A Systematic Review of Primary Health Care Delivery Models in Rural ad Remote Australia 1993–2006

Centre for Remote Health, Joint Centre of Flinders University & Charles Darwin University, Alice Springs, Northern Territory, Australia.
BMC Health Services Research (Impact Factor: 1.71). 01/2009; 8(1):276. DOI: 10.1186/1472-6963-8-276
Source: PubMed


One third of all Australians live outside of its major cities. Access to health services and health outcomes are generally poorer in rural and remote areas relative to metropolitan areas. In order to improve access to services, many new programs and models of service delivery have been trialled since the first National Rural Health Strategy in 1994. Inadequate evaluation of these initiatives has resulted in failure to garner knowledge, which would facilitate the establishment of evidence-based service models, sustain and systematise them over time and facilitate transfer of successful programs. This is the first study to systematically review the available published literature describing innovative models of comprehensive primary health care (PHC) in rural and remote Australia since the development of the first National Rural Health Strategy (1993-2006). The study aimed to describe what health service models were reported to work, where they worked and why.
A reference group of experts in rural health assisted in the development and implementation of the study. Peer-reviewed publications were identified from the relevant electronic databases. 'Grey' literature was identified pragmatically from works known to the researchers, reference lists and from relevant websites. Data were extracted and synthesised from papers meeting inclusion criteria.
A total of 5391 abstracts were reviewed. Data were extracted finally from 76 'rural' and 17 'remote' papers. Synthesis of extracted data resulted in a typology of models with five broad groupings: discrete services, integrated services, comprehensive PHC, outreach models and virtual outreach models. Different model types assume prominence with increasing remoteness and decreasing population density. Whilst different models suit different locations, a number of 'environmental enablers' and 'essential service requirements' are common across all model types.
Synthesised data suggest that, moving away from Australian coastal population centres, sustainable models are able to address diseconomies of scale which result from large distances and small dispersed populations. Based on the service requirements and enablers derived from analysis of reported successful PHC service models, we have developed a conceptual framework that is particularly useful in underpinning the development of sustainable PHC models in rural and remote communities.

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    • "With regard to services, larger regional centres tend to have a range of primary healthcare and a general hospital, while smaller towns might have a hub of more limited primary healthcare services and a community hospital. Suitable service arrangements for small remote settlements are hard to define [3] and remote places are vulnerable to small changes in population and healthcare providers. "
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    ABSTRACT: This paper explores how community participation can be used in designing rural primary healthcare services by describing a study of Scottish communities. Community participation is extolled in healthcare policy as useful in planning services and is understood as particularly relevant in rural settings, partly due to high social capital. Literature describes many community participation methods, but lacks discussion of outcomes relevant to health system reconfiguration. There is a spectrum of ideas in the literature on how to design services, from top-down standard models to contextual plans arising from population health planning that incorporates community participation. This paper addresses an evidence gap about the outcomes of using community participation in (re)designing rural community health services. Community-based participatory action research was applied in four Scottish case study communities in 2008-10. Data were collected from four workshops held in each community (total 16) and attended by community members. Workshops were intended to produce hypothetical designs for future service provision. Themes, rankings and selections from workshops are presented. Community members identified consistent health priorities, including local practitioners, emergency triage, anticipatory care, wellbeing improvement and health volunteering. Communities designed different service models to address health priorities. One community did not design a service model and another replicated the current model despite initial enthusiasm for innovation. Communities differ in their receptiveness to engaging in innovative service design, but some will create new models that fit in a given budget. Design diversity indicates that context influences local healthcare planning, suggesting community participation impacts on design outcomes, but standard service models maybe useful as part of the evidence in community participation discussions.
    BMC Health Services Research 03/2014; 14(1):130. DOI:10.1186/1472-6963-14-130 · 1.71 Impact Factor
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    • "In terms of dissemination and implementation, the overall process evaluation findings reported here support the benefits of a significant government investment in a community-based child obesity treatment program to reach into socially disadvantaged communities, including Aboriginal and rural children. We found that the up-scaling of Go4Fun® into a real world setting was successful in its reach into Aboriginal families and families from lower socio-economic groups and more geographically remote locations where communities not only face significant greater health disadvantage, but limited access to health care services [16]. Almost 6% of participants identified as Aboriginal or Torres Strait Islander and given the significant health disadvantage of Aboriginal Australians [17,18], including higher rates of paediatric obesity [19], this finding was encouraging as the Go4Fun® program had not been specifically designed for Aboriginal communities and had a greater representation than would be expected from the community (NSW population prevalence of 5 to 15 year old Aboriginal children is approximately 4%) [20]. "
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    ABSTRACT: Community-based obesity treatment programs for children that have a large program reach are a priority. To date, most programs have been small efficacy trials whose findings have yet to be up-scaled and translated into real-world settings. This paper reports on the process evaluation of a government-funded, translated obesity treatment program for children in Australia. It describes the characteristics and reach of children participating in the New South Wales (NSW) Ministry of Health Go4Fun(R) program. Delivered across the state of NSW (Australia) by Local Health Districts (LHDs), Go4Fun(R) is a community-based, multidisciplinary family obesity treatment program adapted from the United Kingdom Mind Exercise Nutrition Do it (MEND) program that targets weight-related behaviours. Children aged 7-13 years with a BMI >=85th percentile and no co-morbidities were eligible at no cost. Parents/carers self-refer via a toll-free phone number, text messages, online registration or via secondary referrals. LHDs deliver a 16 to 20-session program based on length of school term, holidays and recruitment challenges. Both parent/carer and child attend bi-weekly after school sessions. Parent-reported socio-demographic and measured child weight characteristics are presented using descriptive statistics. Differences between completers (attended at least 75% of sessions) and non-completers were assessed using chi-square tests, independent sample t-tests and adjusted odds ratios. Analyses were adjusted for clustering of programs. Between 2009 and 2012, a total of 2,499 children (54.8% girls; mean age [SD]: 10.2 [1.7 years]) participated in the Go4Fun(R) program. Children were mainly from low-middle socioeconomic status (76.5%), resided in major cities (63.3%), and 5.7% were Aboriginal. At baseline, 96.5% of children were overweight or obese. Mean BMI-z-score was 2.07 (0.41) and 94.5% had a waist-to-height ratio >=0.5. More than half (57.9%) completed at least 75% of sessions. Amongst completers (N = 1,446), girls (56.8%; p = 0.02), non-Aboriginal children (95.9%; p < 0.01) and children residing in less socially disadvantaged areas (25.9%; p = 0.02) were significantly more likely to complete the program. The Go4Fun(R) program successfully reached the targeted population of overweight/obese children at socioeconomic disadvantage and is a rare example of an up-scaled translational program.
    BMC Public Health 02/2014; 14(1):140. DOI:10.1186/1471-2458-14-140 · 2.26 Impact Factor
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    • "It may reflect the increase time pressure on rural GPs coping with increased workloads [49]. It reinforces the case for greater availability of other health professionals including nursing and allied professionals to provide preventive interventions as well new models of primary health in rural Australia [50,51]. "
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    ABSTRACT: Background Despite being at high risk, disadvantaged patients may be less likely to receive preventive care in general practice. This study aimed to explore self-reported preventive care received from general practitioners and the factors associated with this by healthy New South Wales (NSW) residents aged 45–74 years. Methods A self-completed questionnaire was sent to 100,000 NSW residents in the 45 and Up cohort study. There was a 60% response rate. After exclusions there were 39,964 participants aged 45–74 years who did not report cardiovascular disease or diabetes. Dichotomised outcome variables were participant report of having had a clinical assessment of their blood pressure (BP), blood cholesterol (BC) or blood glucose (BG), or received advice to eat less high fat food, eat more fruit and vegetables or be more physically active from their GP in the last 12 months. Independent variables included socio-demographic, lifestyle risk factors, health status, access to health care and confidence in self-management. Results Most respondents reported having had their BP (90.6%), BC (73.9%) or BG (69.4%) assessed. Fewer reported being given health advice to (a)eat less high fat food (26.6%), (b) eat more fruit and vegetables (15.5%) or (c) do more physical activity (19.9%). The patterns of association were consistent with recognised need: participants who were older, less well educated or overweight were more likely to report clinical assessments; participants who were overseas born, of lower educational attainment, less confident in their own self-management, reported insufficient physical activity or were overweight were more likely to report receiving advice. However current smokers were less likely to report clinical assessments; and rural and older participants were less likely to receive diet or physical activity advice. Conclusions This study demonstrated a gap between reported clinical assessments and preventive advice. There was evidence for inverse care for rural participants and smokers, who despite being at higher risk of health problems, were less likely to report receiving preventive care. This suggests the need for greater effort to promote preventive care for these groups in Australian general practice.
    BMC Family Practice 06/2013; 14(1):83. DOI:10.1186/1471-2296-14-83 · 1.67 Impact Factor
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