ABSTRACT: Policy makers and researchers increasingly look to systematic reviews as a means of connecting research and evidence more effectively with policy. Based on Australian research into rural and remote primary health care services, we note some concerns regarding the suitability of systematic review methods when applied to such settings. It suggests that rural and other health services are highly complex and researching them is akin to dealing with "wicked" problems. It proposes that the notion of "wicked" problems may inform our understanding of the issues and our choice of appropriate methods to inform health service policy. Key issues including the complexity of health services, methodological limitations of traditional reviews, the nature of materials under review, and the importance of the service context are highlighted. These indicate the need for broader approaches to capturing relevant evidence. Sustained, collaborative synthesis in which complexity, ambiguity and context is acknowledged is proposed as a way of addressing the wicked nature of these issues.
Australian health review: a publication of the Australian Hospital Association 11/2009; 33(4):592-600. · 0.55 Impact Factor
ABSTRACT: To describe the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of primary health care (PHC) service delivery in rural and remote Australia.
Case-study approach, including review of relevant literature, interviews with key informants, site visits and direct observation. Thematic analysis and template analysis were used with interview transcripts. An expert reference group provided feedback and advice on policy relevance.
Six PHC services in small communities across rural and remote Australia were selected based on results of a previous systematic review; they reflected diverse rural and remote settings and PHC models, and the multidisciplinary nature of PHC. Sites were visited, and 55 individuals associated with the establishment and operation of these services were interviewed between July 2006 and December 2007.
Independent and template analysis confirmed the usefulness of a conceptual framework, which identified three key "environmental enablers" - supportive policy; federal and state/territory relations; and community readiness - and five essential service requirements - governance, management and leadership; funding; linkages; infrastructure; and workforce supply. Systematically addressing each of these factors improves effectiveness and lessens the threat to service sustainability.
Evidence from existing effective rural and remote PHC services can inform the health care reform agenda, in Australia and other countries. The evidence highlights the need for improved governance, management and community involvement, as well as strong, visionary political leadership to achieve a more responsive and better coordinated health system which could help eliminate existing health status differentials between cities and rural areas. In Australia, establishment of a single national health system, operationalised at a regional level, would obviate much of the current inefficiency and poor coordination.
The Medical journal of Australia 08/2009; 191(2):88-91. · 2.81 Impact Factor
ABSTRACT: Successful, "innovative" primary health care (PHC) models exist that have adapted to the specific circumstances of their rural and remote context. A typology of discrete, integrated, comprehensive and outreach rural and remote services exists rather than a "one coat fits all" PHC health service model. Successful models are characterised by macro-scale environmental enablers (supportive health policy, federal-state relations, and community readiness) and five essential service requirements (workforce organisation and supply; funding; governance, management and leadership; linkages; and infrastructure). Service sustainability depends on ensuring that key systemic service requirements are met at the local level in ways that accord with, and are supported by, the broader macro-scale environmental enablers. Based on these principles, these model types are amenable to generalisation and evaluation in other regions.
The Medical journal of Australia 05/2008; 188(8 Suppl):S77-80. · 2.81 Impact Factor
ABSTRACT: To validate earlier findings that lack of access to health services is the most likely issue of complaint by rural consumers, and that lack of knowledge about how to make effective complaints and scepticism that responses to complaints bring about service improvement account for the under-representation of complaints from rural consumers.
Unaddressed reply-paid mail survey to 100% of households in small communities, and 50%, 20% or 10% in progressively larger communities.
Eight communities in the Loddon-Mallee region of Victoria.
983 householders most responsible for the health care of household members, responding to a mailed questionnaire.
Issues of complaints actually made; issues of unsatisfactory situations when a complaint was not made; reasons for not complaining; to whom complaints are made; and plans for dealing with any future complaint.
Earlier findings were confirmed. Lack of access to health services was the most important issue, indicated by 54.8% of those who had made a complaint, and 72% of those who wanted to but did not. The most common reason given for not complaining was that it was futile to do so. Lack of knowledge of how to make effective complaints which might contribute to the quality assurance cycle was evident.
Rural consumers' disaffection with health complaints as a means to quality improvement poses a significant barrier to consumer engagement in quality assurance processes. Provider practices may need to change to regain community confidence in quality improvement processes.
Australian health review: a publication of the Australian Hospital Association 09/2006; 30(3):322-32. · 0.55 Impact Factor
ABSTRACT: To identify which explanations account for lower rural rates of complaint about health services--(i) fear of consequences where there is little choice of alternative provider; (ii) a higher complaint threshold for rural consumers; (iii) lack of access to complaint mechanisms; or (iv) reduced access to services about which to complain.
Ecological study incorporating consumer complaint, population and workforce distribution data sources.
All health care providers practising in Victoria.
De-identified records of all closed consumer complaints made to the Health Services Commissioner, Victoria, between March 1988 and April 2001 by Victorian residents (13 856 records).
Differences in the percentage of under-representation in complaint rates in total and for each of four categories of health services providers for different size communities.
No consistent relationship was observed between community size and either degree of under-representation of complaints against any category of provider, or the proportion of serious or substantial complaints. Rural under-representation was highest (41%) for dentists, the provider category with the lowest proportion working in rural areas (17%), and lowest (18%) for hospitals, with the highest representation in rural areas (28% of beds). More rural complaints were about access issues (10.7% rural and 8.4% metropolitan).
Reduced opportunity to use health services due to rural health and medical workforce shortages was the best-supported explanation for the lower rural complaint rate. Workforce shortages impact on the quality of rural health services and on residents' opportunities to improve their health status.
Australian Journal of Rural Health 01/2006; 13(6):353-8. · 1.00 Impact Factor
ABSTRACT: To investigate the reasons for complaint or non-complaint by rural consumers of health services.
Qualitative study using focus group discussion of hypothetical scenarios.
Selected rural communities in the Loddon-Mallee region of north-western Victoria.
Sixty volunteer participants in eight focus groups recruited through advertising.
Issues and themes concerning circumstances leading to, and factors inhibiting, complaints about a health service and awareness of complaints mechanisms.
Compared with residents of larger towns, those of small communities were more likely to report they would complain to the local provider, whereas those in larger towns were more likely to mention Hospital Boards or the Commissioner. Deterrents to making complaints included the lack of services, scepticism about the role of complaints in bringing about change and an attitude that it was more appropriate to try to fix the problem than complain about it. Lack of awareness of appropriate complaint mechanisms which feed into quality assurance processes was also identified.
Previously documented lower complaint rates from rural consumers can not be taken to mean greater satisfaction with health services.
Australian health review: a publication of the Australian Hospital Association 12/2005; 29(4):447-54. · 0.55 Impact Factor
ABSTRACT: To evaluate whether rural consumer preferences for health services have changed over time or vary across communities with different models of health service delivery.
Questionnaire survey replicating a 1989 study, with ranking of seven different healthcare services.
Adult occupants from a 20% sample of private residences, in towns and on farms, in the rural shires of Bogan and Warren in north-west New South Wales. The survey was conducted in September 2002.
Rank order of preferences for different healthcare services; preference structure intervals showing relative "distance" between preferences.
Response rates were 68% (Nyngan town), 78% (Nyngan farms) and 59% (Warren town). The doctor was the most valued health service in rural communities, followed by the hospital. These preferences occurred regardless of age, sex or place of residence, persisted over time, and were similar for residents of towns with different models of healthcare service provision.
Rural people, both in towns and on farms, rate acute primary healthcare services provided by the doctor and hospital as the two most important services. These preferences have not changed substantially after a decade of restructuring rural health services and reorienting them towards a primary healthcare approach. The stability of rural consumer preferences may reflect a bias towards the status quo.
The Medical journal of Australia 08/2004; 181(2):91-5. · 2.81 Impact Factor
ABSTRACT: To examine the complexity of activities undertaken in general practice in relation to degree of rurality of the practice.
National mail questionnaire survey across non-metropolitan Australia in July 2002.
1498 respondents out of 4406 GPs providing at least 375 Medicare-rebatable consultations in rural and remote locations during January-March 2002 (response rate, 35%).
Responses to five sentinel measures of practice complexity.
In general, the proportion of GPs providing complex services increases with increasing rurality or remoteness. Isolated rural and remote GPs manage myocardial infarctions to a higher level than GPs in larger rural and regional centres, are more likely to administer cytotoxic drugs, perform forensic examinations, stabilise injured patients pending retrieval, and coordinate discharge planning more often.
The more rural or remote the area, the more likely a GP is to be regularly engaged in complex care. These findings have implications for the workload, responsibility, vocational satisfaction, need for professional education and support, and costs and remuneration of practice.
The Medical journal of Australia 11/2003; 179(8):416-20. · 2.81 Impact Factor
ABSTRACT: To ascertain which factors are most significant in a general practitioner's decision to stay in rural practice and whether these retention factors vary in importance according to the geographical location of the practice and GP characteristics.
National questionnaire survey. The method of paired comparisons was used to describe the relative importance of the retention items.
Non-metropolitan Australia, September 2001.
A stratified sample of all rural GPs practising during April-June 2001.
A rank ordering of factors influencing how long GPs stay in rural practice, and an index of their relative perceived importance.
Professional considerations -- overwhelmingly, on-call arrangements -- are the most important factors determining GP retention in rural and remote areas. Rural doctors consistently ranked on-call arrangements, professional support and variety of rural practice as the top three issues, followed by local availability of services and geographical attractiveness. Proximity to a city or large regional centre was the least important factor. Retention factors varied according to geographical location and GPs' age, sex, family status, length of time in the practice, and hospital duties.
A broad, integrated rural retention strategy is required to address on-call arrangements, provide professional support and ensure adequate time off for continuing medical education and recreation.
The Medical journal of Australia 06/2002; 176(10):472-6. · 2.81 Impact Factor
ABSTRACT: Quality of health services is a matter of increasing importance to health authorities. Monitoring consumer satisfaction of health care is an important input to improving the quality of health services. This article highlights a number of important considerations learned from rural consumer studies relevant to ensuring the valid measurement of consumer satisfaction with rural health services, as a means of contributing to quality improvements.
This article compares two methods of analysing rural consumers' satisfaction with healthcare services. In one study of three rural communities in western New South Wales (NSW) and eight communities in north-west Victoria, residents were asked to rate their satisfaction with five key aspects of local health services (availability, geographical accessibility, choice, continuity, economic accessibility as measured by affordability) using a 5 point Likert scale from: one = very satisfied to five = very dissatisfied. An alternative method of assessing levels of consumer satisfaction was undertaken in the survey of eight rural communities in north-west Victoria by investigating consumers' experiences with actual and potential complaints in relation to health services.
Both the NSW and Victorian respondents reported generally high levels of satisfaction with the five indicators of quality of health care. At the same time, 11% of Victorian study respondents reported having made a complaint about a health service in the previous 12 months, and one-third of the Victorian respondents reported experiences with their health services about which they wanted to complain but did not, over the same period.
Interpretation of apparent consumer satisfaction with their health services must take particular account of the measures and research methods used. In assessing consumer satisfaction with health services in rural areas, specific attention should be given to maximising the engagement of rural consumers in order to ensure representativeness of findings, and to minimise possible biases in satisfaction ratings associated with the use of particular tools.
Rural and remote health 6(4):594. · 0.98 Impact Factor