Same principles, different practices: the distance for geographic parity in health is not so great after all (Editorial)

Same principles, different practices: the distance for geographic parity in health is not so great after all (Editorial) Journal Article

JBI Database of Systematic Reviews and Implementation Reports

  • Author(s): Carey, Timothy A.
  • Published: 2018
  • Volume: 16
  • ISBN: 2202-4433

Abstract: In 2016, a review of funding for Aboriginal and Torres Strait Islander programs in Australia reported that, of the 1082 programs funded annually with $5.9 billion of government funding, less than 10% had been subjected to any sort of evaluation.1 Anecdotal evidence indicates that there is a similar paucity of health services evaluation throughout rural and remote Australia. Furthermore, there is a well-documented geographic disparity in health outcomes with people in metropolitan centres enjoying better health than people who have rural and remote addresses.2 Given the persistent health disparities experienced by Aboriginal and Torres Strait Islander Australians, those Aboriginal and Torres Strait Islander people who live in rural and remote locations experience a double-disadvantage. When the concept of evidence-based healthcare is understood, the reasons for the absence of a rampant pandemic of evidence-based practice in rural and remote settings can be more easily appreciated. The JBI model of evidence-based healthcare articulates the integration of: the best available evidence; knowledge of the context in which the care is delivered; client preferences; and the professional judgement of the health professional.3 Two of these components are particularly relevant in rural and remote settings. Firstly, context is crucial, particularly in remote settings, where personal, family, and other social relationships are the bedrock of communities and English might not be the main language spoken. In the Warlpiri language of central Australia, for example, wajampa is the word for “anxiety” but also means: worry; concern; upset; sorrow; and grief.4 Also, there are different words for “anxious for” and “anxious over”. Moreover, wajampa-wajampa means “determined to kill” and “relentless” as applied to hunting as well as “a worrier”.4 Furthermore, there are five different words for “worry” (of which wajampa is one), four different words for “worry about”, and still different words for “worry about someone” and “worry about something”.4 A mental health professional, therefore, who is working in the community of Yuendumu where Warlpiri is widely spoken, will need to have a nuanced understanding of context if they are referred someone for treatment of their “anxiety disorder”. Secondly, despite the acknowledged importance of patient preferences, they are not routinely sought or used to guide treatment decisions in healthcare.5 Our failure to pay close attention to patient preferences has led to the global phenomenon of inappropriate health care which currently accounts for billions of wasted dollars globally.6 The extent to which the role of patient preferences is overlooked or minimized in health service delivery has prompted a call to adopt a “patient-perspective” model of health care rather than the standard patient-centered approach which emphasizes position (the center) rather than preferences.5 In rural and remote areas, context and patient preferences can be tightly interrelated. The impact of context and patient preferences, therefore, may be felt most strongly outside of metropolitan centres where health services can be provided, wholly or in part, by a visiting workforce with varying levels of knowledge about the local area and its people. These important factors affect not only the implementation of evidence-based practice but also the way in which “evidence” is understood. Evidence includes, not only evidence of effectiveness, but also evidence of feasibility, appropriateness, and meaningfulness.3 Understanding the FAME (feasibility, appropriateness, meaningfulness and effectiveness) approach to evidence can help explain why the transfer of services from urban to nonurban settings is not always straightforward. What is feasible and appropriate in a city, for example, will not necessarily be feasible and appropriate outside the city. Rather than focusing on the transfer of practices, therefore, it is imperative that policy makers and service providers pay attention to important principles of service delivery. It is entirely possible to endorse the principle of high quality, evidence-based service provision while also recognising that, in order to incorporate this principle, different practices will need to be adopted and adapted to the local context. In late 2017 and early 2018, I undertook a four-month Fulbright Scholarship at the Center for Behavioral Health Innovation (BHI), Antioch University New England.7 The center works with underserved communities in a variety of locations including rural areas of New Hampshire, to improve service provision by embedding ongoing monitoring and evaluation within the routine practices of service providers. This work lies at the nexus of different initiatives such as routine outcome monitoring (ROM),8 continuous quality improvement (CQI),9 and the use of patient experience data.10 In this approach, it is understood that the effectiveness of a program is not a property of the program itself. Rather, effective outcomes are created through the interaction between the service provider and the service recipient. Outcomes should be negotiated at the outset between the service provider and service recipient (that could, for example, be a school community) with subsequent service provision being continually monitored and adjusted to ensure the ongoing and sustained feasibility, appropriateness, meaningfulness, and effectiveness of the program or intervention. Thus, evaluation is considered to be more of a learning process to ensure that services are delivered flexibly and responsively for the benefit of service recipients, rather than a decision-making tool to determine the effectiveness or otherwise of a service. Unless we can begin to rethink the way we currently approach the accumulation and implementation of evidence in rural and remote settings, we will never “close the gap” on the health disparities that exist. We must hold a hard line regarding the important principles of high-quality service provision and incorporate these principles in policy documents and routine practices. Above all, it is important to recognize that, to apply the principle of evidence-based health care ubiquitously, we must vary our practices in whatever way we need to so that people who choose residences away from the city can enjoy the same standard of health that city dwelling citizens take for granted.

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Suggested Citation
Carey, Timothy A., 2018, Same principles, different practices: the distance for geographic parity in health is not so great after all (Editorial), Volume:16, Journal Article, viewed 04 December 2023,

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