PHC : unravelling a maze

Abstract

The thesis explores the complexities of primary health care in a setting characterised as being both isolated and remote, and in the process identifies factors critical for developing successful PHC programs in such settings and more broadly. The four questions underpinning the study are 1) is a PHC approach relevant to the chosen small remote Australian community; 2) to what extent was a PHC approach being implemented; 3) what are the barriers and enablers to developing and implementing a PHC approach; and 4) what are the crucial factors for PHC programs in similar communities. The first chapter provides the background to the study, beginning with the range of descriptions of primary health care and the many themes needed to understand how it plays out in a small community. The Menindee community and some of the local health service players are introduced. Chapter Two explores complexity theory and complex adaptive systems and its relevance to organisations and managing change, particularly in complex environments. Chapter Three examines the evolution of primary health care, its philosophy, principles and elements as both a model of health care and of development. Chapter Four addresses social determinants, the life course and the long-term effects of inequity, before considering current factors that impact on health and health services. These include the beginning and end of the life course and those in the ‘middle’ where the effects of the obesity and diabetes epidemics are being played out at a younger age. The chapter concludes by noting common themes across the three chapters. Chapter Five describes the research design and methods. A case study using mixed methods was chosen and the theoretical framework provides an exploration of complexity and transdisciplinarity. What changed during the course of the study, questions of scope and its limitations are stated. Chapter Six is a quantitative analysis of the study community, which examines community demographics, the life course, a summary of adult and child health, and service use. These enable an understanding of the community profile, its uniqueness and its similarity to other communities that might benefit from a comprehensive PHC approach. The questions to be explored in the qualitative phase are identified. Chapter Seven is a qualitative study of the community in the midst of change. An individual interview guide approach was used and representatives from the community, local and regional health service providers were interviewed. Chapter Eight provides a synthesis of the two studies as they address themes from the complexity, PHC and social inequity literature. Five themes had particular significance to the study community: social determinants and Indigenous health; community size, resilience and change; chronic disease programs and prevention; vulnerable groups; and a complex adaptive systems perspective. The second section answers the four study questions. The thesis concludes with a discussion of PHC rhetoric and reality, the relevance of the study and its limitations, and issues requiring further research when considering primary health care in smaller communities.