Background
Ageing populations, longer life expectancy, and increased prevalence of chronic disease and complex comorbidities place a burden on health care services and contribute to rising health care costs in Australia This includes expenditure on health goods and services such as hospitals, primary health care (PHC), referred medical services, research, and capital expenditure [
1].
PHC is the front line of the health care system and often the first point of contact for a person. Effective PHC can help avoid unnecessary hospitalisations and improve health outcomes [
2]. However, expenditure has shifted away from PHC to hospitals over the last 20 years, from 37% of total health budget due to PHC and 36% due to hospitals in 2000/1 to 34% on PHC and 40% on hospitals in 2017/18 [
1]. It is delivered across a variety of settings that do not require a referral and includes a range of practitioners for example, general practitioners (GP), and other allied health practitioners and health professionals (i.e. pharmacists, dentists and Aboriginal and Torres Strait Islander health workers and practitioners pharmaceutical, and community and public health services) [
3,
4].
Health professionals deliver PHC services in various settings, including allied health practices, community health centres, general practices, and through communication technology with the emerging use of ‘telehealth’ and online health information [
5] websites such as Healthdirect (Government website for free Australian health advice) [
6] playing increasing and integral roles. Since 2020 and the onset of the COVID-19 disease pandemic, the Australian Government expanded Medicare-subsidised telehealth services so that Australians could access essential PHC from their home [
7].
Hospital systems are under pressure due in part to the prevalence of preventable non-communicable diseases (NCDs), increasing hospital waiting lists, higher patient co-payments, rising private health insurance premiums and increasing out-of-pocket health-related expenses [
8]. Locally delivered, place-based PHC can increase timely access to essential services reducing pressure on hospital wait lists and increasing the efficiency and efficacy of patient care. Place-based primary care works by integrating and coordinating government programs and services and incorporating the resources and ideas of local residents, government, service providers and businesses to improve equity in access and accessibility to health services within a geographical area [
9]. However, the onus still often falls to the client or patient to seek out these services.
Health literacy (HL), the wide range of skills needed to manage one’s health, plays a key role in the ability to access health care. HL includes the consultation, engagement and communication with healthcare providers and navigation through complex healthcare systems [
10‐
12]. The concept of HL also includes the critical appraisal of health information from different sources, identifying social supports needed to access services and maintain health, keep abreast of available services, and understanding ones’ consumer rights to healthcare [
10‐
12]. Lower HL levels are associated with less knowledge of individual’s health problems [
13,
14], how to effectively self- manage [
15], lower uptake of health screenings [
16] and engagement in health promoting behaviours [
17], poor medication adherence [
18], as well as higher rates of hospitalisation [
19‐
21], readmission after discharge [
22], and poorer overall health [
17]. HL is vital to timely access to primary care but many Australians report low levels (59% in 2006) [
23].
Access can be defined broadly as the capacity of people to obtain appropriate services in response to need for care. It represents a fit between patient needs and services that meet those needs, or the dynamic interaction between supply and demand [
24]. This has been conceptualised by Levesque and Harris’ (2013) whose framework illustrates the active relationship between health consumers and characteristics of the health service providers: ability to perceive, ability to seek, ability to reach, ability to pay and ability to engage and the services’ approachability, acceptability, availability and accommodation, affordability, and appropriateness [
25]. Barriers to access can occur due to problems with the abilities of individuals or the attributes of services [
10].
There is a dearth of evidence on integrating place-based primary care within local government settings. Local governments are considered well-positioned to engage with communities and lead local planning and initiatives that can influence equity in health outcomes [
25]. Little is known about West Australians’ perceptions and understanding of place-based primary care and health literacy.
This study aims to:
-
Examine the intersection between health and local government authorities to identify ways to better connect people to place-based PHC.
-
Better understand touch points for health in local government, particularly those related to Local Government Frameworks and regulation, for example the Public Health Act (2016).
-
Identify opportunities for localised reciprocal referral pathways between community organisations and PHC services.
Discussion
This year-long mixed-methods study was designed to achieve three ambitious aims, to:
1.
Examine the intersection between health and local government to identify ways to better connect people to place-based PHC.
2.
Better understand touch points for health in local government, particularly those related to Local Government Frameworks and regulation, for example the Public Health Act (2016).
3.
Identify opportunities for localised reciprocal referral pathways between community organisations and PHC services.
The research identified issues that influenced PHC use in four local government areas in Western Australia, with common variables and themes identified during GMB processes resulting in combined CLD and prioritised action ideas. Systems science methodologies and community health literacy surveys were used to understand how to better connect people to place-based PHC and identify touchpoints for health from the perspective of community members and local organisations. In some circumstances community-led working groups were formed after the GMB to further develop and implement the action ideas. During the final stages of the project, the findings were presented to stakeholders who then identified opportunities for reciprocal referral pathways and better ways of working together. Although place specific, many of the findings are similar as so are likely to be transferable across other metropolitan LGAs in Western Australia.
A recurrent theme across all LGAs was the urgent need for greater access to services, the findings suggest that this could be achieved by building the health literacy of community members and service providers, and by creating more inclusive services. At the GMB workshops some participants were surprised to learn of the types of services that were on offer locally, suggesting a need to promote them. This information is likely to increase access to services and may assist health care practitioners in developing treatment plans and local referral pathways. Greater access would be facilitated by outlining culturally specific capabilities of services, for example, the languages spoken by practitioners, whether Cultural Safety Education and Action training had been undertaken, availability of female practitioners, and areas of speciality (e.g. mental health, sex specific health care, child health, etc.). Overcoming barriers such as poor or no internet connection, low levels of digital literacy, or lack of technology could also increase health service access, LGAs and local service providers could work together to offer internet access, education in digital literacy, and alternate ways to book services, and local librarians could upskill older people, those with disabilities, and help with the technology or accessing data.
Findings suggest that the provision of outreach services and facilitating transport may assist with service access for some community members. Outreach or pop-up services reduce transport needs as does co-location of services within the local community centres. People said they would feel more comfortable seeing mental health counsellors while attending health at local shopping centres or other community locations. Regularly offering medical checks at local seniors’ clubs, for example blood pressure, or blood glucose, were reported as successful in one LGA. Youth hangouts in underutilised local government spaces was another proposition embraced by community members. Our survey showed that these types of local touchpoints were supported by 83% of respondents who indicated that they would be likely to attend a health screening at a local government facility such as a library.
Vulnerable groups, people accessing mental health or disability services, those from culturally and linguistically diverse backgrounds, and older people were a priority consideration in each LGA, and there was a strong perception that these groups were misunderstood or dismissed by health care practitioners, leading to further service exclusion and referrals to inappropriate treatment pathways. The lack of knowledge of health services, allied health and other community services was a major concern across all LGAs.
The findings support the notion that local community organisations can play a role in reducing or preventing some of the common determinants of mental health and chronic disease through methods such as social prescribing [
37]. This approach provides healthcare that is person-centred, holistic and acknowledges the social determinants of health. Social prescribing has been shown to reduce emergency department usage, inpatient admissions, general practice over-attendance and reduce GP workload in some cases but the evidence is mixed [
38‐
40]. This type of strategy may go some way to alleviating the waiting lists and lack of services, including the shortage of GPs outlined during the consultations, however, further research is necessary. This type of non-medical prescription to improve health and wellbeing can include referrals to social activities, sources of information or guidance, and skills development opportunities. The facilitation of partnerships and collaboration at the local level is a key strategy to address health and wellbeing. There was evidence during the GMB discussions of this type of opportunity being used to build mental wellbeing, for example, through partnership with the Act Belong Commit mental health promotion campaign which increases awareness of the importance of the link between social connection and mental health [
41]. The campaign subscribes to Margaret Barry’s (2019) view that “mental health promotion cannot be undertaken by any one sector or any single organization on its own” pg 81[
42] and World Health Organization’s recommendation that that different sectors and organisations work together to impact public health [
43]. The Act Belong Commit campaign’s message to Act (do something), Belong (do something with someone), and commit (do something meaningful) [
44] has been implemented in a number of countries [
45,
46], as it provides a mechanism for numerous organisations to work together to promote mental wellbeing [
47]. Discussions across all LGAs revealed that organisations such as Men’s Shed [
48], the local service clubs, clubs for seniors, multicultural groups, and faith-based groups provide social support and could be used by local primary care practitioners in community referrals. Participation in these social groups can help break the cycle of isolation, loneliness and depression. However, just referring people to these groups and activities may not be enough as lack of appropriate transport was a major barrier across LGAs. Community buses, or volunteers driving their private cars were raised as possible solutions.
Local sports clubs and exercise groups help reduce the burden of chronic disease as they provide opportunities to exercise and to socialise. The local seniors exercise group in one LGA has been running for many years helping members to build new friendships, gain social support and grow a strong sense of community. There was concern about the sustainability of this, and groups like it, as they rely heavily on ageing volunteers, with few younger people ready to take their place. Despite the benefits to the individual of volunteering[
49], the declining number of volunteers was commonly cited by organisations, that has increased since the COVID-19 pandemic [
50]. Additionally, consistent with existing evidence, volunteers in these LGAs report fatigue leading to stress, burnout and associated problems [
51].
Mental health was identified as a key issue by all LGAs, as was the need to build the appropriateness and availability of mental health services at the local level. Shortcomings of mental health services were across the health care system, from insufficient access to locally based accessible counsellors and psychologists (with recommendations to increase the number of local specialists), a lack of skills among general practitioners (with suggestions to provide professional development),and prioritise mental health in tertiary education.
Preventive services were considered important, with specific recommendations to build local organisational capacity, for example, through establishing youth ‘hang out’ centres, local community activities to build wellbeing and foster and maintain connections and co-locating services within existing local government facilities. There was a shared understanding that these actions were presented as ways to halt and reduce the ever-increasing waitlists for counselling services.
The current study findings suggest that mental health literacy across the community needed to be improved, with one GMB group suggesting that mental health first aid training be made available to all community members and organisations. Given this training addresses mental health first aid, increases knowledge regarding recognition and treatment of mental disorders, and addresses stigma and improving confidence in engaging with people with mental health issues [
52], this training would likely be benefit all communities in this study. However, given the complexity of issue relating to mental health identified in this study (including domestic violence, economic hardship, alcohol and other drugs, discrimination, and stigma), targeted training is recommended. Also, there have been recent changes in workplace legislation around domestic violence and bullying [
53] and this information should be incorporated into mental health first aid training.
For many reasons, community members felt there was a need to build trust in the health system. The racism, stigma, culturally inappropriate, and discriminatory practices were described as negative experiences leading to vulnerable people being less likely to be engaged with health services. Racism has long been recognised as a social determinant of health in Australia with evidence that culturally respectful health care delivery can lead to improvements in the short term, but that more is needed to reduce disparities in the long term [
54,
55]. One group recommended that the GMB process be conducted with a group of Aboriginal and Torres Strait Islander people to address this issue, this is consistent with recommendations to build HL through a two-way capacity (Aboriginal people and health service providers) [
55].
Community health literacy scores were of a level similar to those published in recent Australian studies [
36,
56]. The lowest health literacy scores were in the scales related to the ability to actively manage one’s own health, to appraise health information, having social support for health, having sufficient information to manage health, and feeling understood and supported by healthcare practitioners. These findings were also confirmed in the CLDs reported in this study. Socio-demographics play an important role in determining levels of health literacy. Cluster profiles demonstrated the associations between health literacy and education, paid employment, and ability to save money, and this is consistent with a recent literature review which found that there were associations between social gradients and health literacy in all analyses of national population surveys [
57]. Low levels of health literacy have also been found to be associated with being a male from a racial/ethnic minority, who is highly influenced by family or significant other, and is unable to work [
58]. Among a sample of Australian First Nations people, high health literacy levels were related to being less than 55 years old, female, having only one chronic disease, higher levels of education and an income of less than AUD$55,000 [
59].
The current study findings suggest there is a need to improve health literacy among vulnerable target groups and to understand local issues. Feedback sessions with health service and local government organisations suggested that the vignettes would be particularly useful for them in helping them to describe the types of people who should be targeted in any intervention, and the areas that already have high levels of health literacy. The locally identified and prioritised action ideas identified by those attending the workshops will require resourcing and support to reach fruition. Follow-up workshops with key stakeholders identified that some of the services recommended already existed, and this confirmed the need for ongoing collaboration and development of communication mechanisms to sharing information at the local level. The final outcomes of the research were reported to funders with key recommendations, based on the findings, emphasising the expectations of participants to changes in service delivery as a result of the consultation.
Finally, this research applied a systems mapping approach as the purpose was to try to understand this complex, adaptive system in a practical, actionable, and participatory way. The mapping resulted in a real-world, shared understanding of causal relationships described at a local level in four different communities. This paper presents the common themes, there were also some local differences. The time taken to build relationships and engage local stakeholders was needed, and it was valuable placing researchers in each organisation to assist with this engagement. The research aimed to consider the intersection between health, health literacy and local government to identify ways to better connect people to place-based primary health care (PHC).
Barnrook-Johnson and Penn (2022) assert in there reflections on systems mapping, that “There is a growing need in a range of social, environmental, and policy challenges for a richer more nuanced, yet actionable and participatory, understanding of the world” pg vii [
60], and this current study using a systems approach coupled with the measurement of health literacy provided rich insights and delivered community driven place-based priorities actions.
Strengths and limitations
A strength of this research is that we had wide consultation with community members, we used several data sources across four LGAs. Researchers were embedded within each of the areas for about a year which built strong relationships and facilitated engagement with both the LGAs, community members and organisations. A limitation of this research was that it was a scoping exercise, rather than participatory research to develop and implement interventions. Several of the community action ideas identified could be developed further and implemented at the local level however, would require collective impact which needs organisational support and funding [
61]. Although explicitly stated at the initial workshop that this was not the case, the consultations and engagement created expectations of future support and action. This may have impacted on the willingness of people to engage in the ongoing process. It is important not to over consult, rather, projects like this one should focus on collaboration and dissemination of findings across relevant sectors.