Factors in accessibility of general practice in rural Australia

Abstract

MJA 1997; 166: 577-580  

Introduction

The importance attributed to rural doctors, in particular, is influenced by two factors. Firstly, most rural dwellers (like most Australians) take health for granted. Invariably, their prime concern is with illness and sickness, so that the focus has traditionally been on the availability of curative treatment. Secondly, inaccessibility of GPs remains the greatest source of disuse and disadvantage for most rural residents. It is problems associated with lack of accessibility, combined with the shortage and mal distribution of GPs within rural Australia, that have contributed to the establishment of the General Practice Rural Incentives Program,^3,6 designed to overcome the problem of lack of access to rural general practitioners and to improve their recruitment and retention in rural and remote areas.

The importance of good access to health care services is not in dispute. However, we need a better understanding of specific criteria for measuring accessibility. Penchansky and Thomas identified five distinct factors underpinning access to a doctor.⁷ These were: availability (the existence of services in relation to patients' needs); accessibility (measured in terms of distance, time, cost and availability of transport); accommodation (how the service is organised to accept patients, measured in ways such as waiting time); affordability (in terms of economic access to the service); and acceptability (in terms of patients' attitudes towards a particular doctor).

The issue of accessibility in relation to the decisions of rural people to consult a doctor has not been thoroughly investigated in Australia. As a result, ac cessibility is simply equated with geographical proximity. However, consumer perceptions of accessibility to health services are important considerations for policies designed to increase the availability and location of doctors in sparsely populated rural and remote areas.

Here, we report some findings from a major study investigating ways of facilitating the provision of health care services to people in small rural and remote communities.⁸ In particular, we sought to identify the importance that consumers attribute to different factors of accessibility in their decision to consult a doctor.  

Methods

During July and August 1996, residents aged over 16 years from all occupied dwellings in these communities were invited to participate in a survey, either by interview or delivery-and-collection questionnaire. This choice was offered to maximise the response rate and to avoid inconvenience to participants.

We asked respondents to consider the following five factors relating to social, geographical and economic factors of accessibility that were relevant to their decision to consult a doctor:

• A doctor who bulk bills;
• A doctor you can call any time;
• A doctor who is close or easy to get to;
• A doctor you feel comfortable with; and
• Being able to see the same doctor each visit.

We used paired comparisons to elicit respondents' attitudes relating to their decision to consult a doctor. The method involves presenting participants with pairs of stimuli, with instructions to choose one member of each pair on the basis of some criterion.^10-12 Each factor is paired with every other factor in all possible combinations. The number of alternatives must be constrained as too many can result in fatigue for both respondents and researcher. The paired comparison method gives not only a rank order for the stimuli, but also an estimate of the interval separating the importance attributed to each, enabling a good deal of information to be obtained from a limited amount of material. The scale values for each of the factors reflect the characteristics of the data, and hence the origin is arbitrary. However, for purposes of comparison, the scaling is transformed to a base of zero.

Thus, in this study, respondents were asked to choose, for each possible combination of our five factors, which of the two was more important in their decision to consult a doctor.

To reduce bias, the pairs of alternatives were arranged so that each alternative appeared equally on the right and left (to control for space error), was alternated from right to left, and did not appear in consecutive pairs (instead, being spaced as far apart as conditions would permit).^13,14

To ascertain any differences in the pattern of preferences, the data were broken down by age groups and the degree of isolation of the community. Consistent with previous research, the age groups used were: young (less than 35 years); middle age (35-54 years); and old age (55 years and over).¹ A community's isolation was determined by the distance to the nearest doctor and the conditions of the roads. Isolated communities were designated as those located at least half an hour's drive from the nearest doctor (ranging between 55 and 100 kilometers), and whose residents were required to negotiate unsealed or minor roads regularly closed after rainfall.  

Results

Box 2 shows the sex, age and degree of residential isolation of the participants, and the results of the paired comparison analysis together with the co- efficient of agreement (a measure of variation in responses) in each case.¹⁰ In all cases the coefficient of agreement was significant at the 99% confidence level, indicating that, within groups, the respondents showed significant agreement in the factors they considered most important in the decision to consult a doctor.

The most important factor in deciding to consult a doctor was having a doctor with whom participants felt comfortable. Being able to see the same doctor generally ranked a close second. For people over 55 years, being able to see the same doctor was most important, especially for those whose place of residence was isolated.

Being able to call a doctor at any time was the third most important factor, ahead of geographical proximity. This factor was very important for young and middle-aged people and for men living in more isolated communities (see Box 2). Geographical proximity to the doctor was consistently rated more highly for people living in isolated communities, and was the most important consideration for men from isolated communities.

The significance of bulk billing (an indicator of economic access) did not rate highly among the five factors for any population subgroup.

The importance attributed to the factors influencing participants' decisions to consult a doctor varied across age groups. For example, while geographical proximity to the doctor decreased in importance with increasing age, the significance of acceptability and continuity of care increased.  

Discussion

Geographical proximity is undoubtedly an important issue, more so at times when acute and emergency care are needed than in relation to more discretionary health care. It is interesting to note our finding that men from isolated communities rank geographical access to doctors as the most important consideration. This is consistent with recent studies that suggest rural men generally neglect their health, often choosing only to consult a doctor for acute medical care and invariably visiting the closest doctor to minimise work disruption.¹⁵

However, our findings show that, overall, rural residents consider social accessibility (or acceptability) and continuity of care to be more important than geographical proximity in both their decision to consult and their choice of a doctor. Rural Australians are prepared to travel further than necessary, often bypassing the closest GP, to consult a doctor with whom they feel more comfortable.¹⁶ This finding is also consistent with results of earlier research which showed that less than one-third of patients indicated proximity as the main reason for choosing their usual doctor.¹⁷

These results are particularly significant in regard to the rural elderly population. While it is commonly believed that elderly people are most disadvantaged by geographical distance (and hence that this factor might be the one they identify as most important), our results confirm findings from other studies showing that continuity of care and acceptability, rather than geographical proximity, are the more important aspects in explaining where rural elderly people seek medical care.^7,18

The importance of acceptability and continuity of care over geographical accessibility has significant implications for recruitment and retention schemes, such as the General Practice Rural Incentives Program, as well as for rural general practice training programs generally. Our findings support the recommendations made at the 1994 Undergraduate Rural Curriculum Conference, which highlighted the importance of social factors, community issues and communication skills in developing a curriculum for rural general practice.¹⁹ It follows that a critical component of the evaluation of the effectiveness of the Rural Incentives Program should be the extent to which the program is attracting doctors who understand rural culture, the background and health needs of rural patients, and who appreciate and develop the personal skills and attitudes necessary to practise medicine effectively in rural communities.

While acceptability is unquestionably an important factor in the decision to consult a doctor, exactly what determines acceptability requires further research. Results from a hospital-based consumer satisfaction survey undertaken in 1993-94 indicated information and communication, concern, respect and personalised attention, attention to the patient's condition, and skill were the most important variables affecting patients' satisfaction with doctors.²⁰ One of the few Australian rural case studies into patients' attitudes to general practice services found that the most important qualities sought in a doctor were compassion and an ability to communicate.²¹ The authors of this study acknowledged that these priorities were not reflected in undergraduate medical education at the time. However, more focused and comprehensive research is required to identify the particular attributes patients value most highly from rural general practitioners.

People use and choose health and medical services on the basis of not only their need for them, but also their perceptions of them and the value they place on them. A knowledge of the importance people attribute to the various factors associated with access to health services will assist policymakers in planning how best to allocate scarce resources, and the form those resources should take if they are to result in improved health outcomes in the community.  

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