13. Kirakli C, Tatar D, Cimen P, et al. Survival from severe pandemic H1N1 in urban and rural Turkey: a case series. Respir Care. 2011; 56(6): 790-795. doi:10.4187/respcare.00988 14. Reddy D. Narasimha, Reddy Amarender A, Nagaraj N and Banti- lan Cynthia. 2014. Emerging Trends in Rural Employment Structure and Rural Labor Markets in India, Working Paper Series No. 56. Patancheru 502 324, Telangana, India: International Crops Research Institute for the Semi-Arid Tropics. 26 pp. 15. Ohl M, Tate J, Duggal M, Skanderson M, Scotch M, Kaboli P, et al. Rural residence is associated with delayed care entry and increased mortality among veterans with human immunodeficiency virus infec- tion. Medical care. 2010; 48(12): 1064-1070.
  • 4. http://www.acmcasereport.com/ 4 Volume 6 Issue 18 -2021 Review Article 16. Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2018; 93(1): 130-140. doi:10.1097/ACM.0000000000001839 17. Hancock C, Steinbach A, Nesbitt TS, Adler SR, Auerswald CL. Why doctors choose small towns: a developmental model of ru- ral physician recruitment and retention. Soc Sci Med. 2009; 69(9): 1368-1376. doi:10.1016/j.socscimed.2009.08.002 18. Richards HM, Farmer J, Selvaraj S. Sustaining the rural primary healthcare workforce: survey of healthcare professionals in the Scottish Highlands. Rural Remote Health. 2005; 5(1): 365. 19. Sempowski IP. Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: sys- tematic review of the literature. Can J Rural Med. 2004; 9(2): 82-88. 20. Fyfe TM, Payne GW. Rural healthcare delivery: Navigating a com- plex ecosystem. Healthc Manage Forum. 2020; 33(2): 80-84. doi: 10.1177/0840470419886938. PMID: 32090634. 21. Russell DJ, Humphreys JS, Ward B, Chisholm M, Buykx P, McGrail M, Wakerman J. Helping policy-makers address rural health access problems. Aust J Rural Health. 2013; 21(2): 61-71. doi: 10.1111/ ajr.12023. PMID: 23586567. 22. O’Sullivan B, Leader J, Couch D, Purnell J. Rural Pandemic Pre- paredness: The Risk, Resilience and Response Required of Pri- mary Healthcare. Risk Manag Healthc Policy. 2020; 13: 1187- 1194. doi: 10.2147/RMHP.S265610. PMID: 32904086; PMCID: PMC7450525.