title: Communicable diseases in rural and remote Australia: the need for improved understanding and action.
abstract: BACKGROUND
  Rural and remote communities of Australia, particularly those including Aboriginal people, experience greater morbidity and mortality across a range of health outcomes compared to urban communities. Previous national data have demonstrated that rural and remote communities experience a disproportionate burden of communicable diseases compared to their urban counterparts. This systematic review was undertaken to describe the types of research that have explored the epidemiology of communicable diseases in rural and remote communities in Australia, with particular reference to the social determinants of health.
  
  
  METHODS
  We conducted a keyword search of several databases (EMBASE, MEDLINE/PubMed, RURAL, Aboriginal and Torres Strait Islander Health Database, Web of Science Core Collection, and Google and Google Scholar websites) for peer-reviewed and grey literature that described or analysed the epidemiology of communicable diseases in rural and/or remote communities of Australia from 2004 to 2013. Exclusion criteria were applied to keep the review focused on rural and/or remote communities and the population-level epidemiological analysis of communicable diseases.
  
  
  RESULTS
  From 2287 retrieved articles, a total of 50 remained after applying exclusion criteria. The majority of included articles were descriptive studies (41/50). Seven of the total 50 articles contained analytical studies; one systematic literature review and one experimental study were also identified. Due to the diversity of approaches in measuring disease burden, we performed a narrative synthesis of the articles according to the review objectives. Most of the articles investigated the disease burden in remote (n=37/50) and Aboriginal communities only (n=21/50). The studies highlighted a high prevalence or incidence of skin, eye and respiratory infections for remote Aboriginal communities, particularly children over the past decade. There was emerging evidence to suggest that housing and social conditions play an important role in determining the risk of skin, ear, respiratory and gastrointestinal infections in children. Other health service and sociocultural factors were also discussed by authors as influencing the epidemiology of communicable diseases in rural and remote communities.
  
  
  CONCLUSIONS
  This systematic review identified several communicable diseases that continue to cause considerable morbidity in remote Aboriginal communities, including skin, eye and respiratory infections, particularly for children. Overall there is a substantial amount of descriptive epidemiology published, but few analytical or experimental studies. Despite a lack of empirical investigation into the social determinants of the burden of communicable disease, there is emerging evidence that has demonstrated a significant association between housing conditions and skin, ear, respiratory and gastrointestinal infections in children. There is also growing recognition of other social and environmental factors that can influence the burden of diseases in rural and remote communities. Further investment into higher quality community-based research that addresses the social determinants of communicable diseases in remote communities is warranted. The lack of research investigating zoonoses and tropical diseases was noted.
authors.affiliation: NSW Ministry of Health, Sydney, New South Wales, Australia. emma.quinn@sswahs.nsw.gov.au.
authors.forename: Emma K
authors.initials: EK
authors.lastname: Quinn
authors.affiliation: Hunter New England Population Health, Tamworth, New South Wales, Australia. peter.massey@hnehealth.nsw.gov.au.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Massey
authors.affiliation: Tropical Health Solutions Pty Ltd, Townsville, Queensland, Australia. rickspeare@gmail.com.
authors.forename: Rick
authors.initials: R
authors.lastname: Speare
mesh_terms: D001315:Australia / Q000453:epidemiology; D003141:Communicable Diseases / Q000453:epidemiology* / Q000208:ethnology; D004777:Environment; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006798:Housing; D006801:Humans; D015995:Prevalence; D012423:Rural Health / Q000706:statistics & numerical data*; D064890:Social Determinants of Health / Q000208:ethnology*; D012959:Socioeconomic Factors; D000095283:Australian Aboriginal and Torres Strait Islander Peoples
keywords: Australia/Pacific; Determinants of Health; Epidemiology; Public Health