Improving access to pulmonary rehabilitation in rural and remote Australia
Improving access to pulmonary rehabilitation in rural and remote Australia Thesis
Faculty of Health Science
- Author(s): Johnston, Catherine Louise
- Published: 2014
- Publisher: University of Sydney
- Volume: PhD
Abstract: Pulmonary rehabilitation, consisting of exercise training and education, is one of the most effective strategies for improving the health outcomes of people with chronic obstructive pulmonary disease (COPD) and reducing associated healthcare costs. Prior to the work presented in this thesis a description of the structure and content of pulmonary rehabilitation programs in Australia had not been published. In addition, whether existing programs met Australian recommendations for practice such as those contained in the Pulmonary Rehabilitation Toolkit, was unknown. Despite the significant benefits for both individuals with COPD and the community, access to pulmonary rehabilitation is limited, particularly for those in rural and remote regions. A lack of adequately trained healthcare professionals may contribute to difficulties with establishing and maintaining pulmonary rehabilitation. However, the effect of healthcare professional training on the availability of pulmonary rehabilitation had not been previously investigated. There were no published reports documenting existing knowledge and skill levels, evaluating training strategies to up-skill rural/remote healthcare professionals or evaluating the impact of such training on the delivery of pulmonary rehabilitation. The aims of the studies presented in this thesis were to: describe the current provision of pulmonary rehabilitation in Australia and the alignment of these pulmonary rehabilitation programs with evidence-based recommendations; determine the level of knowledge and skills of rural and remote healthcare professionals in the management of people with chronic lung disease; investigate the ability of an educational training program for healthcare professionals to improve knowledge and confidence and improve the availability and delivery of pulmonary rehabilitation in rural and remote regions and explore the attitudes, opinions and concerns of healthcare professionals regarding the delivery of pulmonary rehabilitation. The first study (Chapter 2) was a cross sectional, observational study using a purpose designed anonymous paper-based survey. The national database of pulmonary rehabilitation programs, maintained by Lung Foundation Australia (LFA), was used to identify known programs in all states and territories of Australia. All pulmonary rehabilitation programs listed on the database at that time were included (n=193). Healthcare professionals who coordinated pulmonary rehabilitation were invited to participate. This study had a response rate of 83% (n=163) and all states and territories in Australia were represented. The responses enabled the structure and content of Australian pulmonary rehabilitation programs to be elucidated. Most Australian pulmonary rehabilitation programs broadly met recommendations for practice contained in the Pulmonary Rehabilitation Toolkit in terms of included components (exercise training and education), program length, patient assessment and exercise training (duration, frequency and mode). Many respondents were not aware of major evidence-based practice guidelines (including the Pulmonary Rehabilitation Toolkit). Interestingly, despite not being aware of guidelines, most respondents indicated that they perceived a gap between current evidence and their practice in terms of exercise prescription and training. The studies presented in Chapters 4-7 were undertaken as individual components of a mixed methods study to evaluate the impact of the Breathe Easy Walk Easy (BEWE) program on healthcare professional knowledge and confidence, service delivery and patient outcomes in rural and remote Australian regions. The BEWE program was an interactive education and training program related to providing components of assessment and management (in particular pulmonary rehabilitation) for people with chronic respiratory disease. The BEWE program consisted of a training workshop, access to online resources, provision of community awareness-raising materials and ongoing telephone/email support. Details of the development of the BEWE program are presented in Chapter 1. Further information regarding the content and structure of the BEWE program along with relevant methods for the studies contained in Chapters 4-7, are presented in Chapter 3. The evaluation process was conducted by a researcher (the PhD candidate) who was independent of the development and delivery of the BEWE program. The study presented in Chapter 4 was a descriptive cross-sectional, observational survey design using a written anonymous questionnaire. Participants were healthcare professionals (n=31) who registered to attend the BEWE program initial workshop in either one rural or one remote Australian region. The main outcomes were participant attitudes, objective knowledge (case vignette-based) and self-rated experience, training, and levels of confidence. Participants were from a variety of professional backgrounds (allied health, medical, nursing) but were predominantly nurses (n=13) or physiotherapists (n=9). The main findings of this study were that that rural and remote healthcare professionals had low levels of experience, training, knowledge and confidence in providing components of management for people with COPD. Most participants reported that they had minimal or no experience or training in this area of practice. The scores in the measured knowledge quiz were generally poor, with mean knowledge score (number of correct answers out of 19) being 8.5 (SD=4.5). There were higher numbers of correct responses for questions relating to COPD disease pathophysiology and diagnosis than for questions relating specifically to pulmonary rehabilitation. In addition, most participants reported particularly low confidence in the delivery of pulmonary rehabilitation. Based on the findings of the study, the need for an education and training program for rural and remote healthcare professionals in the evidence-based management of people with COPD with an emphasis on pulmonary rehabilitation was evident. The effects of the delivery of an education and training program on healthcare professional knowledge and confidence in the management of people with COPD and on the availability of pulmonary rehabilitation were investigated and are presented in Chapter 5. This study was a quasi-experimental, before and after repeated measures design. Healthcare professionals (n=33) from various backgrounds who participated in the BEWE program were eligible to participate. The BEWE program was delivered in one rural and one remote region. Participant knowledge, confidence and attitudes were assessed via anonymous written questionnaire before, immediately after and at three and 12 months following the BEWE workshop. Participation in the BEWE program resulted in significant improvements in participants’ self-rated knowledge and confidence immediately after the workshop, and at three and 12 month follow-up. Measured knowledge (case vignette score out of 19) improved significantly immediately after the workshop compared to before (mean difference 7.6 correct answers, 95% CI 5.8 to 9.3). At 12-month follow-up, three locally run pulmonary rehabilitation programs had been established in participating regions. The availability of pulmonary rehabilitation following delivery of the BEWE program, as well as patient outcomes and the factors contributing to the change in service delivery were further explored and results are presented in Chapter 6. Data were collected regarding the provision of pulmonary rehabilitation services before and after delivery of the BEWE program and patient outcomes (six-minute walk test and health related quality of life) before and after pulmonary rehabilitation. Pulmonary rehabilitation was not available in any of the participating sites before the BEWE program. At 12-month follow-up three sites had established locally-run pulmonary rehabilitation programs which had a structure and content broadly meeting Australian practice recommendations for pulmonary rehabilitation. Initial patient outcome data for the six-minute walk test and the St George’s Respiratory Questionnaire demonstrated evidence of the effectiveness of these pulmonary rehabilitation programs in improving functional exercise capacity and health related quality of life. Providing targeted specific training, the retention of key staff and strong local healthcare organisational support were important factors which contributed to the successful establishment of pulmonary rehabilitation. A study involving interviews with key healthcare professionals involved in the delivery of pulmonary rehabilitation in rural and remote regions was conducted and is presented in Chapter 7. Those healthcare professionals who participated in the BEWE program and who were identified as key informants, were invited to participate in semi-structured interviews. The purpose of the interviews was to gain a deeper understanding of the participants’ attitudes and opinions regarding developing, establishing and delivering pulmonary rehabilitation in rural and remote regions. This study was designed to add perspective to the quantitative data rather than to inform the design of the evaluation process. Interviews occurred at three and 12 months following the BEWE workshop in the remote region and at 12 months following the BEWE workshop in the rural region. Interviews were recorded and transcribed verbatim. A process of thematic analysis was used to analyse the transcripts. Healthcare professional staffing levels, time and case load constraints, knowledge and confidence, ensuring sustainability, individual and community attitudes, and practical issues related to the setting, structure and content of pulmonary rehabilitation were identified as the main concerns of informants. The results of this study indicate that dedicated funding to support additional healthcare professional staffing and to assist with providing specific education and training may facilitate the availability and delivery of pulmonary rehabilitation in rural and remote regions. The body of work contained in this thesis has contributed to a greater knowledge of the practice and availability of pulmonary rehabilitation in the Australian rural and remote context and has provided evidence that the provision of a training program for healthcare professionals can facilitate the delivery of effective pulmonary rehabilitation in rural and remote Australian regions.
- Urls: https://ses.library.usyd.edu.au/handle/2123/11738 Download site (need university access or non-university access may be obtained by visiting the University of Sydney Library)
- Publisher Location: Sydney
- Keywords: Obstructive lung diseases, Obstructive lung disease patient rehabilitation, Rural health, Remote health, Pulmonary rehabilitation, Chronic respiratory disease, Health professional education, Physiotherapy