title: Accessing doctors at times of need-measuring the distance tolerance of rural residents for health-related travel.
abstract: BACKGROUND
  Poor access to doctors at times of need remains a significant impediment to achieving good health for many rural residents. The two-step floating catchment area (2SFCA) method has emerged as a key tool for measuring healthcare access in rural areas. However, the choice of catchment size, a key component of the 2SFCA method, is problematic because little is known about the distance tolerance of rural residents for health-related travel. Our study sought new evidence to test the hypothesis that residents of sparsely settled rural areas are prepared to travel further than residents of closely settled rural areas when accessing primary health care at times of need.
  
  
  METHODS
  A questionnaire survey of residents in five small rural communities of Victoria and New South Wales in Australia was used. The two outcome measures were current travel time to visit their usual doctor and maximum time prepared to travel to visit a doctor, both for non-emergency care. Kaplan-Meier charts were used to compare the association between increased distance and decreased travel propensity for closely-settled and sparsely-settled areas, and ordinal multivariate regression models tested significance after controlling for health-related travel moderating factors and town clustering.
  
  
  RESULTS
  A total of 1079 questionnaires were completed with 363 from residents in closely-settled locations and 716 from residents in sparsely-settled areas. Residents of sparsely-settled communities travel, on average, 10 min further than residents of closely-settled communities (26.3 vs 16.9 min, p < 0.001), though this difference was not significant after controlling for town clustering. Differences were more apparent in terms of maximum time prepared to travel (54.1 vs 31.9 min, p < 0.001). Differences of maximum time remained significant after controlling for demographic and other constraints to access, such as transport availability or difficulties getting doctor appointments, as well as after controlling for town clustering and current travel times.
  
  
  CONCLUSIONS
  Improved geographical access remains a key issue underpinning health policies designed to improve the provision of rural primary health care services. This study provides empirical evidence that travel behaviour should not be implicitly assumed constant amongst rural populations when modelling access through methods like the 2SFCA.
authors.affiliation: Centre of Research Excellence in Rural and Remote Primary Health Care, School of Rural Health, Monash University, Northways Road, Churchill, VIC, 3842, Australia. matthew.mcgrail@monash.edu.
authors.forename: Matthew Richard
authors.initials: MR
authors.lastname: McGrail
authors.affiliation: Centre of Research Excellence in Rural and Remote Primary Health Care, School of Rural Health, Monash University, PO Box 666, Bendigo, VIC, 3552, Australia. john.humphreys@monash.edu.
authors.forename: John Stirling
authors.initials: JS
authors.lastname: Humphreys
authors.affiliation: Centre of Research Excellence in Rural and Remote Primary Health Care, School of Rural Health, Monash University, PO Box 666, Bendigo, VIC, 3552, Australia. bernadette.ward@monash.edu.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Ward
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002391:Catchment Area, Health / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009517:New South Wales; D011320:Primary Health Care / Q000706:statistics & numerical data*; D019035:Rural Health Services / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D013997:Time Factors; D014195:Travel / Q000706:statistics & numerical data*; D014739:Victoria