The Anabranch Framework for the Ruralization of Health Professional Education

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for submitting this highly relevant and timely paper. I have attached a copy with suggestions, mostly minor. For example, however, is used frequently to start a sentence but is superfluous. Two areas I would like clarity on are whether when referring to rural you are including rural and remote, or just rural. Secondly, the need to undergraduate and new health professional graduates to understand the intersectionality of place and the SEC and climatic determinants of health in relation to Aboriginal people is only likely touched on, yet within rural and remote settings these are the communities with the greatest need but the ones who finding engaging with a system that holds their health knowledge, values and beliefs in low regard. Surely, HPE needs to have a significant focus on this, if we can ensure health professionals who are prepared for working respectfully and effectively with Indigenous communities in rural and remote Australia, the rest would fall into place. 

Comments for author File: Comments.pdf

Author Response

Responses to Reviewer 1 comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions in track changes in the re-submitted manuscript.

Comments 1: Thank you for submitting this highly relevant and timely paper. I have attached a copy with suggestions, mostly minor. For example, however, is used frequently to start a sentence but is superfluous.

Response 1: The authors agree and have removed however from the following Lines 18, 107, 137, 187, 345, 385, 399, 497, 656, 701, 802. Transdisciplinary has been included in the manuscript Lines 679 and 683. Additional revisions have included addressing sentence length.

Comments 2: Two areas I would like clarity on are whether when referring to rural you are including rural and remote, or just rural.

Response 2: The following clarification has been included in the introduction:

“Health professional workforce shortages and the resultant health inequities confronting rural and remote (referred to as rural throughout this paper)…” [Line 78]

Comments 3: Secondly, the need to undergraduate and new health professional graduates to understand the intersectionality of place and the SEC and climatic determinants of health in relation to Aboriginal people is only likely touched on, yet within rural and remote settings these are the communities with the greatest need but the ones who finding engaging with a system that holds their health knowledge, values and beliefs in low regard. Surely, HPE needs to have a significant focus on this, if we can ensure health professionals who are prepared for working respectfully and effectively with Indigenous communities in rural and remote Australia, the rest would fall into place. 

Response 3: The authors acknowledge the importance of First Nations Peoples within the broader rural and remote health care context. The following has been included in the manuscript to address comments:

“The authors propose that the AF can be utilized to inform the development of indigenized HPE models (i.e. the indigenization of AF domains, constructs, structural elements and outcomes). This would necessitate comprehensive and culturally respectful engagement, consultation and leadership of First Nations Peoples, academics, and health professionals in consideration of the cultural acceptability of the AF and advancement of culturally responsive Indigenized models.” [Lines 647-652]

Reviewer 2 Report

Comments and Suggestions for Authors ***Please check lines 15-39 are in which section of this paper.   ***According to the abstract’s methods, the framework was developed through an iterative process involving a series of systematic steps. The process included individual and group critical dialogues with internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments; an internal review of empirical studies of relevance to the ruralization of health professional education and practice; the visualization of a place-based framework; the academic conceptualization of the framework; and further critical dialogues to test the framework's face validity. It implies that experts or researchers are internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments. Please identify the sampling for these four groups.   According to the abstract’s results, the Anabranch Framework comprises four interrelated rural domains: theories, pedagogies, practices, and connectivity; four constructs:  (1) knowledge acquisition and generation, (2) immersion in rural curriculum, (3) knowledge translation and sharing, and (4) relational practice; and two structural elements: spiraled and scaffolded curriculum and duration and quality of rural placement and practice. Please check that the statement reflects Table 2.   ***The Anabranch Framework lacks detail in the literature review based on previous studies to support it; please add more detail.   ***According to Lines 251-253; 2.2. Methods: The process of developing the Anabranch Framework was iterative, involving a series of systematic steps presented in Figure 1. Please identify the previous studies to support Figure 1. Typically, a systematic review such as the PRISMA METHOD is adopted for a systematic review in meta-analysis.   ***Lines 296-297; Figure 2. Place-based conceptualization of the Anabranch Framework. Please add methods for creating Figure 2 based on previous studies to support it.   ***Lines 305-315 without any citations.   ***The theories are suggested to be added, such as Figure 3, similar to Knowledge Management (KM).   ***According to 3.7. Framework Outcomes: The outcomes of the AF are aspirational, reflecting the results expected from the ruralisation of HPE. These outcomes are the transformation and ruralization of health professional worldviews, advancement of rural person-centered practices, health professional acquisition of a deeper understanding of rural places, and the development of a sustainable rural-literate health workforce – a workforce equipped with the knowledge, skills, and attributes required to address the health inequities experienced by rural and First Nations peoples. It should be mentioned that there are theories, such as KAP: knowledge, attitude, and practices.   ***The conclusion aims to enhance the outcomes by incorporating relevant theories and variables or factors. Please ensure that the conclusion reflects them as mentioned.   ***Please add the limitation that the present paper is a systematic review and does not involve respondents; thus, perceptions based on questionnaires or interviews are recommended for further studies.   ***Please check for 49 references that are not related to the Anabranch Framework.

Author Response

Responses to Reviewer 2 comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions in track changes in the re-submitted manuscript.

Comments 1: Please check lines 15-39 are in which section of this paper.  

Response 1: Lines 15-29 align to the journals request for a highlights section to be included in the Front matter: “General Considerations

• Research manuscripts should comprise:
• Front matter: Title, Author list, Affiliations, Highlights, Abstract, Keywords.”

https://www.mdpi.com/journal/healthcare/instructions

Comments 2: ***According to the abstract’s methods, the framework was developed through an iterative process involving a series of systematic steps. The process included individual and group critical dialogues with internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments; an internal review of empirical studies of relevance to the ruralization of health professional education and practice; the visualization of a place-based framework; the academic conceptualization of the framework; and further critical dialogues to test the framework's face validity. It implies that experts or researchers are internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments. Please identify the sampling for these four groups.   According to the abstract’s results, the Anabranch Framework comprises four interrelated rural domains: theories, pedagogies, practices, and connectivity; four constructs:  (1) knowledge acquisition and generation, (2) immersion in rural curriculum, (3) knowledge translation and sharing, and (4) relational practice; and two structural elements: spiraled and scaffolded curriculum and duration and quality of rural placement and practice. Please check that the statement reflects Table 2.  

Response 2: The following clarifying statement has been made in the manuscript to address this comment:

‘AF domains and constructs have been integrated in this table to highlight the complex interplay and connectivity that exist between these components.’ [Lines 656-657]

 

Comments 3: ***The Anabranch Framework lacks detail in the literature review based on previous studies to support it; please add more detail.  

Response 3: Previous studies associated with the Anabranch Framework have not been undertaken given this is a new conceptualization of HPE in a rural/remote context. The literature discussed in the paper describes contemporary approaches to health professional education specifically, approaches used in rural contexts. Two studies and associated papers describing the impact for nursing and allied health student and academic participants in the Anabranch Framework are currently under development/review and as such are not currently available or cannot be cited in this paper. The authors also note that the Supplementary Table identifies the place-based empirical studies (n=59) that were reviewed to inform the conceptualization of the AF.  The authors were also unable to integrate these publications into the manuscript given the need to mitigate self-citation concerns.

 

Comments 4: ***According to Lines 251-253; 2.2. Methods: The process of developing the Anabranch Framework was iterative, involving a series of systematic steps presented in Figure 1. Please identify the previous studies to support Figure 1. Typically, a systematic review such as the PRISMA METHOD is adopted for a systematic review in meta-analysis.  

Response 4: This paper does not present a systematic review of the literature. This has been clarified with the Academic editor of the Journal and the paper has been re-classified as a viewpoint paper.

Comments 5: ***Lines 296-297; Figure 2. Place-based conceptualization of the Anabranch Framework. Please add methods for creating Figure 2 based on previous studies to support it

Response 5: A previous body of work using a similar method to the one described in this manuscript has been included in the methods section, cited and referenced. Please see the description below:

“This process was informed by the work of McCormack and McCance (2006) in their development of a conceptual framework to inform person-centred nursing [28].” [lines 304-306]

Reference section: McCormack B, McCance T. Development of a framework for person-centred nursing. Journal of Advanced Nursing. 2006:56(5);472-479. Doi: 10.1111/j.1365-2648.2006.04042.x

Comments 6: ***Lines 305-315 without any citations.  

Response 6: Lines 305-315 are a narrative description of the artistic place-based conceptualization of the Anabranch Framework. As such no citations are available.

Comments 7: The theories are suggested to be added, such as Figure 3, similar to Knowledge Management (KM).  

Response 7: The authors acknowledge this comment and the range of theories can be be integrated into the AF.

Comments 8: ***According to 3.7. Framework Outcomes: The outcomes of the AF are aspirational, reflecting the results expected from the ruralisation of HPE. These outcomes are the transformation and ruralization of health professional worldviews, advancement of rural person-centred practices, health professional acquisition of a deeper understanding of rural places, and the development of a sustainable rural-literate health workforce – a workforce equipped with the knowledge, skills, and attributes required to address the health inequities experienced by rural and First Nations peoples. It should be mentioned that there are theories, such as KAP: knowledge, attitude, and practices

Response 8: A reference has now been added to 3.7 that specifically relates to the KAP required for rural practice. [Line 667] Adams M. Education to Prepare Health Professionals for Rural Practice: A Scoping Review. Australian and International Journal of Rural Education. 2023;33(1):17-40. doi: 10.47381/aijre.v33i1.349.

 

Comment 9:    ***The conclusion aims to enhance the outcomes by incorporating relevant theories and variables or factors. Please ensure that the conclusion reflects them as mentioned

Response 9: The following has now been included in the conclusion:

“The AF highlights the importance of theoretically informed HPE in rural contexts, tailored pedagogical approaches that disrupt traditional knowledge hierarchies and privilege, practice experiences that align curriculum and service provision to community need and contexts and the importance of connectivity between higher education, health systems and professionals and the rural populations they serve… [Lines 790-794]

This will necessitate engagement with alternative evaluation approaches that move HPE insights beyond reductionist interpretations to those that seek to understand the complexity and programmatic implications and impacts of AF utilization in the ruralization of HPE.” [Lines 798-801]

Comments 10: ***Please add the limitation that the present paper is a systematic review and does not involve respondents; thus, perceptions based on questionnaires or interviews are recommended for further studies.  

Response 10: Please see response to Comment 4

Comment 11: ***Please check for 49 references that are not related to the Anabranch Framework.

Response 11: References have been reviewed to ensure relevance to the Anabranch Framework. Self-citations have been removed, new references have been included to replace these removals. Please note that additional references have been included in response to Reviewer 3 comments.

Reviewer 3 Report

Comments and Suggestions for Authors

This review addresses a current and highly relevant problem for health professional training systems, particularly in historically marginalized rural contexts. Its main strength lies in its ability to clearly and coherently articulate a systemic diagnosis of the limitations of the dominant educational model and translate it into an integrative conceptual framework that connects theory, pedagogy, and practice with a situated and context-sensitive perspective. In this sense, the work is relevant and necessary, not only because it highlights persistent structural inequalities, but also because it offers a thoughtful proposal that contributes significantly to the academic debate and the orientation of future transformations in health education.
However, prior to its publication, I would like to make two observations so that the authors can respond/correct their work:
1) Although the review emphasizes not replicating and adapting, in several passages it affirms the international relevance of the Anabranch framework. This is defensible as a hypothesis, but it requires the authors to describe some explicit criteria for transferability, such as what minimum conditions must exist so that the framework does not become a new form of imposition, which the text itself seeks to avoid.
2) The authors need to operationalize, even if only as a proposal, what measurable results would correspond to each aspirational outcome of the framework, and what educational, practice, and rural retention/employment indicators could be used to evaluate them.

Author Response

Responses to Reviewer 3 comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions in track changes in the re-submitted manuscript.

Comments 1: This review addresses a current and highly relevant problem for health professional training systems, particularly in historically marginalized rural contexts. Its main strength lies in its ability to clearly and coherently articulate a systemic diagnosis of the limitations of the dominant educational model and translate it into an integrative conceptual framework that connects theory, pedagogy, and practice with a situated and context-sensitive perspective. In this sense, the work is relevant and necessary, not only because it highlights persistent structural inequalities, but also because it offers a thoughtful proposal that contributes significantly to the academic debate and the orientation of future transformations in health education.

Response 1: The authors acknowledge and thank the reviewer for their comments relating to the relevance and necessity of the Anabranch Framework.

Comments 2: However, prior to its publication, I would like to make two observations so that the authors can respond/correct their work. Although the review emphasizes not replicating and adapting, in several passages it affirms the international relevance of the Anabranch framework. This is defensible as a hypothesis, but it requires the authors to describe some explicit criteria for transferability, such as what minimum conditions must exist so that the framework does not become a new form of imposition, which the text itself seeks to avoid.

Response 2: The following paragraph has been included in the discussion section to describe explicit criteria for transferability, including minimum conditions necessary to avoid framework burden:

The authors propose that the following minimal criteria are required to enable the transferability of the AF: the presence of rurally embedded health academics with close linkages to regional health and education stakeholders and metropolitan academic allies; access to educational infrastructure (i.e. safe learning environments, teaching spaces, physical or IT enabled spaces for critical reflection); access to rural health and curricula expertise to inform the design, implementation and evaluation of HPE models underpinned by the AF;  sustainable funding to support academic and key stakeholder contributions to the adaptation, implementation and evaluation of the AF and associated HPE models; policy, academic and place-based willingness to engage in HPE innovations. In the Australian context, UDRH have capacity to address the minimal criteria described through policy mandates, Commonwealth funding allocations, university and community connectivity and place-based responsiveness.  [lines 728-737] 

 

Comments 3: The authors need to operationalize, even if only as a proposal, what measurable results would correspond to each aspirational outcome of the framework, and what educational, practice, and rural retention/employment indicators could be used to evaluate them.

Response 3: A new section relating to the evaluation of the AF has been included in the paper to address this comment. Please see section 4.3 Evaluating the Anabranch Framework. [lines 738-766]. The authors have not explicitly described the measurable indicators that will be used to evaluate the impacts and outcomes of the AF. The authors are engaged in respectful early engagement with a range of diverse stakeholders in the design of the research protocol and are sensitive to the need to ensure multiple voices and perspectives are heard prior to progressing this body of work. The authors will produce a subsequent manuscript that will describe the AF research protocol and rationale, including the identification of relevant measurements. This has been made explicit on Line 765.  

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors ***Comments 1 & Authors’ response 1: The inquiry is addressed.   ***Comments 2: According to the abstract’s methods, The process included individual and group critical dialogues with internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments; an internal review of empirical studies of relevance to the ruralization of health professional education and practice; the visualization of a place-based framework; the academic conceptualization of the framework; and further critical dialogues to test the framework’s face validity. It implies that experts or researchers are internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments. Please identify the sampling for these four groups. Authors’ Response 2: The issues are not addressed.   ***Comments 3: The Anabranch Framework lacks detail in the literature review based on previous studies. Authors’ Response 3: Previous studies associated with the Anabranch Framework have not been undertaken given this is a new conceptualization of HPE in a rural/remote context. Comment 3 response to Authors’ Response 3: The reviewer suggests adding the K-A-P theory, which could be used to compare with the Anabranch Framework, but it was not found in the literature review. Thus, this comment 3 is not addressed.   ***Comments 4: Methods: The process of developing the Anabranch Framework was iterative, involving a series of systematic steps presented in Figure 1. Please identify the previous studies to support Figure 1. Typically, a systematic review such as the PRISMA METHOD is adopted for a systematic review in meta-analysis. Authors’ Response 4: This paper does not present a systematic review of the literature. This has been clarified with the Academic editor of the Journal and the paper has been re-classified as a viewpoint paper. Comment 4 response to Authors’ Response 4: Scholarly papers based on art and sciences. The art is used to present the content on the paper, with a focus on logic, reasonable methodology, and results. The sciences use the previous studies to support the scholarly papers. When the paper does not include a methodology for selecting (data collection) and analysing (data analysis) the data, it still raises questions. Thus, this comment 4 is not addressed.   ***Comments 5: Please explain how to create Figure 2. Authors’ Response 5: A previous body of work using a similar method to the one described in this manuscript has been included in the methods section, cited and referenced. Please see the description below: This process was informed by the work of McCormack and McCance (2006) in their development of a conceptual framework to inform person-centred nursing [28].” (lines 304-306), Reference section: McCormack B, McCance T. Development of a framework for person-centred nursing. Journal of Advanced Nursing. 2006:56(5);472-479. Doi: 10.1111/j.1365-2648.2006.04042.x Comment 5 response to Authors’ Response 5: It is still unclear. Thus, this comment 4 is not addressed.   ***Comments 6: Lines 305-315 without any citations. Authors’ Response 6: Lines 305-315 are a narrative description of the artistic place-based conceptualization of the Anabranch Framework. As such no citations are available. Comment 6 response to Authors’ Response 6: It could be a bias, please add this comment in the limitation and recommendation for further studies.   ***Comments 7: The theories are suggested to be added, such as Figure 3, similar to Knowledge Management (KM). Authors’ Response 7: The authors acknowledge this comment and the range of theories can be integrated into the AF. Comment 7 response to Authors’ Response 7: It is needed to add to the literature review for comparison between the two concepts. And it should be discussed and added in the conclusion.   ***Comments 8: According to 3.7. Framework Outcomes: The outcomes of the AF are aspirational, reflecting the results expected from the ruralisation of HPE. These outcomes are the transformation and ruralization of health professional worldviews, advancement of rural person-centred practices, health professional acquisition of a deeper understanding of rural places, and the development of a sustainable rural-literate health workforce – a workforce equipped with the knowledge, skills, and attributes required to address the health inequities experienced by rural and First Nations peoples. It should be mentioned that there are theories, such as KAP: knowledge, attitude, and practices. Authors’ Response 8: A reference has now been added to 3.7 that specifically relates to the KAP required for rural practice. [Line 667] Adams M. Education to Prepare Health Professionals for Rural Practice: A Scoping Review. Australian and International Journal of Rural Education. 2023;33(1):17-40. doi: 10.47381/aijre.v33i1.349. Comment 8 response to Authors’ Response 8: The issues are still not addressed.   ***Comment 9: The conclusion aims to enhance the outcomes by incorporating relevant theories, variables or factors. Please ensure that the conclusion reflects them as mentioned. Authors’ Response 9: In the conclusion section. Comment 9 response to Authors’ Response 9: When AF is the new framework and not compared to the other theories, it is an invalid analysis. Comment 9 response to Authors’ Response 9: The issues are still not addressed.   ***Comments 10: Please add the limitation that the present paper is a systematic review and does not involve respondents; thus, perceptions based on questionnaires or interviews are recommended for further studies. Authors’ Response 10: Please see the response to Comment 4 Comment 10 response to Authors’ Response 10: The issues are still not addressed. (Please see comment 4).   ***Comment 11: Please check for 49 references that are not related to the Anabranch Framework. Authors’ Response 11: References have been reviewed to ensure relevance to the Anabranch Framework. Self-citations have been removed, new references have been included to replace these removals. Please note that additional references have been included in response to Reviewer 3 comments. Comment 11 response to Authors’ Response 11: The issues are still not addressed. If AF is new, the similar or related theories need to be added. The added references are still not related to KAP or KM.

Author Response

Please see attached word document with responses to Round 2 reviewer comments

Author Response File: Author Response.pdf