This article was written by Dr. Ali Lakhani, and published in issue 99 of Position magazine.
Australia’s urban/rural divide has implications far beyond cultural attitudes and turns of phrase.
A significant health disparity yawns between Australians living in remote regions, and those that dwell in major cities. The Australian Institute of Health and Welfare 2017 report Rural and Remote Health found that compared to people living in major cities, people living in remote and very remote Australia tend to experience higher rates of disease and injury – For example, in 2015, people residing in remote and very remote regions of Australia were 2.3 times more likely to die from diabetes compared to people residing in major cities.
While the health disparities faced by people in remote regions are due to a variety of factors, the lack of proximately available health services is notable amongst these. In this regard, findings from a 2017 Australian Bureau of Statistics report concluded that over a 12-month period, people in major cities were more likely to have visited a general practitioner and dentist compared to those living in remote regions. The lack of access and use of health services for people in remote parts of Australia is problematic, as this may adversely impact quality of life in these regions and result in hospital admissions which could have been avoided.
Access to health services for people with disability
Arguably, for people with disability and/or injury, access to health services can have a greater impact on health and wellbeing outcomes compared to . In particular, access to disability-specific support services is essential to promote the health and wellbeing, as well as community participation outcomes for people with disability. In a 2012 study, Worobey and colleagues identified several consequences resulting from wheelchair breakdown including being stranded, missing medical appointments and missing school or work. In this regard, as expected, the proximate availability of aids, equipment and disability support services may impact the ability for someone using a mobility aid to receive timely service and as a result, exacerbate adverse consequences.
Researchers from The Hopkins Centre, Menzies Health Institute Queensland at Griffith University have been conducting research investigating the impact of spatial environments on the health and wellbeing of people who have experienced a traumatic injury. This work is being done to inform the launch of the new Epidoros-V2 platform, which is intended to engage GIS and non-GIS experts with relevant spatial data to address research questions pertaining to disability and rehabilitation. In preparation for the launch, multiple studies running concurrently have investigated the geographic dispersion of disability support services in relation to people with disability in Queensland.
Queensland: the need for further research
To date, the geographic dispersion of disability services in relation to remote regions within Queensland has yet to be investigated. Such research is imperative to establish which disability support types are least available based on remoteness, and further, where investment is most urgently needed. Additionally, given the roll-out of the National Disability Insurance Scheme (NDIS) and National Injury Insurance Scheme (NIIS) within Queensland, such an analysis can guide investment decisions and ultimately impact the health and wellbeing of people with disability and/or injury in diverse regions within the state. With this in mind, a spatial analysis study was conducted to ascertain the travel time to diverse disability services for localities within different regional classifications in Queensland, and investigate the difference in travel time for localities to services based on remoteness.
Data sources and analysis procedures
Three datasets from two sources were used to undertake this research. Localities within Queensland that included over 200 residents were identified from the Australian Bureau of Statistics (ABS) Urban Centre and Locality (UCL) Classification, while remoteness levels were identified from the Australian Statistical Geography Standard (ASGS) 2016 Remoteness Structure. The ASGS 2016 Remoteness Structure is a five tier structure which classifies regions as being (in order from least to most remote): major cities in Australia, inner regional Australia, outer regional Australia, remote Australia, and very remote Australia. Geocoded data for Disability Services offered in Queensland were obtained from the Health Direct National Health Services Directory. Disability Services across diverse domains were aggregated into three overarching categories: aids and equipment, support and advocacy, and information and referral.
Data analysis was undertaken using a sequential approach. Initially the Environmental Systems Research Institute (ESRI) software ArcMap 10.4.1 was used and after IBM’s statistical analysis software SPSS was used. Initially, both the ASGS 2016 Remoteness Structure, and the UCL Classification shapefile were imported into ArcMap. After, using the ‘Feature to Point’ function, a centroid was produced which represented the geographical centre of each UCL polygon. Subsequently, a spatial join was undertaken so that each locality was delegated the relevant ASGS 2016 Remoteness Structure attribute (i.e. major city in Australia, inner regional Australia etc.). Then, disability services aligned with each of the disability service types were imported into ArcMap, and the travel time from localities to each of these services established via three separate ‘Origin Cost Destination Matrix’ analyses. Each analysis was progressed so that the closest service was considered, and that travel time was established via driving an automobile, on publically available roads. Finally, a series of spatial joins were conducted so that the travel times to each service type were delegated to the relevant locality.
Once analyses within ArcMap 10.4.1 was complete, the UCL attribute table which included the remoteness level aligned with each locality and the travel time to each service type was exported into a SPSS database file. Then within SPSS, descriptive statistics were calculated so that the mean travel time to each disability service type for localities within each remoteness level were produced. Furthermore a series of non-parametric tests were conducted. Specifically, a series of inferential analyses using the Kruskal-Wallis test were conducted to ascertain if there was a difference in travel time to the three support service types across localities within the five considered remoteness categories.
Findings: travel times and underserviced regions
Findings conclude that mean travel times from localities to each disability service type increased based on remoteness level. The mean travel time to each disability service type was shortest for localities within the regional classification ‘major cities of Australia’ while longest for localities within the regional classification ‘very remote Australia’. Furthermore, thematic maps 1-3 illustrate the travel time in minutes for localities within each regional classification to each service type. Within each figure, localities are represented by coloured circles, and in minutes to each service type clarified by the size of the circle.
Findings also conclude that travel times to all disability service types – aids and equipment, information and referral, and support and advocacy – for localities within very remote and remote Australia were significantly higher than for localities within major cities in Australia and inner regional . For example the mean travel time to the nearest aids and equipment provider for Gununa, a locality within very remote Queensland, was approximately 1,532 minutes compared to 30 minutes for Springbrook, a locality in inner regional Queensland. In relation to mean travel times, the mean travel time to aids and equipment, information and referral, and support and advocacy services for localities within very remote Queensland were approximately 359 minutes, 252 minutes, and 731 minutes respectively, while the mean travel time to the same services for localities within major cities in Queensland were approximately 12 minutes, 11 minutes, and 15 minutes.
Implications for providers, government, and end users
The findings from this research confirms the notion that localities within remote and very remote regions of Australia lack the proximate availability of health and social services which are essential to promote favourable health and wellbeing outcomes. In this regard, the findings confirm those presented in a Coffee et al. (2012) article. Specifically, their findings confirmed that rural and remote regions of Australia had poorer access to cardiac affiliated health services, a finding which we have also confirmed here, however in relation to disability-specific services.
The findings from this research have considerable implications for disability specific health and social service providers, government, and people with disability. In relation to health and social service providers, the paucity of services within remote Australia means that innovative methods to engage with people in these regions are necessary. In this regard, it may be worthwhile for such providers to use mobile and digital outreach approaches to engage with potential clients/members in rural and remote Australia. Furthermore, outreach should be undertaken to ascertain the specific contextual factors which are being faced by people with disability in these regions, such outreach will ensure that services and programs offered address the distinct needs to these groups.
It is essential that spatial research underpins decisions made by disability-specific health and social service providers. In this regard, researchers from The Hopkins Centre have partnered with Spinal Life Australia – an end user representative support and advocacy organisation for people with spinal cord injury – to conduct a range of studies to clarify the geographic dispersion of health and social services in relation to people with spinal cord injury in outer regional, remote and very remote Australia. Findings from research to date have informed the programs and services offered by Spinal Life Australia. In particular, spatial research comparable to that presented in this article has supported their development of service centres in Rockhampton, Toowoomba, and Cairns.
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For government, with the roll-out of the NIIS Queensland, and NDIS, the lack of disability-specific health and social services available within remote Queensland means that funding packages offered to people within these regions need to account for the unique health and social service costs (ie. travel costs) aligned with offering services in remote settings. Most recently, perspectives from NSW service providers detailed in a 2017 article by Llina Flynn clarified that the unique costs of offering health and social support to people with disability in rural and remote regions are not adequately addressed by individual NDIS budgets, and as a result, in some instances, people with disability and service organisations are carrying the burden of these costs. This outcome was also identified as an unintended consequence of self-directed policies for people with disability within a 2018 systematic review undertaken by the author and colleagues and published in the Journal Health and Social Care in the Community.
For people with disability within rural and remote Australia, there is potential that the lack of disability-specific health services available are adversely impacting their health and wellbeing. People in these regions may be receiving disability support which is not adequate. In this regard, Barr and colleagues 2018 systematic highlighted that services provided to young people with hearing loss in remote settings may be inferior. Furthermore, they clarified that service use amongst the group is compromised. These findings may also be applicable for people with disability within the remote and very remote localities considered within this study.
Finally, this study has limitations which are also important to consider. The disability services provided by Health Direct’s, National Health Service Directory are exhaustive, however may not reflect the entirety of disability specific services available in Queensland. Furthermore, while the proximate availability of disability services is important, it is also important to consider that people in remote areas of Queensland may be able to liaise with relevant disability support organisations via phone or online. Consequently, increased travel time is not indicative of a complete lack of access for people within these localities.
Next steps: Spatial methodologies essential to clarify underserviced regions in Australia
This study clarified that people with disability within remote and very remote Australia experience significantly higher travel times to disability services than people with disability within major cities of Australia and inner regional Australia. The study is seminal as it is amongst the first to utilise spatial methods to ascertain the geographic dispersion of disability services in relation to people with disability in Queensland. It is important that future research utilise spatial methods to establish the geographic proximity of disability specific support services in relation to localities within areas with a significantly high number or proportion of people with disability. Furthermore, it is also important to investigate the impact of long travel times on disability service use, and subsequent health and wellbeing outcomes amongst people with disability.
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