Perspectives of major traumatic injury survivors on accessibility and quality of rehabilitation services in rural Australia

Abstract Purpose For the 30% of Australians who live in rural areas, access to rehabilitation services after sustaining a major traumatic injury can be challenging. This study aimed to explore the experience of rural major traumatic injury survivors accessing rehabilitation services. Materials and methods Semi-structured interviews were conducted with 21 rural major traumatic injury survivors (Mage = 47.86; SD = 11.35; Range: 21–61) who were an average of seven years post-injury (SD = 3.10; Range: 3.25–13.01). Transcribed interviews were thematically analysed. Results Four themes were identified: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality. While injury-related symptoms persisted for many participants, they expressed strong determination for independence and self-management of their recovery. Barriers to accessing rehabilitation services included poor knowledge of local services, travel burden, financial costs, and a lack of local practitioners experienced in major traumatic injury rehabilitation. Facilitating factors included financial, psychological, community, and informal supports. Conclusions To support recovery, future rural service models should improve consideration of factors resulting from living at a distance to services and harness independence to self-manage. IMPLICATIONS FOR REHABILITATION Rural major traumatic injury survivors need support to navigate numerous barriers to accessing rehabilitation services. Rural participants expressed their preference for greater involvement in planning their transition back home following hospitalisation and help to link with available services in their local area. Specialist training and support for rural rehabilitation practitioners is needed, to effectively treat impairments related to major traumatic injury, particularly psychological and cognitive difficulties. Future service delivery models should incorporate methods to locate rural services; facilitate telehealth access and client self-management; and provide financial and mental health support to both rural survivors of major traumatic injury and their carers.


Introduction
Major trauma is characterised by severe injury or a combination of injuries that are life-threatening or that result in death, and that have the potential to lead to long-term disability [1]. In Australia and globally, major traumatic injuries contribute significantly to permanent physical and psychological disability [2]. Annually, nearly 5,000 people in Australia who sustain major traumatic injuries survive [2]. Many will have a prolonged need for rehabilitation [3]. In particular, residual pain, limited mobility, cognitive dysfunction, and psychological distress affect 15-84% of survivors, negatively impacting independence and quality of life [4][5][6].
For individuals who sustain the most severe major traumatic injuries, ongoing specialist rehabilitation services are needed to ensure the best outcomes [7]. Most people are discharged directly home from hospital after major trauma [2] and have access to rehabilitation services primarily delivered by medical practitioners, nurses and allied health professionals through hospitals and community health services, private clinics and non-government organisations [8]. However, nearly one-third of Australians reside in areas considered rural (i.e. regional, rural or remote) and are more likely to experience restricted access to quality healthcare [9,10]. Indigenous persons are even more likely to reside in the most rural and remote regions, have comorbidities and experience additional barriers to accessing healthcare [11]. Historical events, including the treatment of indigenous people, still strongly impact the health and wellbeing of indigenous people, and these experiences can influence interactions with health services today [12]. Consequently, culturally sensitive health services are often difficult to access and instead, services are predominantly developed for and provided by white Australians [13]. Such occurrences lead to health services that do not meet the needs of indigenous Australians, low treatment access and ultimately, inequalities in service provision. These issues are not unique to the Australian indigenous population and are reported in other countries [14]. In health care generally, initial studies have shown there can be limited access to local health specialists that usually provide rehabilitation services due to their underrepresentation in rural areas [15,16]. When rehabilitation services can be accessed in local rural communities, individuals commonly perceive that their local practitioners lack adequate understanding of their treatment needs, and report poor communication with the referring trauma hospitals to facilitate continuity of care [17,18].
Surprisingly, our knowledge of specific gaps in services available and the barriers and facilitators of rehabilitation service quality and access in rural locations is still limited for major traumatic injury survivors. The existing literature examining rehabilitation experiences of major trauma survivors after hospital discharge has predominantly applied retrospective quantitative and content analysis approaches [16,19] mostly from the perspective of clinicians, not from major traumatic injury survivors directly. Further, studies that have undertaken in-depth qualitative interview approaches [17,20] have either focussed on one specific traumatic injury group (e.g. spinal injury), have had a narrow geographical scope, or the rural perspectives have not been the principal focus of the investigation.
The current literature suggests there can be challenges for major traumatic injury survivors living in rural regions when accessing rehabilitation services. However, little research has explored this from the perspective of survivors who have a range of major traumatic injuries. This qualitative investigation, therefore, aimed to gain insights into service access, quality and challenges faced by a range of major traumatic injury survivors residing in rural Victoria, Australia. It is anticipated that an appreciation of these perspectives could help identify gaps, barriers and facilitators to develop effective rehabilitation services that are likely to be valued by rural major trauma survivors.

Method
The study was approved by Monash University's Human Research Ethics Committee (ID: 18016). All participants provided informed consent.

Setting
Participants were drawn from a larger study that used registry data from the Victorian State Trauma Registry (VSTR) and scheme data from the Transport Accident Commission (TAC). The TAC is a government organisation that promotes road safety and supports individuals who sustain injury caused by transport-related accidents (i.e. motorised and rail-operated vehicles) in Victoria, Australia [21]. For the remainder of this article, individuals with a TAC claim will be referred to as compensable. The VSTR captures data, monitors acute practices and measures outcomes relating to all major traumatic injury cases sustained in Victoria resulting in hospital admission [22]. The VSTR facilitated recruitment of non-compensable cases, that is, where government compensation was not available and instead post-injury rehabilitation needs would primarily have been met through the public health system (Medicare, Pharmaceutical Benefits Scheme, etc.), private health insurance or personal funds.

Participants
People were eligible if they were community-residing adults (aged 18-65 years) with a rural residential address in Victoria who sustained injury between 1 January 2007 and 31 December 2017. The cases recruited from the VSTR met the VSTR criteria for major trauma, including an Injury Severity Score >12 [23]; urgent surgery for intracranial, intrathoracic or intraabdominal injury, or for fixation of pelvic or spinal fractures; or admission to an intensive care unit for >24 h requiring mechanical ventilation. The cases recruited from the TAC were injuries classified (by the TAC) using the International Classification of Diseases (ICD) injury codes as catastrophic (e.g. traumatic brain injury and quadriplegia), severe (e.g. internal injury and paraplegia) and orthopaedic (e.g. fractures). For this study, four injury categories were defined: traumatic brain, spinal, orthopaedic, and internal injuries. Exclusion criteria were burn injuries (due to the associated unique service provision and recovery patterns) or individuals who did not need rehabilitation services in the preceding 12 months.
Using purposive sampling, individuals were selected from each remoteness level and invited for an interview. To ensure adequate representation across geographic areas in rural Victoria, participants who expressed interest in completing an interview were classified by their level of geographical remoteness using the Modified Monash Model (MMM) [24]. For this study, three remoteness categories were defined: regional centres (MMM 2), consisting of towns with more than 50,000 residents and have some restriction in access to goods and services; large to medium rural communities (MMM 3 À 4), consisting of towns with between 5000 and 50,000 residents and have moderate restriction in access to goods and services; and small rural to remote communities (MMM 5 À 6), consisting of towns with less than 5000 residents and have high to extremely high restriction in access to goods and services. See Supplement A for a flow diagram of participant recruitment according to TAC and VSTR settings from the larger survey study through to the current qualitative study. A greater proportion of participants were recruited through the TAC due to a differing procedure for this group in the larger study, whereby follow up by telephone to invite potential participants to complete the survey was possible.

Procedure
The larger study invited people to complete a survey that asked questions about their years of education, living situation (alone or with others), employment (employed or not employed) and perception of their recovery status (deteriorating, improving, stable or variable) at the time of survey completion. A further 44-items explored their perceived rehabilitation needs and service use in the preceding 12 months for endorsed need items. Other sociodemographic and injury characteristics were obtained from the respective databases (TAC or VSTR). Relevant to this current study, the final survey question enabled interested participants to express their interest in also undertaking an interview. Semi-structured interview guides focussed on two key areas: (1) the experience of returning home following acute care and/or inpatient rehabilitation, and (2) ongoing rehabilitation needs and health service use. The interview guide was adapted from a format developed by the Agency for Clinical Innovation [25] for interviewing individuals accessing brain injury rehabilitation services. Community representatives who were major traumatic injury survivors living in rural Victoria provided feedback on the adapted interview guide, which was then further refined by the research team. Specific questions were developed to understand barriers and facilitators to accessing services both at the time of returning home post-injury and at the time of the interview, the availability of services within their community, and the perceived quality of services they received. Questions were also included to determine any use of telehealth and future consideration of its use for rehabilitation services. The guide was also developed with questions to identify the experience of indigenous participants (see Supplement B). Ten interviews were conducted shortly after the implementation of COVID-19 restrictions in Victoria, at which time there was increased use of telehealth. Participants were asked to respond in relation to their care needs and experiences before these restrictions to keep findings consistent across participants. Neutral prompts and probes were used to encourage respondents to clarify or expand on particular answers without introducing bias or distortion to responses [26].
Interviews were conducted between November 2019 and April 2020 by a female neuropsychology trainee (VLS) with training and previous qualitative interviewing experience. The interviews were conducted via telephone (n ¼ 7), videoconference (n ¼ 6) or faceto-face (n ¼ 8) based on participant preference and COVID-19 physical distancing restrictions at the time of interview. Questions were presented in a prearranged order and were audio-recorded after verbal consent was obtained from the participant. Interviews took approximately 45-60 min, and participants were compensated for their time with a $50 gift card.

Data analysis
Audio recordings were professionally transcribed and uploaded into NVivo software (version 12 Plus) for inductive analysis [27]. A thematic approach to coding was applied to the transcribed data [28], first involving familiarisation by VLS with each interview by reading the transcriptions multiple times. Next, a complete semantic coding method conducted by VLS started with the selection of participant-generated phrases that retained the original language and concepts used. Interviews continued until this process was unable to identify any new codes, and thereby data saturation reached [29]. Labels that conceptualised the selected phrases were developed (codes) and refined into a codebook that outlined the codes and their definitions [30]. To enhance reliability, communicability and transparency of the coding process, a random selection of seven interviews were independently crosscoded by a student researcher who also had qualitative research methods experience (AL). Discrepancies in coding were identified and resolved (codes merged, removed, or newly created) during a collaborative discussion with the research team, and the codebook was revised accordingly. Next, similar or related codes were grouped to capture the salient features and resulted in theme generation. This process was achieved using a collaborative virtual sticky note tool, Ideaflip [31], in conjunction with investigator discussion to ensure the findings remained neutral and representative of the participant experiences. Lastly, participant phrases that represented the themes were identified for inclusion in the results. Selected quotes were edited to assist readability and preserve anonymity where necessary. At the end of quotes, parentheses provide participant pseudonyms, sex, geographic remoteness level, injury and time since injury (years), respectively.

Results
A total of 63 (29.6%) participants expressed interest to partake in an interview, of whom 23 were ineligible. Of the 40 who were approached, 12 did not respond, and 3 declined inclusion. A further four were not contacted due to saturation being reached (see Supplement A). Saturation was appraised after each interview, when variation, including new information, was apparent in the reports provided, interviews continued [32]. At 21 interviews, limited variation was seen, and no further interviews were scheduled on the basis that no new information was likely to be collected. Sociodemographic and injury variables are presented in Table 1. There was representation across all levels of remoteness and injury characteristics. The majority of participants were living with a partner (61.0%), employed at the time of the interview (57.1%), self-reported their recovery as stable (57.1%) and most were compensable (80.9%). Participants were on average 47.86 years old at the time of injury (SD ¼ 11.40, Range: 20-61) and 7.02 years post-injury (SD ¼ 3.10, Range: 3.25-13.01). Interview participants were comparable with the larger survey participants on all measured sociodemographic and injury variables, except for sex and years of education, where there were fewer males (interview ¼ 66.7%, survey ¼ 71.4%) with a greater number of years of education interviewed (see Table 1).
The thematic analysis identified four themes: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality. The themes are presented in Figure 1 as key experiences relating to survivor rehabilitation service access. The following results section will report each theme with supporting participant quotes included.

Managing the transition back to local services
This theme related to participants' experiences after leaving subacute inpatient or rehabilitation services, typically in metropolitan areas or large regional towns, and being linked in with community-based supports. Many participants described a perceived lack of involvement in discharge and transition planning, particularly if they had sustained a traumatic brain injury, and reduced consideration of their concerns regarding their return home. Concerns were typically related to worries about receiving continuity of health services in their local community, which participants felt were not shared concerns by discharging hospitals: You're basically told by the physio "it's your time to go home". I didn't want to go. I was terrified. I was really scared of going home and being stuck in my house with no services because I was also told I'd be on a waiting list for physio back home. (AZ, F, Regional, Orthopaedic injury, 4 years post-injury) Other participants felt they were the instigator of discussions to return home and noted that service access was not a consideration. Rather, these discussions were often driven by their desire to be closer to home, family and friends: I don't know if I was ready, but I asked to go home because I was so far away from everyone. I had one friend, she would come up every second day using public transport and I never saw my mum the whole time I was in hospital. It was just too far. (RG, F, Small Rural -Remote, Brain injury, 12 years post-injury).
p values for categorical data are based on chi-square and associated effect sizes calculated using Phi for 2 � 2 designs and Cramer's V for larger designs; effect sizes for ratio data uses Cohen's d. a Survey data based on n ¼ 204; interview data based on n ¼ 20. b Survey data based on n ¼ 129; interview data based on n ¼ 12. Other participants felt metropolitan hospitals lacked an understanding of services in their local community and placed the responsibility on them to source local services. This was particularly challenging for participants who had not used rehabilitation services previously: When you're in the hospital they say, "Do you know of any physios that you prefer to go to?" Well no, I've never used a physio before. (AZ, F, Regional, Orthopaedic injury, 4 years post-injury) Despite a lack of local service knowledge, participants reported that metropolitan hospitals appeared to acknowledge the need to link individuals with services closer to home, and this was a preference also favoured by participants: As further needs became apparent once they were home, the majority of participants were not aware of which services were available and how to access them: Many of the participants noted linking carers into services was an area that was often not well addressed. Participants indicated that their families would have welcomed access to services to help understand their injuries and symptoms, particularly those related to mood and behaviour, and not just when there was a brain injury: I always think about the first couple of months after the accident I was extremely moody, and she [spouse] was not offered any support for how to overcome that. (FS, M, Small Rural -Remote, Orthopaedic injury, 12 years post-injury)

Independence and determination to get better
Most participants described a great sense of determination to get better and resilience in the face of challenges, often in the context of stoic attitudes: A desire to be independent of services was also expressed by some participants. At times this was exacerbated by travel and time commitment needed to access services: There was a strong reliance on informal supports by the majority of people interviewed, particularly to assist with travel to appointments, but also for psychological support: Notably, nearly all compensable participants felt that there was an expectation from their compensation case manager that other family members would "pick up the slack" at home and facilitate access to rehabilitation. There was also a strong desire to connect with other participants who could offer support through shared experience and mentorship.

Rehabilitation is an ongoing process
Nearly all participants reported experiencing persistent symptoms from their injuries, particularly pain and mobility, despite being an average of seven years post-injury. For others, cognitive (particularly memory and concentration) and psychological problems persisted. Participants affected by these symptoms described a need to continue receiving rehabilitation services to maintain their function. Some participants felt that compensation bodies, however, did not understand this need and were reluctant to fund services if progress had plateaued:

Limited service access and quality
Participants discussed their interactions with services in their local areas, including barriers encountered, aspects that facilitated access, and service quality perceptions. Almost all participants indicated limited options available locally, which necessitated travel to larger regional or metropolitan centres for services. This was further complicated when the physical, cognitive and/or psychological impacts of the injuries affected their ability to travel long distances by car or public transport: The necessity to find providers who were registered with insurance schemes to deliver services further limited service options:

I only had one choice. There weren't a lot of [compensation] approved companies in the area. (MN, F, Large -Medium Rural, Internal injury, 3 years post-injury)
Limited experience in major traumatic injury for practitioners and rehabilitation services were noted as barriers to accessing adequate rehabilitation by the majority of participants:

The trouble is, they don't come into contact with a lot of these injuries. Their knowledge is a bit lacking and that's where I fell short with the physio here. There was a group of us, and we're all doing exactly the same exercises and routine, no matter what your problem was. There was nothing special for your individual needs. (KP, F, Large -Medium Rural, Brain injury, 12 years post-injury).
Availability and access to practitioners was impacted by several factors, including extended waiting lists. These experiences were particularly pronounced for services provided by occupational therapists (OTs), psychologists, and primary care physicians: The occupational therapist took a long time because there isn't a lot in the area, and she was from quite far away. So, it was a long time to get her here to see me. (MN, F, Large -Medium Rural, Internal injury, 3 years post-injury) In addition, primary care physician consultation times were often shortened to accommodate servicing a high number of other patients. Participants with home visiting practitioners reported their treatment frequency was reduced due to practitioners needing to incorporate extensive travel time into their serviceable hours.
Notwithstanding the reports of limited experience and expertise in major traumatic injury rehabilitation needs of their healthcare practitioners, there was also a sense of reluctance to criticise local practitioners for these shortcomings, noting practitioners were often "doing the best they could" given they do not see these injuries frequently. This also resulted in somewhat conflicting statements by the same participants who described the overall quality of services as "good" despite practitioners' lack of experience. Consequences of practitioner inexperience meant that some participants were advised to return to specialised services in metropolitan locations, which added indirect costs (e.g. transportation costs, absence from paid employment, access to child care) for the participant and potentially also their family members. For compensable participants, although informal supports were used frequently to access services, they felt well supported financially for both service and travel costs. However, nearly half of the non-compensable participants, and individuals with compensation claims that were no longer funded, spoke about the need to make difficult decisions about withdrawing from services altogether or prolonging time between treatments for financial reasons: It was suggested I go to [the metropolitan city] to a better physio, but that meant I had to take a day off work. I started stretching it out because I was losing money, and to be honest, I couldn't afford to eat. (PK, M, Small Rural -Remote, Internal injury, 5 years post-injury) In many cases, these factors left participants feeling that service providers and insurance representatives did not understand their physical and emotional needs. Furthermore, many participants felt both practitioners and insurers prioritised their physical needs above their psychosocial needs: In the face of these barriers, and to fill service gaps, some participants reported seeking substitute therapies (e.g. myotherapy instead of physiotherapy). Others expressed wanting to connect with specialists back in the metropolitan city who they felt could more confidently treat their injuries and answer their concerns.
Many participants spoke of the potential benefit of telehealth to improve service access. However, opinions on its use varied. Advocates for telehealth discussed the time it would save and how it could circumvent the need for excessive travel that would often counteract therapy benefits:

Well, it would have been good [for] talking about and understanding pain management strategies because then I wouldn't have had to travel. Because it would defeat the purpose if I had to travel to a pain management specialist. (CX, M, Regional, Internal injury, 5 years post-injury)
Notably, most people who expressed reservations on the use of telehealth had not previously used it or felt that their injuryrelated symptoms or disability would prevent its effective use: Factors that facilitated service access and improved perceptions of having received good quality care included having continuity with practitioners in the community who understood and supported their needs and who had a good understanding of compensation systems and processes. Being supported financially (particularly for associated travel costs) and with consideration of psychosocial factors by compensation case managers was also beneficial.
Despite several challenges faced by living in rural regions, there was an overwhelming sense of greater informal support and personal connection with some of the local practitioners: The reality is, the primary care physician was sort of almost a friend, so there's a real connection. It's just infinitely better than dealing with the large hospitals, and the large systems in a big city. There's a real advantage of living in the country area like that. (LA, M, Small Rural -Remote, Orthopaedic injury, 11 years post-injury)

Discussion
The present study has revealed important insights into the experiences of rural major traumatic injury survivors' access to community rehabilitation services, and their perceived availability and quality of these services. A range of perspectives from across regional and remote areas in Victoria, Australia, were obtained, and overall, four themes summarised the experience of access, availability, quality and preferences of rehabilitation services: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality.
The majority of participants in this study described challenges faced due to their rural location, commencing during the transition back home. Previous studies have shown greater patient and family engagement during discharge planning leads to higher patient satisfaction and preparedness for the transition home and ultimately better outcomes [33]. Unfortunately, a substantial proportion of our sample did not feel they had been engaged by staff in their discharge plan and described feeling apprehensive about returning home, which is similar to previous findings reported in people recovering from orthopaedic injuries [20].
We identified key concerns of rural major trauma survivors, particularly about their potential access to services in their local community. Complicating their concerns was the perception that metropolitan hospitals lacked an understanding of the rehabilitation services available in their local area to enable effective discharge planning. These findings are congruent with previous reports from critical care staff, noting their challenges in maintaining up-to-date knowledge of services and resources available to allow care closer to patients' homes [34]. As a result, participants reported feeling the weight of responsibility to find services in their local rural communities. This suggests there may be an increased requirement for rural individuals to independently navigate the healthcare system, which may be problematic given health literacy in rural regions has been found to be lower than in metropolitan areas [35,36]. Underpinning this finding is the need for better assistance for rural survivors of major traumatic injury to locate and link with local community services. Other participants clearly expressed their preference to return to their local rural area, at the detriment of the discharge planning process, with people not knowing where or how they would receive rehabilitation services once home. Rather, their motivations were influenced by a strong desire to be closer to family and friends. This finding emphasises that the choice is often between undertaking rehabilitation or being close to family for rural people. Ultimately, many people in the present study returned home to their local community with limited engagement or coordination of services. Specifically, future planners may need to be cognisant that people often want to return to rural regions as soon as possible to be closer to informal supports. However, these same individuals may need more support to ensure that formal community services are coordinated before discharge home. More efforts to include the injured person in discharge planning could also help reduce apprehension about the transition.
Psychological services to address mental health and cognitive difficulties were highlighted by participants as particularly difficult to locate and access in their local rural areas. Many participants reported persisting psychological impairment but noted these difficulties received relatively less focus than their physical injuries. The limited provision of psychological services also extended to family and carers, who participants felt were not well supported to understand mood and behaviour symptoms. The psychological response to injury plays a vital role in recovery, including successful social and community reintegration [37]. Current findings suggest a particular gap in supporting injured people and their carers to access psychological services. Considering psychological services was noted by participants in this study to have extended waitlists, innovative approaches such as telehealth might be a mode of delivery that could offer significant promise.
The World Health Organization [38] recognises that all individuals should have access to the healthcare they need, when and where it is needed and without the risk of financial burden. Access to health services can therefore be considered according to three dimensions of physical accessibility, financial affordability and acceptability. Current findings suggest rehabilitation services in some rural communities may not meet these accessibility criteria. With regards to physical accessibility, many individuals reported that their persisting symptoms impacted whether and how they could travel the long distances needed to access services. While persisting conditions also affect people living in metropolitan areas, rural participants in this study discussed how financial burden and injury-related barriers associated with distance to rehabilitation services compromised their ability to continue with needed care. Moreover, physical accessibility was interlinked with financial affordability for some people. The need for extensive travel to services required contemplation of the cost of services in addition to indirect costs of travel and time away from work. These factors were a consideration not only for injury survivors, but also on behalf of their carers or family supports. Compensable participants reported that they did not feel impacted by these concerns earlier in their recovery when financial support was readily available. However, this became a factor when funding for the treatment of persisting conditions was withdrawn due to their injuries being deemed as stable. Better recognition of the impact of direct and indirect costs of living at a distance from services and harnessing individuals' self-determination to manage their recovery should be considered where possible.
The acceptability of services in the present findings appears to have been most influenced by participant's perceptions of whether local services could effectively treat their major traumatic injuries. Participants reported that health practitioners tended to lack the necessary experience to treat their injuries, consistent with previous rural injury research [17,18]. This finding is congruent with a recent investigation where rural allied health practitioners noted a lack of specialised skills to provide optimal care to survivors of serious injury [39]. Current study participants explained that referral back to metropolitan specialists was sometimes arranged to circumvent the shortcomings of local provider knowledge or skills. However, this approach inevitability fed back into the barriers affecting physical accessibility and financial affordability. To overcome these barriers, and facilitated by the stoicism and self-determination of many rural major trauma survivors, the majority of the sample preferred to self-manage their persistent conditions. However, it must be considered that the sample was, on average, seven years post-injury, which might be associated with an expected reduction in formal service frequency and greater self-reliance. Notwithstanding, the present findings highlight the potential of self-management models of care to leverage this self-determination and independence. Furthermore, it highlighted the importance of optimising informal and community supports to "support the supporters" of rural major trauma survivors. Lastly, improving the confidence and skill of rural health practitioners through training and mentoring approaches to treat major traumatic injury may help enhance survivors' perception that their local services are effective and knowledgeable about their injuries. This would improve the acceptability of these services and avoid the cycle of physical inaccessibility and financial unaffordability.
The present findings should be considered alongside some limitations. In terms of sample characteristics, interviewees had significantly more education than individuals who completed the survey; however, the mean education difference was only 1.6 years. Also, the proportion of males interviewed was significantly less than the proportion of males in the larger study. However, given that the proportion of males interviewed reflects the annual proportion of men with major traumatic injury in Australia [2], it is unlikely that this difference has had a substantial impact on the results. Therefore, the interview sample was considered representative of the sample from which they were selected. Of note, a large proportion (80.9%) of the sample were compensable and likely had a case manager to help facilitate access to services [40]. However, individuals in our sample also noted some difficulty organising care due to their compensable status, suggesting having a case manager did not always lead to increased service use. Another consideration is that time post-injury for the participants' was, on average, seven years. It is possible health service, and compensation scheme processes have changed over time and will not be reflected in the experiences reported. It is also possible that this time since discharge, as well as factors at the time of discharge (e.g. medication, stress), may have impacted participants' processing and/or memory of involvement in the discharge planning processes. The results of this study are also, to some extent, reflective of the applicable health policies and geographical landscape of just one region of Australia, the state of Victoria. Victoria has a unique no-fault transport injury compensation scheme that funds the costs associated with injury recovery regardless of their role in the injury event. Further, although the distribution of injury survivors residing in rural areas is similar in other Australian states and territories, the travel distances to services in some of the larger states are even greater where very remote areas exist (MMM 7), of which there are none in Victoria. Therefore, current results may not generalise to regions considered very remote or with different types of compensation schemes (e.g. fault-based schemes). Lastly, this study provides a comprehensive understanding of a specific group of major traumatic injury survivors obtained by conducting interviews until data saturation was reached. Participants of this study were required to be receiving rehabilitation services in the preceding 12 months to be eligible to participate. Accordingly, the transferability of the findings to the broader rural major traumatic injury survivor population, including those not using services, is limited. As such, readers should consider the participant characteristics to establish the applicability of findings to their environment [41].
The present study demonstrates new perspectives of major traumatic injury survivors' experience accessing rehabilitation services in rural areas. However, some topics require further exploration, including the factors that contribute to the experience of transitioning back to rural communities described by current participants. As noted above, it would be helpful to explore the experience of major trauma survivors who were recently discharged back to rural areas to determine if there have been any changes to service accessibility. Furthermore, obtaining the perspectives of practitioners' at metropolitan acute and rehabilitation facilities in discharging rural major traumatic injury survivors would likewise be helpful. This could facilitate a better understanding of current barriers and how processes and resources could be improved to support metropolitan services in finding local community services. Moreover, the acceptability of services in the present findings was most impacted by the perceived effectiveness of local health practitioners with regards to their experience and knowledge in treating major traumatic injuries.
Extending on recent research [39], identifying key factors likely to increase the competence and confidence of rural rehabilitation practitioners in treating major traumatic injuries would be beneficial, including the provision of training opportunities, professional support/mentoring networks, and access to multidisciplinary treatment teams. It is also acknowledged that despite planning for the inclusion of individuals identifying as indigenous, our sample did not have representation of this cultural group. The state of Victoria, where the study was conducted, has a very low indigenous population, with less than 7% of the indigenous population residing within the region [11]. Considering previous literature has identified additional barriers to general health care service access by indigenous Australians [13], this is an important area needing further research in the context of major traumatic injury rehabilitation. Finally, there was substantial variability in attitudes towards telehealth in this study. Notably, participants with more positive views were individuals who had used a telehealth service. Given the extensive implementation of telehealth during the COVID-19 pandemic, it is likely that more individuals have since been exposed to this mode of service delivery. Therefore, a post-COVID-19 evaluation of experiences and future consideration of telehealth use for rural survivors of major trauma is warranted.
To conclude, we have identified a range of themes exploring major trauma survivors' transition home to their rural areas, willingness to take charge of their own recovery, and their perceptions of limited rehabilitation service access and quality. Overall, a lack of coordination and knowledge of local services at discharge, insufficient home follow up, direct and indirect financial costs of treatment, and a lack of local specialist practitioners experienced in major traumatic injury rehabilitation were barriers to accessing rehabilitation services. Factors that facilitated service access included financial and psychological help from compensation bodies, the community and informal supports. These findings highlight the additional rehabilitation needs of rural major traumatic injury survivors, which can be used to guide future planning and delivery of rehabilitation services in rural areas.