Results
Physiotherapy surveys were received from 11 of the 25 (44%) public sector facilities identified as providing physiotherapy services in the investigation area. The sixteen completed surveys received from the 11 sites represented a 29.4% response rate as 54 physiotherapy surveys were distributed. From the surveys a matrix was developed to identify cases for purposeful sampling [
35]. The surveys identified two key factors relevant to rural physiotherapy service provision: rurality and the number of physiotherapists. In view of the expressed limitations of geographic classification systems [
30] participant perspectives of rurality (rural, regional or remote) were used to inform cases. The number of co-located colleagues was the second factor identified as a potential differentiating factor of rural physiotherapy service provision. This is consistent with the literature in which workforce and position shortages are recognised as characteristics of rural physiotherapy [
37].
An example of an stratified purposive sampling [
6], the proposed matrix had a potential total of 12 cells although many may not be applicable (Table
1). A regional setting with only a part time physiotherapist (less than one Full Time Equivalent (FTE)) is one such example. In addition to informing case site selection, participant perspectives of rurality were compared to current rural classification systems to identify commonalities and differences. Interview responses of participants at identified case sites then further contributed to concepts of rurality relevant to rural physiotherapy service provision.
Table 1
An initial matrix
The initial matrix was revised to reflect stakeholder responses including the larger referral centres and mixed stakeholder responses about the rurality of one location (Table
2). Six case types emerging from the physiotherapy responses. A further 23 surveys (five private practitioner, 13 colleague/manager and five consumer) were received from stakeholders at identified case sites. Nineteen interviews were conducted across the sites of the study.
Remote | | | | |
Rural- remote | | | 7 | |
Rural | 3 6* 5 9^ 11* | 1, 10^ | 4 | |
Regional | | | 8 | 2 |
Participant responses highlight the conceptual challenges when describing rurality and defining regional, rural and remote. For example participants who worked in a location with more than ten FTE physiotherapists stated:
“
I suppose regional, yes. I don’t really consider myself to be rural. For me it is, I don’t consider this to be rural just because I can live here and have a city lifestyle without the stress and the traffic and the pollution. I don’t believe I’m living the rural lifestyle. If I had a rural lifestyle I’d have a farm”. [A3]
“
I suppose we’d be regional, I think of myself as rural but I think it’s probably regional”. [D1]
One participant who worked in an area with between four to ten FTE physiotherapists stated that their perception of rurality was to some degree based on patient location.
“And that was the big thing from city versus country physio or rural physio, a lot of my patients travel six hours to see me”. [B4]
Participants also felt that access to services also assisted in defining the rurality of a location. For example a participant from a large country centre noted: “the capacity to access high level services is limited [here]…and so the capacity to access the higher level service I think is one of the things that defines this as remote”. [D4]. This was also reflected in smaller rural locations, adding to the notion of access to services and support as an important consideration in understanding rurality.
“The differences are like in metropolitan – in provincial … we've now got some specialists in most places. Whereas here you're expected to know hands and everything else so at least you’ve got a context. So it’s a video conference with the people for hands in [the capital city] but getting into the video conferences is an issue because that’s in the hold and treat rooms [for mental health patients]”. [A8]
Discussion
The rurality of the case types reflected the way in which physiotherapists identified the setting in which they practice. Physiotherapy participants described eight of the eleven sites as rural, two as regional and one as remote-rural (Table
2). Fulltime equivalent (FTE) physiotherapist numbers ranged from 0.4 FTE (i.e. one physiotherapist working two days per week) to 14 FTE across the sites of this study. Six case types emerged from the responses from the public sector physiotherapists. Physiotherapist perception of rurality (PPR) in sites with four to ten physiotherapists was an important factor in making distinctions between sites, whereas the number of FTE physiotherapists was a greater differentiator in rural and regional sites. Fulltime equivalent categories could be further differentiated, but for the purpose of this study four categories were used.
Fewer case types would have emerged if a single measure of rurality was the only differentiating factor. Three case types would emerge if PPR, RRMA or ARIA were used as a single measure and only two case types if ASGC was to be used as the only differentiating factor. Comparison of rurality for each site using remoteness classifications revealed a variable picture (Table
3). The differentiated case types that emerged from the dual measures of PPR and FTE informed the selection of cases for this study.
Table 3
Comparison of cases using different rurality classification systems
ASGC-RA | 3 | 2 | 3 | 2 | 3 | 2 | 3 | 2 | 3 | 2 | 3 |
RRMA | 5 | 3 | 5 | 3 | 5 | 5 | 4 | 4 | 5 | 3 | 5 |
ARIA | A | HA | MA | A | MA | A | A | HA | A | A | A |
PPR | Rural | Regional | Rural | Rural | Rural | Rural | Remote-Rural | Regional | Rural | Rural | Rural |
Population (,000) | 10-20 | 35-45 | 1-5 | 35-45 | 1-5 | 1-5 | 15-25 | 30-40 | <1 | 5-10 | <1 |
Public HHS beds | <50 | 200-500 | <50 | 100-200 | <50 | <50 | 50-100 | 50-100 | <50 | <50 | 0 |
The complexity of understanding the concept of rurality was revealed by interview participants when discussing perceptions of rurality relevant to their setting. Issues around the concept of rurality include the following:
-
Is it the practitioner or the setting that defines rural health;
-
is it about distance from a centre or a service provider;
-
is it service size including the number of providers or a sole part time worker;
-
is it about workforce availability;
-
is it about the type of work undertaken such as specialist or generalist skills;
-
is it about support available to the health professional;
-
is it being visible and accountable to the community;
-
is it about local knowledge or
-
is it about distance from decision-makers?
Questions such as these reveal the convolutions of rurality and the variability often reported in the literature around rural health service provision [
31,
38,
39]. Such variation further reinforces the need for the development of measures that can reflect this complexity and variation. Use of only a geographical classification of rurality is not sufficient to be able to distinguish between sites and thus cases when undertaking rural health service research. Dual measures, such as rurality and workforce numbers, provide more relevant differentiation than a single measure of rurality as defined by geographic classification. Similarly the continued use of catch-all term such as ‘rural health’ can limit the understanding of the similarities and differences found across locations [
40]. Without understanding the associations between the specifics and context of each place, the attributes within the population and individual health services being delivered there is a large gap regarding the understanding of the specifics of health services in local rural communities.
This study adds to the literature describing limitations in the application of geographical classifications for differentiating rural health services. This study revealed that participant perspective of rurality often differed with the geographical classification of their location. For example, one participant expressed a sense of isolation more consistent with remote areas than that of a rural location.
“in Katherine and things like that, in what's considered remote area and yet [here] I'm the only Allied Health therapist…so I'm actually probably.... professionally more isolated than a lot of these people …at least have teams in more remote areas”. [A8]
Not only does the health professional feel isolated but access to services would be likely to be a key issue for residents in this location. This is consistent with the work of McGrail and Humphreys [
30] which suggests that access to health services is a function of several factors including availability, proximity, health needs and mobility. The effect of distance on the accessibility to health care services has been identified as a key factor differentiating rural and remote from metropolitan health care [
38]. Population size and geographical location then influence the mode and form of service delivery with socio-economic and geographic inequities influencing access to health care [
38]. Implications for provision of health care, particularly primary health care have been discussed in the literature [
38] however implications for provision of specific health services such as physiotherapy in rural settings are less evident.
Variability and diversity are characteristic of rural Australia [
7], and combine with the unique demography of rural and remote Australia as key determinants of health problems and health service needs [
8]. Adopting an approach that enables insight into variability and diversity of different sites is consistent with the dynamic characteristics of place. Health service provision in rural areas is increasingly influenced by networks, connections and linkages that may occur within defined boundaries of a local health system, but are increasingly Examples that emerged in this study include the impact on smaller rural physiotherapy service providers when new regional services are established and how a national decision such as activity based funding influences the health system and service delivery at all levels.
"recently I have told by [the regional centre] that I need to do all these lymphoedema patients and this is the pre assessment in terms of the all the whole population of anyone having breast cancer… to see them all – measure them all up before surgery… I said “I can’t do that” but that’s what I would be expected to do so, that is a direction coming from [the regional centre who are] saying we can’t do all of these". [A5]
"they just send them anywhere they can to get them out of [the regional hospital]…they have to get them out of there… you know within four days....[because of] funding, pressure, bed block … pressure to get them out, get them going, send them home". [A8]
"[Length of stay]…it’s a huge measure and that, with activity based funding, they are going to be huge drivers.... Bed block, length of stay, money, will always stick up in their head and that is the thing that they will see as important … [the national health reform], it sort of sets the big agenda that will trickle down to us in other ways as in if they’ve got a project that they want that has a bucket of money, that will influence some decisions about what services are provided with that bucket of money and it just depends whether we’re in the mix or up in their face or not. Yes, it sets that whole funding agenda that’s going to have a major influence". [A1]
These influences affect health service provision and can be lost when investigating service level decision making in rural health. The combination of missed methods utilising a survey followed by a collective case study and systems theory approach has demonstrated an appropriate framework to identify the issues surrounding rurality. Without further understanding of rurality, investigation into rural health will be lacking. Utilisation of this mixed methods approach could be applied to other rural health issues and may help to add to the research around health service delivery.
Limitations
The research framework described was applied to an investigation of physiotherapy service provision in one area within Australia which had a mixture of remote, rural and regional centres. The framework and results may not be applicable across professions or to other areas with a different mixture of services or locations. Participant perception of rurality and public sector staffing numbers, while relevant to this study to define cases, may not be applicable to other studies.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
RA: was involved in concept development, study design, data collection, data analysis and interpretation and drafting of the manuscript. AJ: was involved in study design, data analysis and interpretation and drafting the manuscript. SL: was involved in study design, data analysis and interpretation and drafting the manuscript. LS: was involved in study design, data analysis and interpretation and drafting the manuscript. All authors read and approved the final manuscript.