A Review of Models Used for Investigating Barriers to Healthcare Access in Australia

Culturally and Linguistically Diverse Community Access and Utilisation of the Mental Health Service: An Explanation Using Andersen's Behavioural Model

Andersen's Behavioural Model of Health Service Use (ABMHSU) is a multilevel model that helps understand the factors influencing health service access and utilisation. This framework is a widely used model for health service use in general, as well as in immigrant populations and vulnerable populations. ABMHSU, in this project, provided a framework to explain how the mental health nurses' cultural competence can influence the Victorian CALD community members' mental health care access and utilisation. A unique model of ABMHSU in the current multiple-method project provided a theoretical framework for examining the factors associated with people from the CALD community accessing mental health services in an Australian context to answer the research questions. The key findings of the research were discussed with reference to the extant literature and with triangulation of research results with the ABMHSU in the context of Victoria. The researchers argue that even though predisposing, enabling, and need factors are necessary to determine whether a person is selected for expert care for mental health issues, these factors alone are insufficient. Ongoing research is essential to ascertain the potential of mental health nurses' cultural competence education and cultural responsiveness in addressing the mental health service access and utilisation of the heterogeneous CALD communities. Additional research is advocated to identify the supplementary factors, as there is a dearth of research exploring the potential of ABMHSU worldwide.

Outpatient encounters, continuity of care, and unplanned hospital care for children and young people with cerebral palsy

AIM

To describe the relationships between outpatient encounters, continuity of care, and unplanned hospital care in children/young people with cerebral palsy (CP).

METHOD

In this population-based data-linkage cohort study we included children/young people with CP identified in the New South Wales/Australian Capital Territory CP Register (birth years 1994-2018). We measured the frequency of outpatient encounters and unplanned hospital care, defined as presentations to emergency departments and/or urgent hospital admissions (2015-2020). Continuity of outpatient care was measured using the Usual Provider of Care Index (UPCI).

RESULTS

Of 3267 children/young people with CP, most (n = 2738, 83.8%, 57.6% male) had one or more outpatient encounters (123 463 total encounters, median six outpatient encounters per year during childhood). High UPCI was more common in children/young people with mild CP (Gross Motor Function Classification System levels I-III, with no epilepsy or no intellectual disability), residing in metropolitan and areas of least socioeconomic disadvantage. Low UPCI was associated with four or more emergency department presentations (adjusted odds ratio [aOR] 2.34; 95% confidence interval [CI] 1.71-3.19) and one or more urgent hospital admissions (aOR 2.02; 95% CI 1.57-2.61).

INTERPRETATION

Children/young people with CP require frequent outpatient services. Improving continuity of care, particularly for those residing in regional/remote areas, may decrease need for unplanned hospital care.

WHAT THIS PAPER ADDS

Many children with cerebral palsy use multiple and frequent outpatient services. Better continuity of care is associated with living in metropolitan and less socioeconomically disadvantaged areas. Outpatient service utilization reduces at the time of transition to adult services. High outpatient utilization is associated with unplanned hospital care. Decreased continuity of care is associated with unplanned hospital care.

Evaluating geographical disparities on clinical outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Rural Australians typically encounter disparities in healthcare access leading to adverse health outcomes, delayed diagnosis and reduced quality of life (QoL) parameters. These disparities may be exacerbated in advanced malignancies, where treatment is only available at highly specialised centres with appropriate multidisciplinary expertise. Thus, this study aims to determine the association between patient residence on oncological, surgical and QoL outcomes following cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC).

METHODS

A retrospective analysis was conducted on consecutive patients undergoing CRS and HIPEC at Royal Prince Alfred Hospital from January 2017 to March 2022. On the basis of their postcode of residence, patients were stratified into metropolitan and regional groups. Data encompassing demographics, oncological, surgical and QoL outcomes were compared. Statistical analysis included chi-square test, t-tests and Kaplan-Meier survival curves.

RESULTS

Among the 317 patients, 228 (72%) were categorised as metropolitan and 89 (28%) as regional. Metropolitan patients presented higher rates of recurrence (61.8% versus 40.0%, p = 0.014) and shorter overall mean survival [3.8 years (95% CI: 3.44-4.09) versus 4.2 years (95% CI: 3.76-4.63), p = 0.019] compared with regional patients. No other statistically significant differences were observed in oncological, surgical and QoL outcomes.

CONCLUSIONS

Most oncological, surgical and QoL parameters did not differ by geographical location of patients undergoing CRS and HIPEC for peritoneal malignancies at a high-volume quaternary referral centre. Observed differences in recurrence and survival may be attributed to the selective nature of surgical referrals and variable follow-up patterns. Future research should focus on characterising referral pathways and its influence on post-operative outcomes.

Measuring Mental Health Service Accessibility for Indigenous Populations: a Systematic Review

Indigenous populations have experienced inequality of accessing mental health services compared with their non-Indigenous counterparts, although the way of measuring mental health service accessibility for Indigenous populations is unclear. This systematic review examines measures of mental health service accessibility for Indigenous people, including the diversity of mental health services that are available to them and the barriers to accessing mental healthcare. Using a systematic search procedure, we identified 27 studies that explored Indigenous populations' mental health service access. Our review shows that 18 studies used interview-based methods to explore how Indigenous people use mental health services, and only nine studies used quantitative methods to measure the uptake of mental health services. While advanced methods for quantifying geographical access to healthcare services are widely available, these methods have not been applied in the current literature to explore the potential access to mental health services by Indigenous populations. This is partially due to limited understanding of how Indigenous populations seek mental healthcare, barriers that prevent Indigenous people from accessing diverse types of mental health services, and scarcity of data that are available to researchers. Future research could focus on developing methods to support spatially explicit measuring of accessibility to mental health services for Indigenous populations.

Travel-associated cost savings to patients and the health system through provision of specialist head and neck surgery outreach clinics in rural New South Wales, Australia

INTRODUCTION

Centralisation of head and neck surgical services means that patients in regional and remote Australia need to travel long distances for treatment and follow-up, imparting a significant financial burden on patients and the health system.

OBJECTIVE

To estimate costs of travel to local outreach clinics and determine potential cost savings to patients and the health system by avoiding patient travel to major cities for head and neck surgical care.

DESIGN

Retrospective audit of three head and neck surgery outreach clinics in New South Wales, Australia over 4 years (2017-2020). Direct costs of travel from a patient's residence to their local outreach clinic were estimated. Costs of travel and accommodation to Sydney for an appointment were calculated for different travel modes. Estimated reimbursements for travel through government support schemes were calculated based on published rates.

FINDINGS

Some 657 patients attended the three clinics, accounting for 1981 appointments. Depending on mode of travel, the estimated median cost of return travel (including accommodation) to Sydney was $379 to $739 per patient per trip and the median government reimbursement ranged from $182 to $279 per trip. In comparison, the cost of return travel by car to local outreach clinics ranged from $28 to $163 per appointment. Outreach clinics were estimated to save patients a median of $285 per trip and avoided government reimbursements of $215 per trip.

DISCUSSION

Despite uptake in telehealth, outreach medical services remain an important asset for people living in regional areas to address inequities in access. However, the cost benefits are likely to be underestimated as our approach did not account for indirect costs associated with travel.

CONCLUSION

Outreach head and neck surgical services located in regional areas can reduce the financial burden on both patients and the healthcare system. Greater investment in outreach clinics could ensure sustainability of services to promote equitable access to specialised surgical services.

Geo-Mapping of the Spatial Accessibility to Public Oral Health Facilities among Schoolchildren in Selangor, Malaysia

Spatial accessibility to health services influences service utilisation and eventually impacts the disease burden. This cross-sectional study analysed the spatial accessibility of schoolchildren to public oral health facilities and school dental services (SDS) and vice versa in Selangor. Overlay and proximity analysis from geo-mapping software was employed to map the primary dental clinics with SDS, the public schools, and the proximity between primary dental clinics with SDS and public schools by travelling distance (5 km, 10 km, 20 km) and travelling time (15 min, 30 min). Over half of the schoolchildren in Selangor are within 5 km of accessibility to primary dental clinics and SDS teams. Meanwhile, nearly half of the primary and secondary schools, particularly in rural areas, are located within a more than 5 km service area of public oral health facilities. The SDS teams have a travel burden of more than 20 km to the public schools in Selangor's northern and north-western districts of large geographical areas. Simultaneously, most public primary and secondary schools are within 15 min of driving time from primary dental clinics. Geo-mapping highlights the inequalities in spatial accessibility to public oral health facilities with SDS among schoolchildren in Selangor. It is time to prioritise the resources, SDS, and preventive programmes to reduce inequalities in oral health accessibility among schoolchildren in Selangor.

An interactive geographic information system to inform optimal locations for healthcare services

Large health datasets can provide evidence for the equitable allocation of healthcare resources and access to care. Geographic information systems (GIS) can help to present this data in a useful way, aiding in health service delivery. An interactive GIS was developed for the adult congenital heart disease service (ACHD) in New South Wales, Australia to demonstrate its feasibility for health service planning. Datasets describing geographic boundaries, area-level demographics, hospital driving times, and the current ACHD patient population were collected, linked, and displayed in an interactive clinic planning tool. The current ACHD service locations were mapped, and tools to compare current and potential locations were provided. Three locations for new clinics in rural areas were selected to demonstrate the application. Introducing new clinics changed the number of rural patients within a 1-hour drive of their nearest clinic from 44·38% to 55.07% (79 patients) and reduced the average driving time from rural areas to the nearest clinic from 2·4 hours to 1·8 hours. The longest driving time was changed from 10·9 hours to 8·9 hours. A de-identified public version of the GIS clinic planning tool is deployed at https://cbdrh.shinyapps.io/ACHD_Dashboard/. This application demonstrates how a freely available and interactive GIS can be used to aid in health service planning. In the context of ACHD, GIS research has shown that adherence to best practice care is impacted by patients' accessibility to specialist services. This project builds on this research by providing opensource tools to build more accessible healthcare services.

A Functional Approach to the Assessment of Non-Suicidal Self-Injury on YouTube

This research explores representations of non-suicidal self-injury (NSSI) on social media. The current study aims to examine the applicability of a functional model of NSSI to videos posted on YouTube by analyzing the 100 most viewed YouTube videos relating to NSSI at a point in time in 2018. Motivations for continued engagement in NSSI were examined for each content creator who posted one of the top 100 most viewed videos relating to NSSI. Categorizations of a content creator's motivation were based on Nock and Prinstein (2004) four-function model (FFM) of NSSI, in which the motivations, or functions, of NSSI are categorized by two dichotomous factors: (a) positive (i.e., involves the addition of a favorable stimulus) or negative (i.e., involves the removal of an aversive stimulus) and (b) automatic (i.e., intrapersonal) or social (i.e., interpersonal). Uploaders most endorsed automatic negative reinforcement (50%), followed by automatic positive (26%), social positive (3%), and social negative (3%). Considering the growing number of children and adolescents with near constant access to internet and social media, there may be implications for further development of safety measures for social media platforms. The results of this study may be valuable for parents, health care professionals, and educators, who should be aware of available social media content relating to NSSI and consider implementing additional media-literacy and media-safety education in school curriculums and programming for children and adolescents. Furthermore, health care professional should be aware that misconceptions of NSSI may have an impact on patients' willingness to seek treatment, or the attitude with which treatment is sought.

Incorporating social determinants of health into individual care—a multidisciplinary perspective of health professionals who work with people who have type 2 diabetes

Social determinants of health (SDoH) and type 2 diabetes mellitus (T2DM) are interrelated. The prevalence of T2DM is increased amongst those with suboptimal SDoH. Poor SDoH can also negatively impact T2DM self-management. Social determinants of health are mostly considered at population and community levels, rather than individually or clinically. This qualitative study combines the perspectives of a multidisciplinary cohort of health professionals to identify and explore the impact of social determinants on self-management, and ways they could be incorporated into individual clinical care. Purposively selected participants chose to partake in an in-depth, semi-structured, one-on-one interview or focus group. Data were analysed, and themes identified using a combination of deductive and inductive thematic analysis. Fifty-one health professionals volunteered for the study. Two small focus groups (n = 3 and n = 4) and 44 one-on-one interviews were conducted. The identified themes were: 1) Support for incorporating SDoH into T2DM care, 2) Effect of SDoH on T2DM self-management, 3) Identifying and addressing social need, 4) Requirements for incorporating SDoH into T2DM individual clinical care. Health professionals reported that poor social determinants negatively affect an individual’s ability to self manage their T2DM. Person-centred care could be enhanced, and people with T2DM may be more likely to achieve self-management goals if SDoH were included in individual clinical care. To achieve successful and sustained self-management for people with T2DM, health professionals require a thorough understanding of T2DM and the effect of social determinants, respect for client privacy, client trust and rapport, effective communication skills, validated tools for assessing SDoH, team champions, teamwork, ongoing education and training, adequate resources, guiding policies and procedures, and management support. Incorporating SDoH into individual, clinical care for people with T2DM was strongly supported by health professionals. If embraced, this addition to care for individuals with T2DM could improve self-management capacity and enhance person-centred care.

Using a knowledge translation framework to identify health care professionals’ perceived barriers and enablers for personalised severe asthma care

Background

Whilst multidimensional assessment enables the detection of treatable traits in severe asthma and has the potential to improve patient outcomes, healthcare disparities exist, and little is known about the factors influencing optimal management in severe asthma. This study aimed to explore perceived barriers, and enablers to implementing personalised care in severe asthma, from the healthcare professionals’ perspective.

Methods

A descriptive, qualitative study involving a single focus group (n = 7) and semi-structured interviews (n = 33) with multidisciplinary healthcare professionals involved in severe asthma care was conducted. A hybrid thematic and content analysis was undertaken to identify themes, which were then deductively mapped to the Theoretical Domains Framework (TDF).

Results

Overall, three emergent themes were identified: (1) Barriers- (2) Enablers- to optimal management; (3) Desired model of care. Across all TDF domains, 6 constructs influenced development and implementation of optimal care: (1) belief about consequences, (2) environmental context and resources, (3) belief about capabilities, (4) social/professional role and identity, (5) goals and (6) knowledge.

Conclusion

Implementation of personalised care in severe asthma is complex and non-linear. The use of a theory-based approach effectively demonstrated how a variety of behaviours could be targeted to optimise and promote personalised care in different clinical setting.

Associations Between Socioeconomic Status, Patient Risk, and Short-Term Intensive Care Outcomes

OBJECTIVES

To investigate the association of socioeconomic status as measured by the average socioeconomic status of the area where a person resides on short-term mortality in adults admitted to an ICU in Queensland, Australia.

DESIGN

Secondary data analysis using de-identified data from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation linked to the publicly available area-level Index of Relative Socioeconomic Advantage and Disadvantage from the Australian Bureau of Statistics.

SETTING

Adult ICUs from 35 hospitals in Queensland, Australia, from 2006 to 2015.

PATIENTS

A total of 218,462 patient admissions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The outcome measure was inhospital mortality. The main study variable was decile of Index of Relative Socioeconomic Advantage and Disadvantage. The overall crude inhospital mortality was 7.8%; 9% in the most disadvantaged decile and 6.9% in the most advantaged decile (p < 0.001). Increasing socioeconomic disadvantage was associated with increasing severity of illness as measured by Acute Physiology and Chronic Health Evaluation III score, admission with a diagnosis of sepsis or trauma, cardiac, respiratory, renal, and hepatic comorbidities, and remote location. Increasing socioeconomic advantage was associated with elective surgical admission, hematological and oncology comorbidities, and admission to a private hospital (all p < 0.001). After excluding patients admitted after elective surgery, in the remaining 106,843 patients, the inhospital mortality was 13.6%, 13.3% in the most disadvantaged, and 14.1% in the most advantaged. There was no trend in mortality across deciles of socioeconomic status after excluding elective surgery patients. In the logistic regression model adjusting for severity of illness and diagnosis, there was no statistically significant difference in the odds ratio of inhospital mortality for the most disadvantaged decile compared with other deciles. This suggests variables used for risk adjustment may lie on the causal pathway between socioeconomic status and outcome in ICU patients.

CONCLUSIONS

Socioeconomic status as defined as Index of Relative Socioeconomic Advantage and Disadvantage of the area in which a patient lives was associated with ICU admission diagnosis, comorbidities, severity of illness, and crude inhospital mortality in this study. Socioeconomic status was not associated with inhospital mortality after excluding elective surgical patients or when adjusted for severity of illness and admission diagnosis. Commonly used measures for risk adjustment in intensive care improve understanding of the pathway between socioeconomic status and outcomes.