Barriers to accessing ambulance services in rural Victoria for acute asthma: patients' and medical professionals' perspectives

OBJECTIVE: To study the attitudes and perceptions of rural asthma patients and medical health professionals towards accessing ambulance services for acute asthma. DESIGN: Health professional and patient based focus groups, audit of ambulance patient care records and self administered survey. SETTING: Asthma patients and medical professionals from rural south-western Victoria. RESULTS: The audit of patient care records included 69 asthma case records, and identified short response times (mean, 7 min; SD, 5 min), and documented patient improvement in clinical status in response to ambulance treatment. The focus group analysis identified patient perceptions which act as barriers to accessing ambulance services in acute asthma. These included the perception of response time delays, '000' call centre delays and misunderstanding of the role of paramedics, and when it is appropriate to call an ambulance for acute asthma. These perceptions were expressed by both patients and medical professionals, and both groups had poor knowledge of how and when to access ambulance services for acute asthma. CONCLUSIONS: The misperceptions expressed are of particular concern in a rural population where distance can cause prolonged response times to treatment, and patients who are acutely ill need to contact emergency services promptly and appropriately to improve patient health outcomes.     

Linkage, coordination and integration: Evidence from rural palliative care

Objective:  Review the findings from the evaluations of three rural palliative care programs.
Design:  Review by the authors of the original material from each evaluation. The conceptual framework for the review was provided by the work of Leutz, including his distinction between linkage, coordination and full integration.
Setting:  Community-based palliative care in rural Australia.
Interventions:  Fifteen projects across all six states of Australia that focused on integration between general practitioners and other community-based health providers.
Results:  The projects set out to improve networking and collaboration between providers; improve coordination and integration of care for patients; reduce duplication of services; and achieve a multidisciplinary, collaborative approach to palliative care. The most common interventions were establishment of formal governance structures, provision of education programs, case conferencing, dissemination of information, development of formal arrangements, development of protocols and use of common clinical assessment tools. The terms 'integration' and 'coordination' were used frequently but without clear definitions. Coordination required someone specifically designated to do the coordinating, usually a nurse. Formal arrangements to improve linkage and coordination were difficult to maintain. The main mechanism to achieve full integration was the development of common clinical information systems.
Conclusions:  The 'laws' proposed by Leutz and the concepts of linkage, coordination and full integration provide a useful framework to understand the barriers to integrating GPs and other health providers. It is important to be clear on what level of integration is required. Improving links might be sufficient (and realistic), rather than striving for full integration.     

Perceptions of occupational therapists practising in rural Australia: A graduate perspective

Background:  The difficulty in recruiting and retaining health professionals into rural and remote areas of Australia is well recognised. This study explored the perceptions of occupational therapists practising in rural locations regarding the essential skills necessary for rural practice and the ability of undergraduate education to prepare them for rural practice.
Methods:  A qualitative study using a phenomenological approach was conducted using semistructured in-depth interviews. Participants included occupational therapists who were graduates of James Cook University, who were practising in rural areas in Queensland and Victoria, and academic staff.
Results:  This study demonstrates that it is important for universities to develop both a mindset in their graduates for rural practice, as well as developing broader skills in addition to core discipline-specific skills. While subjects developing core occupational therapy skills are at the centre of undergraduate education, the importance of developing a broader understanding of rural health issues and skills in public health, primary health care and health promotion was emphasised.
Conclusion:  The development of specific skills to become competent rural practitioners and to cope with the challenges of rural practice can be strengthened through initiatives at the undergraduate level. Ongoing commitment from all universities across Australia to include rural curriculum content has the potential to improve recruitment and retention of occupational therapists and other health professionals into rural Australia.     

Stress and help-seeking for drought-stricken citrus growers in the Riverland of South Australia

Objective:  To explore the psychological impact of a problematic industrial climate for citrus growers, their help-seeking behaviour and perspectives on ways to encourage better use of rural mental health services.
Design:  Thematic analysis of in-depth interviews.
Setting:  The Riverland of South Australia.
Participants:  Sixteen citrus growers (12 male, 4 female) from eight Riverland towns.
Main outcome measures:  Citrus growers' perceived factors relating to psychological stress, coping behaviours, impact of stress on well-being, help-seeking behaviours, barriers to help-seeking and ways to encourage better use of rural mental health services.
Results:  Work-related stresses grouped under broad themes, including 'Uncontrollable events', 'Financial hardship' and 'Pressure', had negative effects on participants' well-being. Furthermore, it was found that significant difficulties arise because many of the stresses which growers endure are not controllable, and that the alleviation of strain with the help of mental health professionals is uncommon because of barriers preventing help-seeking. Five broad themes of barriers to help-seeking were extracted from the data: 'Self-reliance', 'Social image', 'Lack of knowledge', 'Negative perceptions of health professionals' efficacy' and 'Restrictive lifestyle factors'. A specialised model of occupational health for citrus growers was proposed.
Conclusions:  These results highlight the practical need to address the identified issues in delivery and promotion of health services when facilitating help-seeking within this group. The findings also add to our knowledge of occupational health psychology broadly.     

Barriers to managing mental health in Western Australia

Objective: To explore the views of community‐care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Design: Qualitative content analysis of semi‐structured interviews. Setting: Community and mental health services in Esperance. Subjects: One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n =38). Main outcome measures: The views of community‐care and mental health workers on barriers to the management of mental health, and how these could be addressed. Results: Barriers included confusion about the role of mental health services, limited after‐hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi‐agency shared care with clinical streams for adults, those aged > 65 and children. Conclusion: This study revealed a number of barriers that are being addressed through a memorandum of understanding between services.     

An ethical justification for the Chronic Care Model (CCM)

Background:  Chronic diseases are major causes of morbidity and mortality in developed countries. Their effects can be mitigated by high quality evidence-based care, but this is not the norm in most systems. The Chronic Care Model (CCM) is an evidence-based policy response to this practice gap, which uses multiple strategies to promote the quality of chronic care.
Objective:  To review CCM with an ethical lens.
Methods:  We reviewed the published empirical and non-empirical articles of CCM to analyse the ethical underpinnings of this model.
Results and conclusions:  We argue that its principal ethical value lies in the institutional cooperation it builds between the stakeholders involved in health care services. First, we briefly describe CCM and argue that the pathways through which it aims to improve patients' health outcomes are not made explicit. Second, we argue that the potential of CCM to be more beneficent, compared with traditional health care systems, depends on its capacity to promote mutual trust between health care providers and patients. There is no evidence to date that the implementation of CCM enhances mutual trust between health care professionals and patients. Third, we argue that CCM seeks to enhance human agency, allowing increased expression of individual autonomy and increased respect for individuals thereby expanding human freedom and avoiding social discrimination. However, we review the communication patterns that characterize the model of doctor–patient relationship promoted by this model and argue that these communication patterns raise ethical concerns that may prevent the model from reaching its expected outcomes.     

Issues in Rural Palliative Care: Views From the Countryside

Context: Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice palliative services are an essential need in both urban and rural settings. Rural communities, in particular, are vulnerable to receiving inadequate services due to their geographic isolation.
Purpose: To better understand experiences and issues related to rural palliative care.
Methods: Focus groups were held for health professionals, family members and volunteers in 3 rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique.
Findings: Three themes in rural palliative care were established: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural and health aspects of residents in order to optimize care.
Conclusion: Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.     

General practitioner and paediatrician self-reported capacity for the diagnosis and management of childhood and adolescent overweight and obesity

Aim:  The purpose of the present study was to assess and document the self-reported capacity, knowledge, skill and confidence of Central Coast general practitioners and paediatricians in the identification and management of overweight and obesity in children and adolescents, to investigate the barriers they experience in this area of practice and to consider how the local public sector nutrition service may assist.
Methods:  Forty general practitioners and three paediatricians were interviewed using a semistructured purpose-designed questionnaire.
Results:  Most participating doctors perceived that public sector dietitians are not available to assist them in managing overweight and obese paediatric patients. Few (23%) doctors reported using published guidelines and most reported significant barriers limiting their capacity to identify and manage this patient group effectively. All doctors identified at least one way in which the public health system can better support doctors in this role.
Conclusions:  The findings suggest that many doctors may benefit from increased training and a health system that better remunerates them for the time investment needed to provide management consistent with best practice. Reorientation of local public sector nutrition services may also provide them with better support when managing overweight and obese paediatric clients. Future research should examine the actual practices of doctors and how public sector dietitians can best communicate and interact with them to facilitate effective management of these patients.     

Enhancing the dietary management of general practice patients through collaborative care: perspectives of general practitioners and dietitians

Aim:  To describe how general practitioners and dietitians view their role in the dietary management of cardiac patients and to provide insights on how to facilitate collaborative care.
Methods:  Two studies were conducted in Victoria (Australia) 2005–2006. Study One: semi-structured interviews with general practitioners. Study Two: cross-sectional quantitative surveys of general practitioners and dietitians. Study One: texts were analysed using the grounded theory approach. Study Two: frequency analysis was conducted and chi-squared test for independence was used to explore the impact of age, sex and consultation time on the role and reporting scales.
Results:  Study One: Themes arising from the interviews with 30 general practitioners showed their involvement in dietary management fell into three broad roles: 'Influencing', 'Coordinator' of referrals and dietary 'Educator'. They described dietetic education as a process that included dietary assessment, education, application of behavioural change techniques and reporting back to general practitioners. Study Two: Respondents were 248 general practitioners (30% response) and 180 dietitians (60% response). General practitioners' counselling consisted mostly of advocating for dietary change, coordinating dietetic referrals and reinforcing dietitians' recommendations. General practitioners considered dietary education as the role of dietitians. Dietitians reported a much broader role in the management of patients with some overlap with general practitioners' roles.
Conclusions:  The findings indicate the need: (i) for more structured reporting to ensure general practitioners receive appropriate information to enable them to reinforce dietetic counselling and recommendations; and (ii) to streamline the communication process in order to expedite dietitians' reports to general practitioners.     

Improving knowledge transfer on chronic respiratory diseases: A canadian perspective. How to translate recent advances in respiratory diseases into day-to-day care

Background: Chronic diseases represent an increasing burden for health care systems. Ongoing research efforts provide regularly new scientific evidence on how optimize current medical care. In regard to respiratory diseases, as for other health problems, optimal management of these conditions has been summarized in recent consensus guidelines but implementation of these recommendations is still poor. Not only are the key-messages of such guidelines often unknown to the practitioner and the patient but even when it is, they are often insufficiently integrated into current care, often related to behavioral, organizational and communication barriers.Methods: Literature review on the topic of Clinical Practice Guidelines implementation and reference to recent projects aimed at improving management of asthma in the province of Quebec and elsewhere, as models for such implementation process.Results: The basic principles of an effective translation of current knowledge into day-to-day care are known, but healthcare delivery structures, practice tools and resources, and regional/local leadership should be available to make it happen. Ideally, implementation requires a multidisciplinary effort of care providers, specialists, general practitioners, allied health professionals, patients and their family. The general public, health administrators and policy makers should also be aware of the consequences of poor management of these diseases and be supportive of the proposed initiatives. Finally, these last should be adequately evaluated to ensure their effectiveness and determine if they should be improved. Recently projects performed in Quebec have proposed disease management models to identify asthma care gaps and improve translation of current Guidelines into day-to-day care.Conclusions: Although the human and socio-economical burden of chronic diseases is still increasing, their current management is still often deficient. In the recent decades, Practice Guidelines have been developed to guide Practitioners towards optimal care, but implementation of these Guides is still poor. Recent Canadian and International initiatives have proposed valid models to help address current care gaps.     

Key considerations in delivering appropriate and accessible health care for rural and remote populations: Discussant overview

Objective:  To provide an overview of papers discussing optimal service delivery models for rural and remote Australia.
Design:  A synthesis of overarching considerations guiding rural and remote health service policies.
Setting:  Small rural and remote communities in Australia.
Participants:  Invited delegates attending the Inaugural Rural and Remote Health Scientific Symposium in Brisbane 2008.
Main outcome measures:  Key issues underpinning health service provision for small rural and remote communities.
Results:  The formulation and implementation of effective health service provision policies must be underpinned by overarching health goals, agreed health service requirements, recognition of how rural and remote health contexts impact upon health service provision and the constraints limiting health service responses.
Conclusion:  Systemic change is required in order to ensure equitable access to health care services in small rural and remote communities.     

Clinical decision making and the provision of information in PEG feeding: an exploration of patients and their carers' perceptions

Background:  Government health care policy encourages a culture of patient choice and involvement in decision making, although the complexities and challenges involved in fully engaging patients in clinical decision making can be perceived as barriers to effective communication between the professional and patient. The present study aimed to explore the patients and their carers perceptions of the adequacy of the information provided and their subsequent involvement in the decision making process for percutaneous endoscopic gastrostomy (PEG) tube insertion.
Methods:  The study used purposive sampling. A cross-sectional qualitative design was utilised using semi-structured interviews, which were tape recorded. Sixteen patients and 27 carers were interviewed. The interviews were then transcribed verbatim and data analysis was undertaken using thematic analysis.
Results:  Only four patients and 11 carers reported having a choice in the decision for PEG placement, with only four patients and 10 carers, respectively, reporting they received sufficient information regarding the PEG. Poor communication, lack of information and inappropriate information, attitudes of health care professionals and exclusion were key themes for patients.
Conclusions:  Clinicians should develop interdisciplinary and participative practices to agree shared treatment goals and evaluate patient experiences. Consideration should also be given to the use of decision making models; in our opinion, the development of such a model, which supports interdisciplinary and participative approaches to decision making, is urgently required.     

Parent views on enhancing the quality of health care for their children with fragile X syndrome, autism or Down syndrome

Background   International research in recent years has begun to focus on the medical problems of individuals with intellectual disabilities and on family stress in accessing health services for persons with developmental disabilities. Less is known about the needs of individuals in different diagnostic groups, or about their experiences of systems of care. Therefore, we report the results of focus groups with parents of children or adults with fragile X syndrome, autism or Down syndrome.
Methods   Semi-structured group interviews with parents of children, youth or adults from each of three diagnostic groups probed perceptions of challenges and successes in obtaining and negotiating healthcare services in Ontario, Canada.
Results   Parents described diverse barriers to care, the need for advocacy in securing services, perceptions of service delivery and the role of healthcare professionals in regulating access to a wide range of services. Diagnostic services represented one area of central concern to parents from all three groups.
Discussion   Focus group data yielded a wide range of concerns. Suggestions for enhancing the system included expanding syndrome-specific education for medical students and health professionals and creating a centre that could offer service-related information for parents.     

Access to Specialty Health Care for Rural American Indians in Two States

ABSTRACT:  Context: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. Purpose: To examine specialty service access among rural Indian populations in two states. Methods: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). Findings: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. Conclusions: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.     

Establishing an innovative model of nutrition and dietetic care for a mental health service through collaboration with non-nutrition healthcare workers

Aim:  To describe the process of the development of the Web-based resources to extend nutrition care to mental health patients through existing non-nutrition mental healthcare professionals (case-managers).
Methods:  A formative approach was used to identify nutrition-related issues faced by both patients and staff through a synthesis of literature review, professional experience and clinical observations. Decision-making tools to assist case-managers in selecting resources were developed to guide case-managers' choice of effective evidence-based health education materials on the hospital intranet. Practical training was provided for case-managers during their orientation to the new website and the tools and resources it housed.
Results:  A Web-based nutrition site was created on the Royal Brisbane and Women's Hospital intranet. The website consisted of a Nutrition Referral Action Plan (a patient support triaging flowchart), a Nutrition Support Action Plan (action-based nutrition support tool to guide resource selection) and thirteen action-based nutrition education resources.
Conclusion:  By maximising established patient contact through existing health professionals, a Web-based approach to nutrition service delivery was an innovative method for delivering patient information. This collaborative action-based strategy has the potential to raise the nutrition profile in mental health and extend nutrition services to at-risk patients not previously receiving nutrition care.     

Promoting mental health care in a rural paediatric unit through participatory action research

Objective:  To explore, advance and evaluate mental health practices in a rural general paediatric unit through participatory action research.
Design:  A participatory action research approach guided this study, providing an opportunity for nursing staff to become actively involved in the design, direction and outcomes of the research.
Setting:  A 16-bed paediatric unit of a rural general hospital.
Participants:  A purposive convenience sample of all paediatric nursing staff ( n =  20; of 24 nurses).
Outcome measures:  In the first phase of this study, focus groups were conducted to explore the experiences of nurses.
Results:  Participants considered mental health to be a specialist discipline area and the role of the mental health nurse to be complex. They felt that their lack of training and experience with mental health issues was detrimental to the delivery of optimal patient care. There was concern about differing approaches to treatment, relationships with other mental health services and the suitability of the ward environment for young people with a mental health problem. Participants called for training by qualified mental health staff and the development of policies and clinical guidelines to facilitate their delivery of care to patients with a mental health problem in an acute medical environment.
Conclusions:  There is a clear need for nursing specialities to work together to ensure that optimal care is given to patients admitted to general hospital with a mental health issue. Given the absence of accessible specialist child mental health inpatient units in regional and remote areas, upskilling paediatric nurses must be a priority.     

The burden and management of dyslipidemia: practical issues

Abstract The objective of this study is to describe briefly the burden of dyslipidemia, and to discuss and present strategies for health professionals to improve dyslipidemia management, based on a review of selected literature focusing on interventions for dyslipidemia treatment adherence. Despite the availability of effective lifestyle and pharmaceutical therapies for dyslipidemias, they continue to present a significant economic burden in the United States. Adherence to evidence-based guidelines for the treatment of dyslipidemias is unsatisfactory. The reasons for medication nonadherence are complex and specific to each patient. The lack of progress in achieving optimal lipid targets is caused by many factors: patient (medication adherence, cost of medication, literacy), medication (adverse effects, complexity of regimen), provider (lack of adherence to evidence-based practice guidelines, poor communication), and the US healthcare system (being focused on acute care rather than prevention, lack of continuity of care, general lack of use of an electronic health record). Combined interventions that target each part of the system have been effective in improving treatment adherence and achieving lipid goals. Patients, providers, pharmacists, and employers all play a role in management of dyslipidemia. No single approach will solve the complex issue of improving dyslipidemia management. The required lifestyle changes are known and effective medications are available. The challenge is for all interested parties-including nurses, nurse practitioners, doctors, pharmacists, other health care professionals, employers, and health plans-to help patients achieve behavioral changes. (Population Health Management 2012;15:302-308).