Primary health care delivery models in rural and remote Australia – a systematic review

© 2008 Wakerman et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background 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. Methods 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. Results 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. Conclusion 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

Evidence-based practice in rural and remote clinical practice: where is the evidence?

OBJECTIVE: To critically review the evidence regarding barriers to implementing research findings in rural and remote settings, and the ways those barriers have been addressed. DESIGN: A systematic review that included searching several electronic databases, Internet sites and reference lists of relevant articles, assessment of methodological quality of the studies, and data extraction and analysis where possible. Eligibility for the review was not limited by study design. SETTINGS/PARTICIPANTS: Studies that reported on: (1) barriers to the implementation of evidence by health professionals in rural and remote areas, or (2) interventions for implementing evidence-based practice or an element of evidence-based practice in rural and remote areas. RESULTS: There were no experimental data available on the implementation of research findings in rural and remote clinical settings. The small amounts of empirical research undertaken (surveys) showed that some of the problems experienced by general practitioners were exacerbated by rural and remote location, particularly with relation to isolation, lack of time and locum cover, and poor information technology infrastructure. CONCLUSION: There is a paucity of empirical literature on implementing evidence-based practice in rural and remote settings. This is in contrast to the large amount of literature available on implementing evidence in other clinical settings. A clear finding from the literature was that getting evidence into practice needs to be context-specific and yet very little research has been conducted into the rural and remote context. Research is needed into how evidence can be implemented in contextually specific ways in rural and remote areas. WHAT IS ALREADY KNOWN: There is a substantial body of literature about the barriers to implementing research findings into clinical practice and how to address these barriers. This literature includes many systematic reviews and even overviews of systematic reviews. One of the consistent findings of the literature is that the implementation of research findings needs to be context-specific to have any chance of making lasting and worthwhile changes to practice. There is little work, however, on the context of rural and remote clinical practice. WHAT THIS STUDY ADDS: This study aimed to review the literature on the implementation of evidence based practice in rural and remote settings. No experimental studies were found and the limited empirical evidence from surveys found that the rural and remote context exacerbated some of the problems experienced by health professionals in other settings, particularly those related to lack of time, inability to get locum cover and poor and unreliable information technology infrastructure. More research is required to isolate the aspects of rural and remote practice that influence the uptake of research findings.Jacqueline E. Parsons, Tracy L. Merlin, Judy E. Taylor, David Wilkinson and Janet E. Hille