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Investigation of primary health care service delivery models used in allied health practice in rural and remote areas of Australia: a systematic review

BMC Health Services Research volume 25, Article number: 573 (2025) Cite this article

Abstract

Introduction

In Australia, access to primary health care (PHC) services is limited in comparison to major cities. Allied health professionals play a pivotal role in providing necessary PHC in rural and remote areas. However, there is limited evidence about the most effective allied health specific PHC models of care that can be utilised in these settings. The aim of this review was to describe the PHC models used by allied health professionals in rural and remote areas of Australia and report on their impact and effectiveness in improving care.

Methods

A search of five databases (MEDLINE, Embase, CINAHL, PsychINFO and Informit Health) was undertaken. Articles were included that related to a refined list of allied health professions that specifically work in PHC settings, these included: dietetics; occupational therapy; physiotherapy; psychology; speech pathology; social work; podiatry; exercise physiology; pharmacy; optometry; and audiology. Articles with a focus on a PHC model of service delivery in a rural or remote area were included. The effectiveness and impact of these models was examined. The Mixed Methods Appraisal Tool was used to assess the quality of the included articles.

Results

A total of 57 articles met the inclusion criteria, from an initial 1864 unique citations sourced from searches. Of the 57 articles, 22 studies were in the Australian context and were included in this paper. The outcome measures typically included improving access to services, however minimal impact or effectiveness data was reported. Studies were categorised into an existing typology of PHC models: integrated services (n = 9); outreach services (n = 3); virtual outreach services (n = 4); discrete services (n = 4); with an additional model being health promotion (n = 5).

Conclusion

A range of PHC models were used by allied health disciplines in rural and remote areas of Australia. These models focused on improving access to allied health services in primary care settings to address health inequities faced. Given the limited reporting of the impact of these services, it is recommended that rigorous evaluations of existing allied health models are undertaken. There is a gap in the literature regarding the models of service delivery being used by allied health professionals in non-metropolitan areas.

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Background

Access to primary health care (PHC) is a fundamental human right and is considered essential for universal health coverage [1]. PHC relates to patient treatment that is delivered outside of the hospital setting and focuses on disease prevention, early intervention and management of existing conditions [2]. It is a vital component in delivering essential healthcare, particularly as the burden of non-communicable diseases increases, globally [3]. PHC has the ability to decrease hospital admissions and prevent avoidable readmissions [3]. Despite the strong evidence in support for PHC to improve health and wellbeing across all life stages, there continues to be significant challenges to providing PHC in rural and remote settings, globally and in Australia.

Approximately 28% of the Australian population live in rural and remote areas [4]. Those living in rural and remote areas often have poorer health outcomes in comparison to people living in metropolitan areas [4]. In Australia, the total burden of disease and injury has been reported to increase with an increase in remoteness. This includes the burden of disease for chronic diseases such as cardiovascular disease, diabetes, chronic kidney disease and respiratory conditions [4]. Inadequate access to PHC providers and health services in these areas is considered to be a leading cause of the health disparity for people living in rural and remote locations [4]. As such, there is a significant need to improve PHC provision in rural and remote Australia.

Models of care used in rural and remote communities may vary from those used in metropolitan areas to account for the limited access to PHC in these settings [5]. A model of care can be described as the way healthcare services are delivered [6]. The key elements in an effective model of care include: accessible, patient-centred, continuity of care, innovative, fit-for-purpose, efficient service delivery and effectively use available resources [5, 7, 8]. Factors that contribute to limited access to PHC in rural and remote areas include geographical isolation, reduced healthcare infrastructure and workforce shortages, which require tailored approaches to ensure equitable access to care [9, 10]. Types of rural PHC models include private allied health services, discrete services (including walk-in/walk-out), integrated services (such as shared care), comprehensive primary health care services (such as Aboriginal controlled community health services), virtual or telehealth services and face to face outreach services (including fly-in, fly-out) [11, 12]. In addition to adapting service models, improved access to PHC services in rural and remote settings can depend on the willingness of clinicians to use an extended scope of practice [8]. An extended scope of practice is where a health professional develops a broader skill set and therefore offers a wider range of services beyond their recognised scope of practice [13]. In rural areas, where a full range of services may not be available, extended scope of practice may be utilised by allied health professionals to increase the quality and breadth of services provided [14].

Allied health professionals, who provide essential services for preventative, early intervention and chronic disease management, are an important component of the PHC workforce [15]. At present, there is poor distribution of allied health professionals across Australia, with over 70% of all allied health professionals living and working in metropolitan locations, with the number of allied health practitioners decreasing with increasing remoteness [15]. This is often cited to be due to low retention and recruitment of allied health professionals to rural and remote settings [8, 16,17,18]. More recently, there has been national interest in improving the current allied health service distribution in these settings. Evidence of this can be seen in the allied health rural generalist program, where new graduates are supported to undertake generalist roles and undertake postgraduate qualifications in rural practice [16].

Whilst there is renewed focus on improving allied health services in rural and remote areas [16], there is a paucity of evidence around the most effective allied health specific PHC models of care that can be utilised in these settings. A scoping review explored aspects of service models used by allied health professionals to improve service distribution and reported that telehealth services for home-based cardiac rehabilitation was as effective as a face-to-face service [14]. Similarly a systematic review and meta-analysis reported telehealth interventions delivered by allied health professionals and nurses (with the majority being nurses and psychology professionals) were as effective as face to face interventions [18]. However, both reviews focussed on telehealth as a specific model of service delivery and did not consider other models of PHC [14]. A further two reviews explored PHC with a focus on general practice and were not specific to allied health [8, 11]. There have been no systematic reviews that focus specifically on allied health PHC models of service in regional, rural and remote areas. Given the gap in the literature, the aim of this systematic review was to investigate primary health care models of service used by allied health professionals in rural and remote areas, with a focus on the Australian context. The effectiveness and impact of these models was examined in terms of service access and availability, as well as quality of care and health outcomes. Specifically, the research questions were:

  1. i)

    What primary health care models are used by allied health professionals in rural and remote areas of Australia?

  2. ii)

    What was the impact of these primary health care models on service access and availability?

  3. iii)

    What was the effect of these primary health care models on quality of care and/or health outcomes?

Methods

A systematic review protocol was registered with PROPSPERO (CRD42021251696; 11/06/2021). The methodology and reporting for this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and statement [19].

Eligibility criteria

Eligible articles focussed on PHC models that delivered services outside the acute hospital setting. Allied health disciplines were chosen based on the Services for Australian Rural and Remote Allied Health list of allied health professions [20] and this list was further refined to only include allied health professions that are directly involved in primary health care delivery. Therefore, articles were required to include services of one or more of the following allied health disciplines: dietetics; occupational therapy; physiotherapy; psychology; speech pathology; social work; podiatry; exercise physiology; pharmacy; optometry; and audiology. Geographic location was restricted to non-metropolitan areas, encompassing locations fitting the description of regional, rural or remote areas either by author description or according to the location of the service using the Modified Monash Model classification [21] as a guide. Studies were included if they provided comparisons with models used in metropolitan areas, if the rural or remote model data was discernible from any metropolitan model data. Studies reported in English and published from 2000 onwards were included, to ensure practice model currency and relevance. Only articles reporting primary research were included, inclusive of any type of research methodology and study design.

Search strategy

A search strategy was developed in consultation with a university Research Liaison Librarian. Literature searching was conducted in five peer-reviewed databases: MEDLINE; Embase; CINAHL; PsychINFO; and Informit Health. The full search strategy of MEDLINE database is shown in Table 1, this search strategy was adapted for use with other databases. An initial search was conducted on 14 March 2021, with repeated searches on 24 May 2021, 17 November 2022 and 30 August 2024. ‘Grey’ literature was included from government websites, university organisations and works known to the research team. Hand searching was also completed by reviewing reference lists of included articles.

Table 1 Search strategy for this review in MEDLINE
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Study selection

Database searches were uploaded into Endnote (X9.2, Clarivate, Philadelphia, PA, USA) and duplicate articles removed before results were transferred into Covidence (Veritas Health Innovation, Melbourne, Victoria, Australia). Covidence was used to manage references for the review screening [22]. Two researchers (AC, LB, TS, RW, AB or SH) independently reviewed the title and abstract of included articles according to agreed inclusion and exclusion criteria (Table 2). Remaining full text articles were also screened by two researchers and any conflicts resolved by discussion and, if agreement was unable to be reached, a third researcher reviewed the article.

Table 2 Inclusion and exclusion criteria for the literature included in this review
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Data collection process and data items

A data extraction form was developed in Excel and used to extract information including title, authors, publication date, timing of the study, primary aim/s of study, location of service, demographic characteristics of the study sample, allied health professions included, type of primary health care service (as depicted by Table 3), primary and secondary outcomes measures and implications/recommendations. Data extraction was conducted by one researcher and independently checked by a second reviewer, with any conflicts resolved through discussion and reference to the data extraction tool.

Table 3 Existing typology of rural and remote primary health care models [11]
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Quality assessment and risk of bias in individual studies and across studies

Two researchers independently quality appraised each article using The Mixed Method Appraisal Tool (MMAT). The MMAT is used to appraise the methodological quality of qualitative, quantitative and mixed method reviews [23]. While methodological criteria are more difficult to assess, it may be considered more rigorous than simply reporting quality [24]. Articles were assessed with two screening questions and five quality criteria questions, all articles were then given a rating for each criteria, rather than a total score. Scoring of five quality criteria questions, with a score given as; ‘no’, ‘can’t tell’ or ‘yes’. Studies were considered either high or low quality based on the number of ‘yes’ responses given, with more ‘yes’ responses indicating higher quality. The MMAT also identified risk of bias of individual studies through the criteria questions. A description of the questions used to determine the quality of each study is included in Table 4.

Table 4 Summary of mixed methods appraisal tool (MMAT) evaluation criteria [24]
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Synthesis of results

All studies were reported narratively. All studies were categorised to an existing typology of rural and remote primary health care models [11], where there was a clear fit. The primary aim of the PHC model was summarised. This included measures or descriptions of service availability, service delivery method/s, consistency/regularity of services and services being “fit for purpose”. As per the aims, the impact and effectiveness of PHC models was reported, in addition to any other key outcomes and implications of the models.

Results

Study selection

A total of 1864 potentially eligible articles were retrieved from the five databases. An additional six studies were retrieved from the grey literature and a further four studies identified after hand searching the reference lists of included articles. After 461 duplicates were removed, 1413 article abstracts and titles were screened. A total of 197 articles were included in the full text stage. From the full text screening, 57 articles met the inclusion criteria for the initial review. For this paper, a total of 23 articles (22 studies) have been reviewed, as they relate to the Australian context, as per the aim of this review. The study selection process is summarised in the PRISMA flow chart, shown in Fig. 1.

Fig. 1
figure 1

PRISMA flow chart for systematic review of primary health care service delivery models relevant to allied health practice in rural and remote areas of Australia

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Study characteristics

Of the 22 included Australian studies, most were located in four Australian states: New South Wales (n = 6) [25,26,27,28,29,30]; Victoria (n = 5) [29, 31,32,33,34]; Queensland (n = 5) [35,36,37,38,39,40]; and South Australia (n = 4) [41,42,43,44]; with one study across two states [29]. Additionally, there was a study conducted in Western Australia [45] and two studies that did not identify the state [46, 47]. Surveys (n = 9) were the most common method used to measure service outcomes [28, 29, 32,33,34, 38, 44, 46, 47]; followed by interviews and/or focus groups (n = 6) [26, 30, 36, 40, 42, 43]; and health measurements (n = 3) [25, 27, 34]. Studies either focussed on specific health conditions (n = 9), such as diabetes [25, 32, 34], cardiovascular health [30], asthma [27], ear health [39] or mental health [29, 41, 47]; or age specific services (n = 8), such as paediatrics [26, 28, 34, 35, 38, 40, 42] or older adults [44, 45]; or general health needs for remote communities (n = 5) [31, 33, 36, 43, 46]. The majority of studies were able to be mapped to at least one of the existing typology of primary health care service models, as described in Table 3 including integrated services (n = 9) [29, 31, 32, 34, 37, 38, 40,41,42,43]; outreach services (n = 2) [35, 36]; virtual outreach services (n = 4) [26, 33, 38, 40, 45]; and discrete services (n = 3) [30, 39, 46]. A further model of service delivery, not included in the existing typology, health promotion, was also identified (n = 5) [25, 27, 28, 44, 47]. Of the included studies, occupational therapy (n = 10) [26, 33, 35,36,37,38, 40,41,42, 44, 46], dietetics (n = 8) [25, 26, 33, 34, 36, 37, 41, 43], psychology (n = 7) [25, 26, 29, 31, 36, 42, 45], and podiatry (n = 7) [30,31,32, 36, 37, 41, 43] were the top four allied health disciplines involved. A summary of the individual studies is provided in Tables 5 and 6.

Table 5 Summary of the PHC models used by allied health professionals in non-metropolitan areas, n = 22^
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Table 6 Summary of the outcomes of the studies on PHC models used by allied health professionals in non-metropolitan areas, n = 22^
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Quality appraisal & risk of bias

The included studies were assessed across the five categories of the MMAT: randomised studies (n = 1) [45]; non-randomised studies (n = 7) [25, 27, 29, 34, 42, 46, 47]; quantitative studies (n = 4) [28, 30, 32, 33]; qualitative studies (n = 4) [26, 40, 43, 44]; and mixed method studies (n = 3) [36, 38, 39]. Of the 22 studies, eight studies were found to be of low quality [28, 30, 33, 36, 38, 39, 42, 43] and 11 studies were considered to be high quality [25,26,27, 29, 32, 34, 40, 44,45,46,47]. The studies classified as ‘randomised’ or ‘non-randomised’ were assessed as higher quality compared to the remaining studies. Four studies could not be assessed using the MMAT due to being purely descriptive studies and did not meet the tool’s criteria for evaluation [31, 35, 37, 41]. The MMAT ratings of all 22 studies are listed in Tables 4 and 7.

Table 7 Mixed methods appraisal tool results for studies included in this review [24]
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Outreach services

Of the 22 studies, three studies were considered outreach services [35, 36, 46]. In terms of rurality, all the studies were considered remote. None of the studies provided clear measures detailing the effectiveness or impact of the primary health care model. Two of the studies, instead, described the PHC model [35, 36]. All of the studies included a range of allied health professions with a primary aim of the PHC model to improve access to services, with two studies also reporting on other key outcomes such as the sustainability of the model [35, 36]. All of the studies used a different type of outreach service, with one study utilising a fly in-fly out model of care whereby allied health professionals and clinicians provide paediatric healthcare to remote communities in Cape York, Queensland [35]. Another study utilised a hub-and-spoke model of care to provide allied healthcare to remote communities in North-West Queensland [36].

Virtual outreach services

Virtual outreach services were described by four studies (in five publications) [26, 33, 38, 40, 45]. Telehealth was used by all studies as the primary virtual outreach service to assist with the care for older adults with depressive symptoms [45], paediatric feeding clinics [26], paediatric burn review clinic [38, 40] and general access to allied health care [33]. Access to services was the primary aim of the PHC in three studies [33, 38, 40, 45]. Two studies did not report on the impact or effect of the PHC model [26, 33]. Whilst a further two studies reported telehealth support improved depression and anxiety symptoms for older adults in one study [45] and access to a telehealth paediatric burn review clinic improved from reviews every 20 weeks to an average review of every 8 weeks [38, 40] with fewer patients requiring surgical review and higher satisfaction with the telehealth service and continuity of care [38, 40].

Discrete services

Discrete services were described in four studies [28, 30, 39, 46]. The primary aim of each of these studies were related to access to services with one pharmacy based study increasing access to care for those with ear complaints without having to see a general practitioner [39] and another study reporting an increase in access to services by engaging podiatry students in cardiovascular screening clinics, resulting in a sustainable method of care [30]. A further discrete service study conducted surveys with occupational therapists and reported that 89% of respondents provided care in outer regional areas and the majority regularly visited three regional/rural towns, however other key outcomes of sustainability were uncertain due to insufficient long term demand [46].

Integrated services

Integrated services were reported in nine studies [29, 31, 32, 34, 37, 38, 40,41,42,43]. Multidisciplinary integrated services in a PHC team were used in seven studies [31, 32, 34, 37, 41,42,43], whilst 2 studies utilised a shared cared PHC model [29, 38, 40]. Access to services was the primary aim for all studies. A study in very remote QLD described its multidisciplinary team of allied health professionals to improve access to care in the region, highlighting the need for a collective fit-for-purpose approach and focus on improving workforce and community capacity building [37]. Similarly, a study in regional South Australia described its multidisciplinary health and wellbeing team to provide mental health services in the region, however, it highlighted the need for further evaluation measures and resources to be provided to appropriately evaluate the impact of the PHC model [41]. Another mental health study conducted in Victoria and New South Wales reported that the integrated shared care PHC model between general practitioners and psychologists, not only improved access to mental health services but significantly improved the mental health status of the patients in the cohort study [29]. Three studies used integrated services in its paediatric care [34, 38, 40, 42]. One study, described in two articles, utilised both integrated services and virtual outreach services in its paediatric burn telehealth review clinic [38, 40]. A multidisciplinary clinic was described in a study for children with diabetes and reported an increase in the variety of allied health services available resulting in higher levels of satisfaction with the care provided [34]. Another paediatric study in regional South Australia also reported providing services via a multidisciplinary PHC team for early intervention using a range of allied health professionals, that the population previously had no access [42].

Health promotion services

Health promotion services were reported in five of the 22 studies [25, 27, 28, 44, 47]. Access to services was the primary aim of the PHC for four of the five studies [25, 27, 28, 44] with service delivery being the primary aim of one study [47]. All studies reported on the impact of health promotion service. A study of Aboriginal participants with diabetes who received 5 daily workshops to support self-management resulted in improved glycaemic control and lipid levels [25]. Occupational therapy student led education sessions in nutrition and physical activity in older men resulted in improved knowledge of participants [44]. A prospective cohort study of an 8 week health promotion program resulted in a positive effect on the level of physical activity and mental wellbeing [47]. A non-randomised trial for an asthma care model delivered by pharmacists resulted in a significant improvement in asthma severity and access to care [27]. An oral health promotion program in schools increased access to dental professionals and improved oral health status and oral hygiene behaviours [28].

Other initiatives

Other initiatives that support PHC service delivery were reported in four studies [30, 37, 38, 40, 44]. Three studies focussed on student involvement [30, 37, 44], with two studies specifically describing the use of student-led services in the provision of PHC services [30, 44]. Extended scope of practice was also reported in one study via two articles [38, 40].

Discussion

This review is the first systematic review to explore allied health primary health care models in rural and remote Australia. There is a range of PHC models for service delivery that have been identified as being used by allied health professionals in rural and remote areas. This review identified that most of the published papers on Australian allied health PHC models fitted within an existing typology of five PHC models [11], with the addition of a health promotion model. Health promotion has not been described in previous typologies due to a predominant emphasis on healthcare treatment, however it is an important consideration in the context of PHC due to its positive impact on chronic disease prevention and behaviour change [48]. These different models provide some guidance to the options available in providing PHC in rural and remote areas. Understanding what PHC models can be used in rural and remote areas remains an important consideration as the prevalence of chronic disease remains higher in these areas compared to metropolitan regions [4]. As such, this review provides important insight into what allied health PHC models are currently being utilised in rural and remote areas.

The evidence of the effectiveness and impact of these models is limited due to limited measures of impact or effectiveness. Many of the articles descriptively reported on the PHC model of care only and did not have clear outcomes and no comprehensive evaluation, indicating the difficulty in exploring the effectiveness and impact of the models of service used. As a result, this review could adequately describe the types of PHC models used by allied health professionals in rural and remote areas of Australia, however, could not determine the impact or effectiveness of most of the PHC models. The implications of this finding suggest more rigorous evaluations of current allied health PHC service models are needed to enable the effectiveness of the models to be explored. There are however challenges to conducting rigorous evaluation of PHC service models that needs to be considered, including funding constraints, methodological challenges, service delivery focus and infrastructure challenges [49]. It also needs to be considered that studies without an evaluative component or research based funding and support are often excluded from peer-reviewed publications, delaying the process of knowledge sharing and translation.

Despite the potential benefits of an extended scope of practice in rural areas, only one study mentioned its use by allied health professionals [38, 40]. This is an interesting finding given that extending the scope of practice of allied health professionals can assist when there is a lack of services. Other researchers have suggested by implementing an extended scope of practices for allied health can lead to an increase to the quality and breadth of health services provided [14]. Research into the use of extended scope of practice in rural nursing has indicated that many legislative and regulatory barriers exist [50].

The development of student-led clinics with oversight by qualified health professionals or by long-arm supervision, has also been promoted to improve access to allied health services in rural areas and has shown positive impact in improve the health and wellbeing of people living in regional, rural and remote areas [51]. Interestingly, few studies reported on this initiative as part of a PHC model despite the potential benefits. Students may provide a valuable contribution to rural based primary care through targeted programs that facilitate their learning and contribute to improvements in primary care services [52].

When considering the limitations of this review, other initiatives such as student led clinics may not have been fully captured, however given the primary focus of the review was on PHC health services and models of care, this limitation needs to be considered within the aims of the study. This review focussed specifically on key allied health professionals only, which may have limited the findings had a broader definition of allied health professionals been included. Similarly, findings for this study included only studies within the Australian context, which may have limited study findings, however it was considered important to highlight Australian-specific research for relevance to the local context.

The present review demonstrates the gaps in the current research regarding allied health PHC models and the effectiveness of the outcomes, with more rigorous evaluations needed. In addition, there is a need to consider policy drivers to support sustained development of allied health services within PHC models. Further, there is an opportunity for future research to explore service delivery models used in an international context by allied health professionals, and for a comparison to those used in the Australian context. However, the review has highlighted suitable models of service delivery and provided clear descriptions that may be utilised in rural and remote settings.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors would like to acknowledge the following contributions to this project. Nicole Turner, Director Aboriginal and Torres Strait Islander Engagement, Rural Doctors Network, Australia, Chair of Indigenous Allied Health, Australia and Chief Executive Officer Aboriginal Health & Medical Research Council of New South Wales. Katie Carlisle, Operations Manager, Knowledge Mobilisation, Rural Doctors Network. Tony Smith, previous A/Professor at The University of Newcastle Department of Rural Health who contributed to the development and progress of the initial review and Honours student project.

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Authors and Affiliations

  1. University of Newcastle, Callaghan, Australia

    Alison Brown, Rebecca Wolfgang, Susan Heaney & Leanne J. Brown

  2. Hunter New England Population Health, Wallsend, Australia

    Alison Brown

  3. Physio Inq, Sydney, Australia

    Alexandra Cant

  4. Rebecca Wolfgang Consulting, Newcastle, Australia

    Rebecca Wolfgang

  5. Rural Doctors Network, St Leonards, Australia

    Robyn Ramsden

  6. Deakin University, Burwood, Australia

    Robyn Ramsden

  7. Hunter Medical Research Institute, New Lambton, Australia

    Susan Heaney & Leanne J. Brown

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Contributions

A.B. screening and data extraction. prepared final manuscript for co-author review. A.C. conducted searches, screening and data extraction, contributed manuscript to writing. LB, RW and RR supervised initial searches and screening. SH and LB led updated searches and final manuscript review. All authors reviewed final manuscript.

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Correspondence to Leanne J. Brown.

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Brown, A., Cant, A., Wolfgang, R. et al. Investigation of primary health care service delivery models used in allied health practice in rural and remote areas of Australia: a systematic review. BMC Health Serv Res 25, 573 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12913-025-12717-6

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BMC Health Services Research

ISSN: 1472-6963

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