Blackwell Science, LtdOxford, UKAJRAustralian Journal of Rural Health1038-52822005 National Rural Health Alliance Inc.

June
2005133162171Original ArticleBARRIERS TO RURAL SPEECH PATHOLOGY SERVICESA. M. OCALLAGHAN
Et al.

Aust. J. Rural Health (2005) 13, 162171

Original Article
Barriers to accessing rural paediatric speech pathology
services: Health care consumers perspectives
Anna M. OCallaghan, Lindy McAllister and Linda Wilson
School of Community Health, Charles Sturt University, Albury-Wodonga, New South Wales, Australia

Abstract
Objective: An investigation of consumers perceived
barriers to access paediatric speech pathology services.
Design: Self-administered, mail-out questionnaire.
Setting: Rural and remote New South Wales (NSW).
Subjects: Three hundred and twenty-nine members of
the NSW branch of the Isolated Childrens and Parents
Association.
Results: Consumers living in rural and remote areas
experience a number of barriers that affected their ability to access speech pathology services. These barriers
include the lack, and limited choice, of speech pathologists in rural areas; long distances to travel to access
services, expensive travel costs, lack of public transport;
poor awareness of speech pathology services; and delays
in treatment due to waiting lists.
Conclusion: Barriers to access paediatric speech
pathology services limit rural and remote consumers
usage of health services, regardless of need, indicating a
possible inequity if compared to larger, more accessible
urban areas.
KEY WORDS: equity, isolated, paediatric, remote,
speech therapy.

Introduction
Rural health services within Australia command proportionally fewer resources and fewer staff than those
in urban areas.1 For example, 4.5% of Australian speech
pathologists provide services to over 30% of the population living in rural and remote areas.2,3 This finding
gives reason to question the equity of rural health services. Many of the sources of inequity in rural health
care have been documented in the literature, see Table 1.

Correspondence: Ms Anna M. OCallaghan, 510 Garden

Street, Albury, New South Wales, 2460, Australia. Email:
annamocallaghan@hotmail.com
Accepted for publication December 2004.

While previous studies have identified the views of

health professionals and policy makers regarding the
barriers that they thought were faced by rural consumers when attempting to access rural health services, these
studies did not provide consumers perspectives. Therefore, in response to this lack of insight into consumer
perspectives, the study reported here addressed the following questions:
1. What are the barriers experienced by consumers
when attempting to access paediatric speech
pathology services in rural and remote New South
Wales (NSW)?
2. In what ways do consumers believe barriers to
access paediatric speech pathology in rural and
remote areas of NSW can be alleviated?

Method
Informants
The informants in this study were 329 members of the
NSW branch of the Isolated Childrens and Parents
Association (ICPA). A summary of background information and characteristics for the informants is included
in Tables 2 and 3.

Questionnaire
A questionnaire (see Appendix I) was sent out by the
ICPA, with its quarterly newsletter, to the 1100 noninstitutional members. The questionnaire was designed
to determine the perceived needs and barriers that rural
and remote families in NSW face when trying to access
paediatric speech pathology services for their children.
Two weeks after the initial mail-out, follow-up letters
were sent, accompanied by another copy of the
questionnaire.
Data from each questionnaire were coded and
recorded in the project database and then analysed using
the Statistical Package for the Social Sciences (SPSS
Inc.). Results relating to consumers perceived barriers
to access and solutions to these barriers are listed below.

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BARRIERS TO RURAL SPEECH PATHOLOGY SERVICES

What
is
already
known
on
this
subject: Numerous studies have described the
inequities of rural health at a systemic level (e.g.
rural health policies of centralisation,
rationalisation, fiscal constraint) and at the level
of health professionals (e.g. no support, sole
positions, and reduced access to resources and
professional development). However, few have
explored the barriers that consumers face when
attempting to access rural health services,
particularly if allied health services such as
speech pathology are needed.

What this study adds: This paper reports on a

study that investigated the perceived barriers
experienced by consumers when attempting to
access paediatric speech pathology services in
rural and remote NSW. Key findings from this
study are that rural and remote consumers in
NSW experience a number of barriers that affect
their ability to access speech pathology services.
Potential solutions to these barriers are
proposed.

Results

Access barriers to speech pathology services

Three hundred and twenty-nine members (30%) of the

ICPA responded to the questionnaire, and whilst a
return rate of 30% may not be considered a representative sample, with cautious interpretation it offers good
preliminary results.

Seventy-five (63%) of the 139 informants who needed

to access speech pathology services reported problems
in doing so. The access barriers that these informants
reported are summarised in Table 4. Informants indicated these difficulties by answering a closed question

TABLE 1:

Sources of inequity of rural health services

Problems leading to inequities

Access to health services
Travel difficulties (i.e. cost and availability)
Lack of available health services
Delays in treatment due to waiting lists
Low levels of awareness of health services
Limited choice of health services
Appropriateness of rural and remote speech pathology services
Home programs for others to carry out
Reliance on other professionals to provide follow-up
Delegation of tasks to nonhealth professionals
Emphasis on client self-management
Telephone consultations
One-off visits for assessment and provisions of intervention strategies
Improvisation
Use of less specialised equipment
Rural health-care policies
Centralisation
Rationalisation
Fiscal constraint
Recruitment and retention of health professionals
Professional isolation
Perceived decrease in professional development opportunities
Lack of supervision and support
Large caseloads
Reduced access to resources
Inadequate leave and locum provision
Separation from family and friends

References

4
4,5
6
4
4
79
7,8
7,8
7,8
79
7,8
7,8
7,8
4,10
5,11
12
1315
1315
13,15
1315
16
13
13

164
TABLE 2:

A. M. OCALLAGHAN ET AL.

Informants background information

Age
Number of children
Income
Education level

TABLE 3:

Range

Mode

25 to >65 years
1 to >5 children
<$10 000 to >$100 000
Primary school to postgraduate degree

35 to 44 years (44.4%)
3 children (37.1%)
$35 000 to $50 000 (23.7%)
Undergraduate degree (33.7%)

travel to speech pathology services are summarised in

Table 6.

Informants characteristics
n (%)

Sex
Male
Female
Missing data
Ethnicity
ATSI
Caucasian
Other
Missing data
Marital status
Partnered
Single
Missing data

Discussion
25 (7.6)
295 (89.7)
9 (2.7)
0
317 (96.3)
2 (0.6)
10 (3.0)
312 (94.8)
8 (2.4)
9 (2.7)

ATSI, Aboriginal or Torres Strait Islander

that offered a list of potential access barriers. Informants were also given the opportunity to cite other
barriers not included in this list.

Consumers proposed solutions to

access barriers
Of the 75 informants who experienced barriers accessing speech pathology services, 61 (82%) listed ways in
which they believed these barriers could be overcome.
These possible solutions are listed in Table 5. Fifteen per
cent thought students should have compulsory rural
placements.

Travel schemes
One of the possible solutions, proposed by informants,
to alleviate the access barriers listed above included
subsidised client travel. However, only 42 (13%) of the
329 informants reported that they were eligible for any
form of travel allowance in order to access speech
pathology services. The travel schemes reported to have
been accessed by informants to subsidise the cost of

This study identified that rural and remote consumers

in NSW experience a number of barriers that affect their
ability to access paediatric speech pathology services.
Potential solutions to these barriers have also been identified. To date, this appears to be the only rural and
remote, consumer-based, speech pathology study completed in Australia, and as such it provides the first
available set of data examining consumers experiences
when accessing speech pathology services in rural
environments.

Access barriers
The majority of informants included in this study experienced some form of barrier when attempting to access
paediatric speech pathology services. A summary of
these barriers is presented below.

Service availability
Over 85% of consumers who reported access barriers
cited the lack of available speech pathologists as a prime
concern. This finding is supported by the speech pathology labour force survey compiled by Lambier,2 which
found that only 4.5% of respondents to the survey were
employed in moderately accessible, remote or very
remote regions of Australia, compared to 94% of the
workforce being employed in accessible or highly accessible areas.
Results from this study show that the current length
of wait for rural and remote paediatric speech pathology
services varies from less than 1 month to up to 2 years,
with the average being greater than 6 months. The
majority of informants stated that they found the current length of waiting lists unacceptable. Keens study
of parents acceptance of waiting list times when dealing
with paediatric speech pathology services in a community hospital in Western Australia also identified that
parents believed waiting list periods of between 4 and

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BARRIERS TO RURAL SPEECH PATHOLOGY SERVICES

TABLE 4:

Barriers experienced by consumers when accessing speech pathology services

Barriers

Frequency

Percentage

Lack of availability of speech pathology services

Long distances to travel to access speech pathology
Delays in treatment due to waiting lists
Expensive travel costs
Limited choice of speech pathologists
No public transport
Lack of awareness of speech pathology services
Other

63
56
43
38
33
25
24
12

86
76
59
53
45
36
32
16

Other category responses included local residents negative experiences, which led to an informants decision to not access
services; cancelled appointments; no cooperation between states, for example one informant found that she was unable to access
Queensland community services as she lived in New South Wales; and lack of consistency of services.

TABLE 5:

Ways in which consumers believe barriers can be overcome

Resolution strategies

n (%)

General rural health solutions

Implement changes to students education
Increase incentives for rural practice
Subsidise client travel
Speech pathology-specific solutions
Increase the number of speech pathologists employed in rural areas
Increase the number of mobile/visiting speech pathology services
Greater collaboration between schools and speech pathology services
Other
Increase regularity of speech pathology services
Increase funding for rural speech pathology services
Speech pathologists to be more flexible in service delivery
Increase publics awareness of speech pathology services
Agent training

9 (15)
5 (8)
3 (5)
31
10
10
8
7
7
4
3
3

(51)
(16)
(16)
(13)
(12)
(15)
(7)
(5)
(5)

Other category responses include greater public transport, screening of all kindergarten children, reducing government red
tape, greater department collaboration (i.e. between the Department of Disability and Aged Care and the Department of Health
Services) and the use of information technology and telecommunications for the delivery of services.

TABLE 6:

Travel allowance schemes reported to be accessed by isolated families to travel to speech pathology services

Travel schemes

Frequency

Percentage

Home and Community Care (HACC)

New South Wales Community Transport (CPT)
Area Assistance Scheme (AAS)
Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS)
Other
Missing data

0
0
0
35
5
2

0.0
0.0
0.0
83.3
11.9
4.8

Other category responses included that the Royal Far West Childrens Health Service paid for its clients and one parent to
travel to Sydney, and according to one informant Medicare Benefit Fund subsidises travel if it is over 100 kilometres.

166

six months were largely unacceptable, with acceptable

waiting list times being four weeks or less.6

Distance decay
Distance decay refers to the phenomenon whereby the
further away a health service is located from a consumers home, the less likely it is to be accessed.9,17 The
effect of distance decay on the failure of consumers to
access paediatric speech pathology services has been
questioned.9 This study supports this as over 50% of
consumers who reported difficulties accessing speech
pathology services said the length of travel required was
an access barrier.

Choice of services
This study showed that because of the limited number
of speech pathologists employed in rural and remote
areas, choice of speech pathologists is not an option.
Consequently, if consumers feel dissatisfied with the service they receive there is no alternative. This finding is
compounded by that of Bourke who stated that should
any issue arise in rural and remote health care, consumers are unaware of where to complain.4 This implies that
rural and remote consumers accept difficulties in health
care provision because they have few service options
available.4

Consumers awareness of services

The lack of awareness of speech pathology services was
also identified as a barrier to access. An awareness of
health services and increasing health knowledge are
important in small rural communities to ensure consumers make informed decisions regarding their health
needs. However, gaining this knowledge is difficult, as
there are fewer educational programs available to them
than in urban areas.5 This is a subject that needs to be
targeted because consumers who have felt a need for
speech pathology services may be unaware of where to
access them, and may therefore forego these services.

Costs associated with accessing services

Another of the perceived access barriers identified in the
present study was the expense associated with travelling
to services. Bourke also noted that economic issues surrounding access to health services were of most concern
among rural consumers.4
Finally, the lack of public transport in rural areas to
assist subsidised travel costs was identified as an access
barrier. Public transport services are often inadequate in
rural and remote areas, and any services that are available are often of limited usefulness.5 However, without

A. M. OCALLAGHAN ET AL.

public transport, consumers are left to rely on their own

means of transport, which, as noted above, can often be
expensive.
One of the potential solutions identified by consumers
to access barriers is the provision of travel schemes to
subsidise the cost of travel. There are a number of travel
schemes currently in place in rural and remote areas of
NSW as shown in Table 6. Nonetheless, only a small
minority of consumers in the present study stated that
they were eligible to access any form of subsidy. Of this
minority, over 80% stated that they accessed the Isolated Patients Travel and Accommodation Assistance
Scheme (IPTAAS), when according to the NSW exclusion criteria speech pathology services are not covered
by IPTAAS.18 In addition, the majority of informants
stated that they were unsure of their eligibility status
under any scheme. Subsidised travel is an area that
needs further examination as travel costs were identified
by over half of informants as an access barrier.

Consumers proposed solutions to access

barriers
Other solutions to access barriers proposed by consumers included that changes should be made to students
education to make rural work practicums compulsory.
In addition, as recommended for other health professionals, consumers suggested offering increased incentives (i.e. improved wages and conditions, travel
subsidies, professional supervision and support, and
relocation assistance) to attract speech pathologists to
rural and remote areas.5
Governmental and management changes were also
proposed, such as increasing the number, frequency and
funding of speech pathology services provided to rural
and remote areas, and increasing the collaboration
between health and education departments. Changes to
the models of service delivery that speech pathologists
provide were also desired by consumers. For example
consumers also recommended that speech pathologists
become more flexible and accommodating of their needs
(e.g. working weekends when they can be accessed), and
provide more training of school teachers and parents.
Another solution proposed by consumers included
that the general public be made more aware of the
location of speech pathology services, and the important
role speech pathologists play in the remediation of communication and swallowing impairments. This is an
area that can be targeted by the promotion and advocacy of speech pathology services Australia wide.
Overall, this study has identified that rural and
remote consumers face a number of barriers when
attempting to access paediatric speech pathology services. In addition, consumers suggested a range of solutions to these access barriers. However, collaboration

167

BARRIERS TO RURAL SPEECH PATHOLOGY SERVICES

between speech pathologists, consumers and government and nongovernment organisations is required to
overcome barriers and achieve equity of speech pathology service provision in rural and remote areas.
The results of this study gave rise to the formulation
of a number of recommendations aimed at improving
the equity of paediatric speech pathology services. These
recommendations include increased funding for more
speech pathologists and expanded speech pathology services in rural and remote areas; increased public awareness campaigns to make rural and remote consumers
aware of speech pathology services; increased incentives
to attract speech pathologists to rural and remote areas;
and improved schemes to enable consumers to travel to
speech pathology services together with better promotion of such schemes.

10

Acknowledgements
Speech Pathology Australia provided the first author
with a research grant to subsidise the research costs of
this project. The ICPA (NSW) assisted in the distribution of the questionnaires to its members.

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Appendix I: Questionnaire

A. M. OCALLAGHAN ET AL.

BARRIERS TO RURAL SPEECH PATHOLOGY SERVICES

Appendix I: Continued

169

170

Appendix I: Continued

A. M. OCALLAGHAN ET AL.

BARRIERS TO RURAL SPEECH PATHOLOGY SERVICES

Appendix I: Continued

171