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An Evaluation of the Barriers to Health and Social Care for “Hard to Reach” Groups enrolled in an Integrated Care Initiative in Sydney, Australia


Elaine Tennant ,

Sydney Local Health District; University of New South Wales, Sydney, AU
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John Eastwood,

Sydney Local Health District; University of New South Wales, Sydney; University of Sydney, AU
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Katherine Todd,

Sydney Local Health District; University of Sydney, AU
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Erin Miller,

Sydney Local Health District, AU
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Kathryn Costantino

Sydney Local Health District, AU
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Introduction: Sydney Local Health District's Healthy Homes and Neighbourhoods Integrated Care Initiative (HHAN) seeks to improve the care of families with complex needs and/or inter-generational trauma by providing long-term care coordination and promoting inter- and intra-agency integration.  The disadvantage experienced by enrolled individuals is multifaceted, with issues ranging from poor financial and social capital through to adverse health and educational outcomes.  This complexity demands multi-agency support but in turn leaves clients vulnerable to fragmented/poorly coordinated care.  We explored barriers to attaining health and social care for vulnerable families, as perceived by clients themselves and collaborating professionals.

Theory/Methods: A realist CMO (Context, Mechanisms, Outcomes) theoretical approach is being used for program evaluation.  Purposive sampling was used to identify 8 clients and 16 professionals (8 healthcare workers and 8 staff from collaborating NGOs/partnering government agencies) who participated in guided interviews.  Barriers to care were explored as part of the examination of underlying contexts.  All interviews were audio-recorded, transcribed and coded using NVivo v11 software.

Results: Both intrinsic and extrinsic barriers were identified.  Intrinsic factors included: Trauma affecting families both horizontally and vertically, competing priorities, distrust of services and concerns about confidentiality.  Of the extrinsic factors identified, three themes emerged:

1. Accessibility and Economic Barriers including inequitable service coverage geographically, transport issues, strict eligibility criteria, opaque referral systems, lack of financial incentives for seeing vulnerable families, and direct/indirect costs to clients.

2. Misalignment of Service Provision with Client Needs including a perception that needs were assumed not asked, unrealistic care plans given social circumstances, paucity of culturally-appropriate and trauma-informed staff training and short-termism of professionals (resulting in unstable client-service and service-service relationships).

3. Communication Issues including misunderstanding by services or clients of the role, or even existence of other services, trust/territorial issues and technological barriers (e.g. incompatible electronic referral systems).

Discussions: It can be challenging for vulnerable clients to navigate health and social care systems.  Professionals expressed frustration that attaining appropriate/timely referrals and client care was difficult, even when being undertaken by “high-functioning” individuals on behalf of clients.

Conclusions: Families with complex needs face multiple barriers to care.  The extrinsic factors identified should be amenable to cultural and structural shifts in health and social care systems.

Lessons learned: Disadvantaged families are often characterised as “hard to reach” but this implies that the fault lies solely with these individuals.  An examination of the underlying factors for poor engagement illustrates the need for integrated care initiatives such as HHAN, which address the social determinants of health and create enabling systems for integration/communication between professionals.

Limitations: The applicability of findings within our health district to other regions is unknown. In recruiting participants for this study, the most vulnerable members of our society may still have been missed; further exploration of their views could enhance our understanding.

Suggestions for future research: Integrated care initiatives are attempting to tackle some of the barriers described above.  Ongoing data is required to determine which interventions are efficacious, for whom and why, so that optimal service development can be achieved.   

How to Cite: Tennant E, Eastwood J, Todd K, Miller E, Costantino K. An Evaluation of the Barriers to Health and Social Care for “Hard to Reach” Groups enrolled in an Integrated Care Initiative in Sydney, Australia. International Journal of Integrated Care. 2017;17(5):A392. DOI:
Published on 17 Oct 2017.


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