Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

Mapping oncology services in regional and rural Australia

Objective: To map clinical oncology services in regional and rural Australia. Design and setting: A self‐administered survey was sent to 161 regional hospitals administering chemotherapy (RHAC) in Australia. RHAC were categorised by state, Hospital Peer Group and the Australian Standard Geographical Classification (ASGC) Remoteness Areas classification. Main outcome measure(s): Survey data provided percentage and aggregate figures about availability of medical, radiation and surgical oncologists, chemotherapy nurses, breast cancer nurses, palliative care physicians and allied health professionals according to remoteness and state. Chemotherapy prescribing practices, adherence to occupational health and safety guidelines and availability of multidisciplinary clinics were also explored. Results: A 98% survey completion rate was achieved. Significant deficiencies in service provision were identified in RHAC. Only 21% of RHAC reported a resident medical oncology service, 7% had a radiation oncology unit, and 6% had a resident surgical oncologist. Only 24% of RHAC reported a dedicated palliative care specialist and 39% identified a dedicated oncology counselling service. Other issues included administration of chemotherapy by nurses outside a recognised facility or by nurses without recognised oncology training, limited availability of funded breast care nurses and lack of multidisciplinary clinics. Conclusion: Survey data highlight marked cancer service deficiencies in rural and regional Australia. It is not unreasonable to conclude that these deficiencies might contribute to poorer outcomes for cancer patients living in these areas. The results suggest the need for short‐ and long‐term measures to improve access to best‐practice cancer services for patients living in regional, rural and remote areas of Australia.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

Evaluating the impact of sustainable comprehensive primary health care on rural health

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia. Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria. Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria. Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.     

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.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

“If Only Someone Had Told Me …”: Lessons From Rural Providers

Purpose: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains. Methods: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded. Findings: Emergent themes coalesced into 3 overarching themes addressing practice‐related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner. Conclusion: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.     

Older people's mental health in rural areas: Converting policy into service development,service access and a sustainable workforce

This paper describes the older people's mental health workforce development, policy development and implementation process and quantifies the rural service delivery and access impacts over a 15‐year period in New South Wales. It highlights the factors that are considered to be critical to successful rural service development such as commitment to funding parity, investment in strong local service leadership, and development of innovative, locally adapted rural service models. Building on these foundations, the Older People's Mental Health Program in New South Wales was able to address key challenges relating to service access in rural health and develop new, sustainable specialist older people's mental health service networks. A sustained focus on policy and implementation which explicitly supports rural older people's mental health service enhancement, and development of evidence‐based models of care, has significantly improved access to specialist mental health care for older people in rural areas. It has delivered 23 new rural older people's mental health community teams and a 440% increase in the number of people accessing these teams. It has also doubled the number of acute inpatient units and established new specialist mental health‐residential aged care partnership services in rural New South Wales. It has resulted in increased access to services for the “older old,” while not diminishing older people's rates of access to general adult mental health services. It has also supported innovative, sustainable rural service models such as “hub and spoke” models and step‐up step‐down inpatient services that build on existing health and hospital infrastructure and link geographically dispersed specialist clinicians and services together in rural service delivery.     

Critical health infrastructure for refugee resettlement in rural Australia: Case study of four rural towns

Objective: To explore the reported impact of regional resettlement of refugees on rural health services, and identify critical health infrastructure for refugee resettlement. Design: Comparative case study, using interviews and situational analysis. Setting: Four rural communities in New South Wales, which had been the focus of regional resettlement of refugees since 1999. Participants: Refugees, general practitioners, practice managers and volunteer support workers in each town (n = 24). Results: The capacity of health care workers to provide comprehensive care is threatened by low numbers of practitioners, and high levels of turnover of health care staff, which results in attrition of specialised knowledge among health care workers treating refugees. Critical health infrastructure includes general practices with interest and surge capacity, subsidised dental services, mental health support services; clinical support services for rural practitioners; care coordination in the early settlement period; and a supported volunteer network. The need for intensive medical support is greatest in the early resettlement period for ‘catch‐up’ primary health care. Conclusion: The difficulties experienced by rural Australia in securing equitable access to health services are amplified for refugees. While there are economic arguments about resettlement of refugees in regional Australia, the fragility of health services in regional Australia should also be factored into considerations about which towns are best suited to regional resettlement.     

PREVENTIVE SOCIAL HEALTH PROGRAMS: ARE THEY AUSTRALIA’S ANSWER TO RISING HEALTH CARE COSTS IN RURAL COMMUNITIES?

ABSTRACT: Although we have good evidence to support the notion that early intervention, prevention and community education programs can mitigate the impact of preventable disease, expanded primary health care is also being promoted by Australian governments as a panacea for reducing growth in demand generally. While preventive programs do reduce acute demand, they may not do so to the extent that resources, currently allocated to the acute sector, can be substituted to provide the additional primary care services necessary to reduce acute demand permanently. These developments have particular relevance for rural and isolated communities where access to acute services is already very limited. What appears to be occurring, in rural South Australia at least, is that traditional acute services are being reduced and replaced with lower level care and social intervention programs. This is well and good, but eventually the acute care being provided in rural health units now will still need to be provided by other units elsewhere and probably at much higher cost to the system and to consumers. Where rural communities have previously managed much of their own acute service demand, they may now be forced to send patients to more distant centres for care but at much greater social and economic cost to individuals and the system.     

GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Theory in rural health

Objective: This paper offers theories to explain persistent rural health challenges and describes their application to rural health and research. Methods: Review of theories from several disciplines. Findings: Key issues in rural health are poorer health status and access to health care, staff shortages, relationship‐based health provision and the role of health services in community sustainability. These could be fruitfully addressed by applying theory and findings around social determinants of health, economic sociology, the role of culture and capitals approaches to measuring assets. In particular, the concept of rural health might be a barrier to progressing knowledge; and relational approaches, common in geography, offer a more useful conceptual framework for studying health and place. Conclusions: To move beyond its current stage, rural health needs to look to other disciplines' theories and ideas; particularly, it needs a more contemporary understanding of what place means so that health status and service provision can be improved by more thoughtful research.     

Reducing racism in Aboriginal health care in Australia: where does cultural education fit?

Objective : This paper discusses whether educating health professionals and undergraduate students in culturally respectful health service delivery is effective in reducing racism, improving practice and lessening the disparities in health care between Aboriginal and non‐Aboriginal Australians. Approach : The paper supports the concept of race as a social construction that is discursively produced and reproduced. Studies on the effectiveness of cross‐cultural education for undergraduate students and health professionals to reduce racism and deliver culturally respectful health care to indigenous or minority populations are examined for evidence of sustained improvements to practice. Conclusion : Programs in culturally respectful health care delivery can lead to short‐term improvements to practice. Sustained change is more elusive as few programs conducted long‐term evaluations. Long‐term evaluation of programs in culturally respectful health care delivery is necessary to identify whether early changes to behavior and practices are sustained. Strategies linking policies to practice to reduce health disparities between Aboriginal and non‐Aboriginal Australians are also needed. Implications : Confronting the effects of racism in health services towards Aboriginal Australians is a priority requiring a multi‐tiered commitment to strategies linking policy to practice to reduce health disparities between Aboriginal and non‐Aboriginal Australians. Part of this strategy includes preparing undergraduates and health professionals for culturally respectful health care with education programs that are evaluated for long‐term improvements to practice.     

Self-reported patterns of health services utilisation: an urban-rural comparison in South Australia

Objective: To compare self‐reported patterns of health service utilisation among residents of urban and rural South Australia. Design, setting and main outcome measures: Secondary analysis of data generated by computer‐assisted telephone interviews of 7377 adults done in 1995–6. Respondents were asked if they had used each of 18 different health services during the previous 12 months. Residence was classified in three ways: (1) capital city versus rest of the state, (2) by the Rural, Remote and Metropolitan Areas classification (RRMA) and (3) by the Accessibility and Remoteness Index for Australia classification (ARIA). Results: General practitioner services were most frequently used, by approximately 89% of respondents. Only 4% reported not using any service. Comparing capital city with rest of the state, modest but statistically significant differences in utilisation (P < 0.01) were measured for nine services. In eight of these nine, utilisation was higher among rural residents. Analysing by RRMA, eight services were reportedly used differently and seven of these were the same as those identified from the capital city versus rest of state comparison. Across the five ARIA categories, six previously identified services were reported as being used differentially. Overall, rural residents had a higher than expected rate of moderate and high level of health service use. Conclusions: Self‐reported use of a range of health services was broadly similar across urban and rural South Australia, with most cases of higher use were reported from rural areas rather than urban areas. Similar results were obtained when residence was classified in the three different ways. What is already known on this subject: It is widely reported that the health status of and access to health services for rural Australians is worse than their urban counterparts. However, while this is clearly the case for some conditions and some groups, further data is needed to understand rural–urban health differentials better. Few explicit comparisons of different methods of classifying rurality (RRMA, ARIA and capital city vs. the rest) have been published. What does this study add: This study demonstrates that the self‐reported utilisation of a wide range of health services in South Australia is no worse, and is often greater, among rural residents compared to those in Adelaide. The same conclusions are reached irrespective of the method of classifying rurality.     

From 'problem-describing' to 'problem-solving': challenging the 'deficit' view of remote and rural health

Objective: Rural and remote health research has highlighted the many problems experienced in the bush. While attention to problems has raised awareness of the needs of rural and remote health, embedding a deficit perspective in research has stereotyped rural and remote health as poor environments to work in and as inherently problematic. The objectives of this paper are to challenge this thinking and suggest that a more balanced approach, acknowledging strengths, is beneficial. Design: This discussion identifies why the deficit approach is problematic, proposes a strengths‐based approach and identifies some key strengths of rural and remote health. Results: This study suggests alternative ways of thinking about rural and remote practice, including the rewards of rural and remote practice, that rural and remote communities can act as change agents, that these disciplines actively address the social determinants of health, that rural and remote areas have many innovative primary health care services and activities and that rural and remote contexts provide opportunities for evaluation and research. It is proposed that rural and remote health can be viewed as problem‐solving, thus dynamic and improving rather than as inherently problematic. Conclusion: Critical of a deficit approach to rural and remote health, this paper provides alternatives ways of thinking about these disciplines and recommends a problem‐solving perspective of rural and remote health.     

What do we mean by sustainable rural health services? Implications for rural health research

The concept of health service sustainability, endorsed by the Australian Health Ministers as a key dimension of the National Performance Framework, is particularly important in rural and remote communities. To date, however, few Australian studies have demonstrated how the real drivers of sustainability inter-relate or are translated into sustainable rural and remote health services. This article highlights the need for a systemic approach in which the integrated nature of sustainability components are recognised and evaluated in terms of access to rural and remote health services, quality of care and cost of provision.     

Balancing hospital and community treatment: effectiveness of an extended-hours community mental health team in a semi-rural region of australia

Objective: To examine the effectiveness of the introduction of a community mental health team on consumer psychosocial outcomes. Design: Longitudinal panel design. Setting: District general hospital in a semi‐rural region of Australia. Numbers: Two matched groups (n = 37 in each group) Main outcome measure: These included: Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), Rosenberg Self‐Esteem, Life Skills Profile as well as self‐report. Results: The study found that the introduction of the new service resulted in few significant differences in consumer outcomes. Conclusions: The paper argues that because the state was the only specialist mental health service provider and it was unable to offer assertive community treatment, hospital care remained central. Evidence that a substantial proportion of consumers and carers preferred hospital to community care is placed against this background. The paper argues that in regions like these, where community‐based services are likely to remain underdeveloped, it may be best to maintain quality hospital services and to target community services more precisely on what is achievable rather than developing community services at the expense of hospital care. What is already known: Studies on the efficacy of assertive community treatment suggest that it can lead to improved consumer outcomes. However, these studies are usually in urban settings and involve experimental teams. In many rural and regional areas community treatment teams offer standard rather than assertive community care. It is therefore important to investigate the effectiveness of community treatment teams in rural and regional Australia. What this study adds: This study suggests that in rural and regional areas characterised by limited resources, it is too much to expect community treatment teams to have a measurable impact on consumer outcomes. In these settings hospital care remains at the heart of the service. This means that regions such as these need to focus their community services on what is achievable given the level of resources and social ecology. For example, they may need to consider offering either crisis intervention or rehabilitation services and to rely on innovations, such as telehealth or strategic alliances with other service providers to fill the gap.     

Understanding the Landscape: Promoting Health for Rural Individuals After Tertiary Level Cardiac Revascularization

Purpose: The purpose of this pilot study was to describe the needs and experiences of rural individuals commuting to an urban center for percutaneous coronary intervention (PCI). Methods: Data were analyzed from a “Patient Adherence and Satisfaction Survey” conducted by telephone as part of a quality improvement focus, and supplemented with in‐depth semi‐structured interviews with rural patients following PCI. Findings: Both urban and rural patients after PCI experienced few complications, had made some attempts to reduce tobacco usage, and were highly satisfied with explanations of their treatment and their overall treatment experience. Patients in rural settings were more likely to experience chest pain at least rarely following their surgery than people in urban settings (P < .05). Data on participation in cardiac rehabilitation (CR) showed no significant differences between urban and rural dwellers. Four themes emerged from the interviews: standards of care during treatment; transportation; local resources and community support; and lifestyle changes. Although patients were highly satisfied with standards of care during acute treatment, there were unmet needs in relation to transportation and lifestyle changes. Conclusion: Transitions between rural communities and urban centers and rural adaptations of secondary prevention programs require more attention in health service delivery. Further research is required to better understand potential variations in chest pain patterns between urban and rural residents.     

What principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review

Visiting health services are a feature of health care delivery in rural and remote contexts. These services are often described as ‘fly‐in fly‐out’ or ‘drive‐in drive‐out’. Posing the question ‘What are the different types of visiting models of primary health care being used in rural and remote communities?’, the objective of this article was to describe a typology of models of health services that visit remote communities. A systematic review of peer‐reviewed literature from established databases was undertaken. Data were extracted from 20 papers (16 peer‐reviewed papers and four from other sources), which met the inclusion criteria. From the available evidence, it was difficult to develop a typology of services. The central feature of service providers visiting rural and remote districts on a regular basis was consistent, although the service provider's geographical base varied and the extent to which the same service provider should be providing the service was not consistently endorsed. While a clear typology did not emerge from the systematic review, it became apparent that a set of guiding principles might be more helpful to service providers and planners. Focusing policy and decision‐making on important principles of visiting services, rather than their typological features, is likely to be of ultimately more benefit to the health outcomes of people who live in rural and remote communities.     

Stress and anxiety associated with lack of access to maternity services for rural parturient women

Objective: The objective of this study is to compare the level of stress and anxiety between women resident in communities with different degrees of access to local maternity services. Design: Cross‐sectional survey. Setting: Fifty‐two communities across rural British Columbia with different levels of access to maternity care services (ranging from no services to local specialist obstetrician). Participants: A total of 187 women, 40 of whom were from communities with no local access to services. Main outcome measures: Stress score on the R ural Pregnancy Experience Scale including financial and continuity of care subscales. Results: Parturient women who had to travel more than one hour to access services were 7.4 times more likely to experience moderate or severe stress when compared to women who had local access to maternity services. Conclusions: Lack of access is strongly associated with stress in rural parturient women.