Barriers to seeking health care
In a recent article we described some of the factors that drive the health gap between urban and rural Australians. This article takes a closer look at some of the barriers to seeking health care and what is being done to address them.
Access to services.
One of the major problems we identified in our previous article was access to health services. The simple realities of large distances and low population densities make service provision far more difficult in rural than urban areas of Victoria and Australia. Services are more thinly spread, and people have to travel longer distances to reach them.
In 2009, 23 per cent of Australians living in outer regional and remote areas felt they waited too long for an appointment with a general practitioner (GP), compared with 16 per cent of those living in major cities. People living in outer regional and remote areas were also 4.5 times as likely as those living in major cities to travel over one hour to see a GP.
In 2006, on a per capita basis, very remote areas had less than a third as many GPs, less than two-thirds as many registered nurses and less than a fifth as many allied health workers as the major Australian cities. Lack of access to GPs, dentists, pharmacies and other primary health facilities in rural and remote areas is estimated to cause about 60 000 preventable hospitalisations every year.
Ageing and chronic diseases.
Between 1994 and 2014, the proportion of Australia’s population aged 15–64 years was stable at about 66.5 per cent, while the proportion of people aged 65 years and older increased from 11.8 to 14.7 per cent.
Our ageing population means the proportion of Australians living with physical disabilities, chronic health conditions and/or reduced mobility is rising. These factors complicate health service delivery and further reduce access, particularly outside metropolitan areas.
Chronic disease is closely associated with other barriers to health care. Recently published research shows that Australian adults with respiratory conditions spend more than twice as much in out-of-pocket health care costs as those who do not report a health condition. Moreover, 30 per cent reported skipping (forgoing) health care – a rate six times that of Australians without a health condition.
Adults with depression, anxiety and other mental health conditions fare similarly, with 95 per cent higher out-of-pocket expenditure per household. They are nearly eight times as likely as people without a health condition to skip health care.
Rural–urban health gaps exist with respect to many chronic diseases. For example, in 2007–08, people who lived outside major cities were, relative to city dwellers, more likely to have:
- arthritis (13 per cent more likely)
- high blood pressure (15 per cent)
- asthma (20 per cent)
- back pain (23 per cent)
- deafness (27 per cent)
- a mental disorder (in their lifetime: 8 per cent)
- an alcohol problem (in their lifetime: 25 per cent)
Poverty in rural and regional Australia is manifested in lower incomes, reduced access to services such as health, education and transport, fewer employment opportunities, and distance and isolation. Of the 20 electorates in Australia with the lowest household incomes, 18 are outside capital cities.
People living in poverty suffer high rates of physical and mental illness. Moreover, the stress associated with poverty contributes to health risks such as smoking, excessive alcohol consumption and poor diet.
Australians living in the most socio-economically disadvantaged areas have relatively low levels of health expenditure, but pay proportionally more for health services. Overall, households in rural and remote areas devote a higher proportion of weekly expenditure to health-related items than their urban counterparts.
Although gender might not be readily conceptualised as a barrier, there is no doubt that Australian men, despite having lower life expectancies and worse health than women, are poorer consumers of health services and have lower health literacy on average.
In Australian culture, and particularly in rural communities, masculinity is often conceived of and expressed in terms of attributes such as strength, resilience and stoicism. These traditional norms reduce men’s health-seeking behaviour, including disinclination to express emotions or concerns about health, embarrassment and anxiety about health problems, and inhibit communication with healthcare professionals when help is eventually sought.
Poor health-seeking behaviour exacerbates the significant health gap that exists between men living in rural and urban Australia. Men in rural areas are more likely than their urban counterparts to experience chronic health conditions, and suffer higher mortality rates from injury, cardiovascular disease, and diabetes and associated risk factors. They have higher rates of daily smoking and risky drinking behaviour.
Lowering or removing the cultural barriers that prevent many men from seeking preventative health care or treatment is likely to substantially improve population health, particularly in rural Australia.
How are barriers to treatment being addressed?
The National Strategic Framework for Rural and Remote Health (NSFRRH) presents a vision for the health care of Australians living in regional, rural and remote areas, and supports a national approach to policy, planning, design and delivery of health services. One of the NSFRRH’s goals is for rural and remote communities to have improved access to appropriate and comprehensive health care.
Primary health networks
Numerous initiatives in rural health, designed to increase the size of the workforce and improve coordination, are aligned with the NSFRRH. These include the 31 Primary Health Networks (PHNs) which the Australian Government began funding in 2014. PHNs are designed to improve patient outcomes by reducing fragmentation of care.
On 1 July 2015, Western Victoria PHN replaced Barwon, Grampians and Great South Coast Medicare Locals, covering the same geographical footprint as Western Alliance. The PHN focuses on regional health planning, GP and primary care development, health system integration and clinical services.
Incentives for rural and regional GPs
Other aspects of the drive to improve access to health care in rural, regional and remote areas are the General Practice Rural Incentives Programme (GPRIP) and the Bonded Medical Places (BMP) Scheme. These initiatives aim to increase the numbers of GPs working in rural, regional and remote areas, through financial incentives (GPRIP) and the funding of medical school places for students who commit to training and/or working in areas with workforce shortages (BMP).
Mobile and wireless technologies are already being used in healthcare to increase rates of attendance at medical appointments and to facilitate treatment scheduling and communication. They are likely to play a much more important role in improving access to health services in the future. With the appropriate infrastructure, these technologies have the potential to alleviate problems of distance and thinly spread service supply.
As outlined in a previous article , researchers are developing smartphone apps that enable patient data – such as blood pressure, weight and physical activity – to be sent directly to their physicians, who can then make real-time decisions about health management.
Several partners in Western Alliance are already using mHealth in clinical practice, and evaluations of its efficacy are underway.
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