The allied health workforce of rural Aotearoa New Zealand: a scoping review

Keywords: allied health, allied health occupations, allied health personnel, geographic workforce distribution, health workforce, New Zealand, rural health, rural health services, workforce.

The allied health workforce is a crucial, if at times poorly visible, component of modern healthcare systems. ‘Allied health’ can be defined as the group of health professions that excludes medicine, nursing and dentistry. The Aotearoa New Zealand Ministry of Health’s indicative list of allied health professions (Table 1) includes audiologists, dietitians, medical imaging technologists, medical laboratory scientists, occupational therapists, optometrists, pharmacists, psychologists, physiotherapists, and social workers, all of whom are members of healthcare teams in Aotearoa New Zealand. Allied health encompasses a very broad range of professional groups, many of which have specialised skills and small workforces and are therefore less likely to be found in rural areas.

Table 1.  An indicative list of allied health professions within New Zealand.¹⁸

The services provided by allied health professionals may be particularly important for underserved populations, including rural and remote communities.¹ Australia is currently the only country who has looked at the rural allied health workforce in depth. This has resulted in initiatives aimed specifically at supporting and growing the rural allied health workforce.² These rural practice-specific skills were developed in response to rural-practice context, including an increased burden of disease, access to health care, confidentiality, cultural sensitivity, and team practice. Efforts have been made to improve recruitment and retention in Australia, through undergraduate exposure and postgraduate vocational pathways.³ A national Allied Health Rural Generalist Pathway has been developed that has resulted in rural- specific scopes of practice supported by: (i) an education programme; (ii) workforce policy and employment structures; and (iii) rural generalist service models.⁴

In Aotearoa New Zealand, there is evidence that residents of rural towns represent a population with high healthcare needs⁵ and that we may be underestimating the impact of rurality on health.⁶ When compared to other geographic areas, residents of Aotearoa New Zealand’s rural towns are more likely to be Māori, older, experience higher levels of deprivation, poorer access to health services and have poorer health outcomes.⁵ There is considerable variation between rural communities both in the range of healthcare services that are locally available and in the way in which they are organised.⁷ The challenges of rural practice within Aotearoa New Zealand have been documented for doctors and nurses. For example, the geographic maldistribution of the medical workforce, including shortages in rural areas, has been quantified.^8,9 Targeted initiatives have been developed to support recognised scopes of rural medical practice.^10–12 The potential for nurse practitioners to take a larger role in the rural areas has been recognised.^13,14

The aim of this study was to describe what is currently known about the rural allied health workforce in Aotearoa New Zealand.

A scoping review was selected to allow the inclusion of diverse sources of literature, including both formal and grey literature.¹⁵ This scoping review used an adaption of the approach proposed by Peters et al.¹⁶ which extends the Arksey and O’Malley¹⁵ framework.

The research question was kept intentionally broad to extend the breadth of literature coverage. The research question and key terms were deliberated on by the research team, which was made up of both allied health and medical professionals operating within clinical–academic roles. The question was defined as ‘What is currently known through research about the allied health workforce in rural Aotearoa New Zealand?’. The key terms that required clear definition were ‘rural’, ‘research’ and ‘allied health’. Work to define ‘rural’ for the purposes of New Zealand health research and policy is currently being undertaken.¹⁷ Because this is a review of the existing literature, we have accepted the definition of rural adopted by individual authors. ‘Research’ was determined following discussions among the team, and in consultation with an expert subject librarian, as literature characterised by some form of transparent data collection and analysis reported in a way that allowed for review. The 'allied health' workforce is defined as those professions who are not part of the medical, dental, or nursing profession. For the purpose of this review, ‘allied health’ was considered as those professions recognised as ‘Allied Health Scientific and Technical’ by the Ministry of Health¹⁸ (Table 1), and specifically those that are regulated through either the Health Practitioners Competence Assurance Act 2003 or are self-regulated by a professional body¹⁹ and identified through discussion among the research team as being commonly present in rural Aotearoa New Zealand and across public and private services.

Due to the nature of allied health, with a mixture of various independent professions, a comprehensive list of search terms was mapped with the assistance of an expert subject librarian to ensure a balance of broad and specific definitions of the professions within this group could be identified. Generalisability was maximised through an iterative process covered under four key concepts: ‘allied health professions’ AND ‘rural environment’ AND ‘workforce’ AND ‘Aotearoa New Zealand’. An example of the search strategy used can be found in Supplementary Table S1.

Evidence sources included searching for all types of literature published between July 2011 and July 2021, within the following databases: CINAHL, Web of Science, Embase, PsycINFO, Medline, and SCOPUS. An additional web-based search was completed using the Google search engine. The most recent search was executed on 19 July 2021.

Following the initial search, literature selection involved reviewing titles, then abstracts for inclusion. Discussions among the research team based on the research question and iteratively following the initial review of literature helped to develop the review criteria (Table 2). Extracted material included year, topic, key findings, and type of study.

Table 2.  Inclusion and exclusion criteria applied to the scoping review.

The key categories were charted by reviewing the material and sorting it into key issues. Once initial ideas and thoughts were complied, authors then met to discuss these, re-reading the material, and progressively organising, synthesising, and interpreting. Excerpts from the articles were collated within the key categories for presentation within the results.

The results were organised into a narrative, with the purpose of outlining what is currently known about the Aotearoa New Zealand allied health workforce. The type and quality of evidence was also considered in the presentation of categories.

This study used already published data and so did not require ethics review or approval.

There were 105 publications identified overall from all seven databases, and 16 duplicates removed (Fig. 1). Abstract and title screening was completed with 13 publications remaining. A full-text review was then undertaken. Of these, 10 publications met the inclusion criteria; nine empirical studies, and one narrative review (Table 3).

Fig. 1.  Selection of sources of evidence.

Table 3.  Data extraction chart.

The main themes of the publications included were the geographic workforce distribution (n = 8), and the role of the rural allied health workforce (n = 2).

The majority of the publications (n = 8) included information on geographic workforce distribution. Although some allied health professionals are present in rural areas, it is suggested that this is at a lower density than in urban areas.^20–26 Some geographic workforce data were able to be extracted from national workforce surveys (Table 4) published by registration or professional bodies for individual disciplines.^22–26 Mapping the distribution of health professionals across rural and urban areas was not the primary aim of these surveys. The geographic workforce distribution data were a small part of larger reports; the findings were not discussed or considered in recommendations for future research. There was a lack of clear rural data as workforce distribution information was collected, defined, and reported on in a variety of ways (Table 4). This makes it difficult to draw conclusions about both individual professions and the allied health workforce as a whole.

Table 4.  Variation in the rural allied health workforce data reporting.

The geographic workforce distribution was also recognised within other work. Both Gleissner²¹ (in the context of Speech–Language Therapy) and Pullon et al.²⁷ suggested that geographic workforce distribution was a key contributor to obvious health needs not being met within rural areas. Reid and Dixon²⁴ quantified this for physiotherapists, where 81% worked in urban areas, citing challenges in the ability to recruit to rural areas. However, Pullon et al.²⁷ suggested that even with a workforce willing and able to practice in rural areas, there is a perceived lack of opportunity for career diversity or progression.

Exeter et al.²⁰ outlines the challenges of the current workforce distribution, which are anticipated to worsen over time. These authors used Statistics New Zealand population projections from 2011 to 2061 to estimate the implications for the hearing workforce. It was estimated that in addition to an increase in rural populations, there would also be a significant increase in the proportion of those aged >65 within rural areas. This increase of elderly within rural areas is expected to impact heavily on a fragile workforce that is small in nature with a specific area of practice. Exeter et al.²⁰ suggests there is a strong possibility of critical hearing workforce challenges similar to that of general practitioners, nurses, and pharmacists in rural areas.

The remainder of the publications (n = 2) identified the specific challenges the allied health workforce faces in delivering health care and developing a workforce suitable for rural Aotearoa New Zealand.²⁸ Both George et al.²⁸ and Awatere²⁹ acknowledge that practicing in rural areas requires unique practicing characteristics, in part due to the geographical and demographic characteristics of rural areas, but also the professional capacity required and the more generalist nature of clinical work. Interestingly, George et al.²⁸ was the only piece of research included that reported on allied health as a collective group. George et al.²⁸ also highlights the potential benefits for Aotearoa New Zealand’s relatively undeveloped rural allied health workforce by adopting the workforce strategies developed by other New Zealand rural health professions and overseas rural allied health professional groups.

This is the first comprehensive scoping review of the existing literature on Aotearoa New Zealand’s rural allied health workforce. The most notable finding was the paucity of literature that met the inclusion criteria. Rural allied health workforce issues were the primary focus of only three publications, and only one paper considered the allied health professions as a collective group. This makes it difficult to draw conclusions about the allied health workforce in rural Aotearoa New Zealand. This is not the first time a formal review of the literature has generated few articles on a rural health topic in Aotearoa New Zealand.³⁰

The literature identified in this review fell into two broad categories: (i) distribution of the workforce across rural and urban areas; and (ii) role of the allied health workforce in rural areas. The first category provides evidence of geographic workforce maldistribution, with fewer practitioners in rural areas, for a range of allied health professions, although interpretation is complicated by the different definitions of ‘rural’ in use. The much smaller second category (two studies) identifies differences in the roles of rural allied health professional relative to their urban colleagues. Rural-specific scopes of practice or targeted postgraduate rural training were not specifically considered. George et al.²⁸ did, however, highlight the opportunity to build on existing research and training initiatives coming from rural allied health researchers in other countries, and rural medical and nursing researchers in Aotearoa New Zealand.

Rural and remote allied health research is more abundant in Australia. When O’Sullivan and Worley³ undertook a review of the international literature on the provision of allied health services in rural and remote communities, and the training of rural allied health professionals in 2020, they were able to identify 120 publications (Australia (n = 97), Canada (n = 8), USA (n = 2), and New Zealand (n = 1)) that met the inclusion criteria. Four key categories were identified in the O’Sullivan and Worley³ review: (i) workforce and scope of practice; (ii) rural training pathways; (iii) recruitment and retention; and (iv) models of service. The only category echoed in our current Aotearoa New Zealand review is the ‘workforce and scope of practice’ category. Despite the progress made to support rural allied health scopes of practice in Australia, little data has been published on the distribution of this workforce across rural and urban areas. Potential reasons for this have been attributed to the variable nature and definition of allied health as a professional group, the complex context in which rural services are often provided (ie outreach and fly-in, fly-out services), as well as various funding models, lack of supporting infrastructure and policy, and challenges with both state and commonwealth government levels.³¹ The absence of an Australian national dataset has not impeded all progress, but rather has forced a somewhat piecemeal approach with smaller, geographically limited data collection and workforce initiatives growing into national implementation such as the Allied Health Rural Generalist Pathway.^31,32 However, the challenge of quantifying the impact of these initiatives on a national scale remains.

As Aotearoa New Zealand embarks on major health system reforms, policy makers lack a substantive body of national allied health research on which to draw. The limited available evidence suggests that the allied health professions suffer the same geographic workforce maldistribution seen in medicine and nursing, but there are no data on the impact this may be having on health outcomes for rural populations, or the strategies needed to overcome it. Inferences can be made from the international allied health literature and the Aotearoa New Zealand medical and nursing literature. This includes the importance of defined rural scopes of practice and training initiatives that are embedded in rural clinical practice and rural communities. Further research is needed to determine whether these inferences can be generalised to the allied health workforce in the Aotearoa New Zealand context. Priority should be given to: (i) the collection of accurate data on the geographic distribution of the workforce; (ii) the role of allied health professionals in rural health services; (iii) rural scopes of practice and models of care; (iv) training for rural practice; and (v) growing a rural Māori allied health workforce. In all these research areas, there needs to be an emphasis on rural communities with high healthcare needs and poor access to services.

This review was time-limited, focusing on the period from 2011 to 2021 with the intention of identifying research that was both current and relevant to the present workforce. This may have excluded some relevant research published outside of this date range. The selection of material included grey literature; there is less formalised processes for searching this literature and potentially relevant material may have been missed. Not all professions listed in the Aotearoa New Zealand Ministry of Health’s indicative list (Table 1) of allied health professions were included in this study, and some studies referred to specialised disciplines. Professions that were unlikely to be working in rural Aotearoa New Zealand (eg clinical perfusionists), or professions that were unregulated and therefore unregistered, were not included. Although this review does not include all disciplines, the key findings are likely to be relevant to the wider allied health workforce.

The non-medical, non-nursing, and non-dentistry health professionals operating in the Māori cultural context are of particular importance to rural Aotearoa New Zealand, as they may have a crucial role in overcoming health inequities. Rongoā Māori practitioners³³ and Māori community health workers³⁴ are receiving increasing formal recognition, and arguably should be added to the Aotearoa New Zealand Ministry of Health’s indicative list (Table 1) of allied health professionals. Kaupapa Māori researchers need to be supported to undertake research into the role of these emerging health professionals.

There is little published research focusing on allied health care in rural Aotearoa New Zealand. The emphasis placed on describing the geographic workforce distribution and rural-specific roles, as well as professional and training initiatives in both the international allied health literature and Aotearoa New Zealand’s medical and nursing literature, suggests that these are important areas of research with the potential to improve the state of a rural health professional workforce. Similar research is needed, focusing on Aotearoa New Zealand’s rural allied health workforce if it is to reach its full potential in improving health outcomes for rural New Zealanders.

Data sharing is not applicable as no new data were generated or analysed during this study.

The authors declare that they have no conflicts of interest.

This study is part of a PhD project funded by a Health Research Council of New Zealand Clinical Research Training Fellowship.

Supplementary material is available online.