OPINION: A Country Practice: Community Engaged Health Care

A Country Practice screened on Australian televisions from 1981 to 1994. It portrayed the life of rural doctors living and working in a small fictional town delivering primary health care and attending at the local hospital.

The TV series resonated with rural and remote communities as it reflected an ideal of sustainable rural and remote health that they or their parents had grown up with.

In the series the beloved GP Dr Terence Elliot was the clinical leader for health care for the whole community. He was respected, trusted and involved in the local community bringing this knowledge into his clinical practice and health services delivery.

A Country Practice illustrated the type of patient-centred, "integrated", community-engaged health care that we talk about achieving through national health planning but which continues to allude us.

Of course, A Country Practice was a fictional account of rural practice and did not represent the whole story. While the vast majority of rural GPs lived up to this standard of care, there were gaps in quality and safety that needed to be addressed.

But the affection for a system where the community is at the heart of health care decision making remains, despite the difficulties that this sometimes presented. And research suggests that this sort of community-engaged primary health health care represent the best pathway towards a sustainable rural and remote health system.

The importance of community-engaged health services in vulnerable communities was recognised by the Prime Minister and Federal Government in the response to the 12th Closing the Gap report released on 10 February 2021.

In handing down the report in Parliament the Prime Minister, The Hon Scott Morrison, acknowledged the mistake of failing to include Aboriginal and/or Torres Strait Islander communities in decision making about their health and health services delivery:

"Despite the best intentions, investments in new programs and bipartisan goodwill, Closing the Gap has never really been a partnership with Indigenous people. We perpetuated an ingrained way of thinking passed down over two centuries and more, and it was the belief that we knew better than our Indigenous peoples. We don't.

"We also thought we understood their problems better than they did. We don't. They live them. We must see the gap we wish to close, not from our viewpoints, but from the viewpoint of Indigenous Australians."

The lessons from the failure of the Closing the Gap strategy can be applied equally to rural and remote health, LGBTQIA+ health, CALD health and in how we engage with many other vulnerable communities.

Wakerman and Humphries et al's 2009 research has identified the critical importance of effective "a strong [primary health care] approach, encompassing community participation, multidisciplinary practice, a focus on disease prevention, and a shared leadership vision for the service" in building sustainable rural and remote health care systems. [1]

A 2015 literature review of the effectiveness of community engagement in public health for disadvantaged groups found:

  • "Interventions that engage community members in the delivery of the intervention are particularly effective...

  • Both universal and targeted interventions are effective, although universal interventions tend to have higher effect size estimates for health behaviour outcomes ...

  • Interventions that employed skill development or training strategies, or which offered contingent incentives, tended to be more effective than those employing educational strategies for health behaviour outcomes ...

  • Interventions involving peers, community members, or education professionals tended to be more effective than those involving health professionals ...

  • Interventions tended to be most effective in adult populations and less effective in general populations (i.e. those that included all age groups) for health behaviour outcomes ...

  • Interventions tended to be most effective for health behaviour outcomes for participants classified as disadvantaged due to socioeconomic position."[2]

A 2020 study by Jones et al found that bringing "community knowledge, skills and resources into the design, delivery and adaptation of healthcare policies, and services at regional and local levels, with the provision of primary, secondary, and tertiary healthcare that aligns to individual community contexts" can "facilitate transformational community engagement" and improved health literacy. [3]

In 2021 RARMS obtained almost $1 million in funding to expand our existing health centre in Collarenebri to become a community health hub.

The hub will be a place where the community and health staff will meet to talk about priorities; school students interested in health careers will be given support to achieve their goals through direct experience in an operating health services environment; an Aboriginal Elder in Residence will have a space to support local community members and help to inform our practices; a traditional bush garden will teach members of the community about Australia's foods and how to source and prepare them.

This project was developed by talking to the local community about their challenges, and what they saw as priorities to ensure good health in their community.

We must, as the Prime Minister has said, stop perpetuating 'an ingrained way of thinking that we know better' than our communities what needs to happen to address systemic inequality and discrimination in the delivery of health care in rural and remote Australia.

Mark Burdack is the CEO of RARMS and can be contacted on mburdack@rarms.org.au.

The Collarenebri Community Youth and Health Hub is funded by the Australian Government under the Murray–Darling Basin Economic Development Program

[1] John Wakerman, John S Humphreys, Robert Wells, Pim Kuipers, Judith A Jones, Philip Entwistle and Leigh Kinsman. Features of effective primary health care models in rural and remote Australia: a case-study analysis. MJA • Volume 191 Number 2 • 20 July 2009. https://www.mja.com.au/system/files/issues/191_02_200709/wak10496_fm.pdf https://www.mja.com.au/system/files/issues/191_02_200709/wak10496_fm.pdf

[2] Alison O’Mara-Eves,Ginny Brunton,Sandy Oliver,Josephine Kavanagh,Farah Jamal, and James Thomas. The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis. BMC Public Health. 2015; 15: 129. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374501/

[3] Jones, D., Lyle, D., McAllister, L., Randall, S., Dyson, R., White, D., . . . Rowe, A. (2020). The case for integrated health and community literacy to achieve transformational community engagement and improved health outcomes: An inclusive approach to addressing rural and remote health inequities and community healthcare expectations. Primary Health Care Research & Development,21, E57. https://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/case-for-integrated-health-and-community-literacy-to-achieve-transformational-community-engagement-and-improved-health-outcomes-an-inclusive-approach-to-addressing-rural-and-remote-health-inequities-and-community-healthcare-expectations/CB074BF09F4515C3FD33E0B905B96542.