Objective: To validate earlier findings that lack of access to health services is the most likely issue of complaint by rural consumers, and that lack of knowledge about how to make effective complaints and scepticism that responses to complaints bring about service improvement account for the underrepresentation of complaints from rural consumers. Design: Unaddressed reply-paid mail survey to 100% of households in small communities, and 50%, 20% or 10% in progressively larger communities. Setting: Eight communities in the Loddon-Mallee region of Victoria. Participants: 983 householders most responsible for the health care of household members, responding to a mailed questionnaire. Main outcome measures: Issues of complaints actually made; issues of unsatisfactory situations when a complaint was not made; reasons for not complaining; to whom complaints are made; and plans for dealing with any future complaint. Results: Earlier findings were confirmed. Lack of access to health services was the most important issue, indicated by 54.8% of those who had made a complaint, and 72% of those who wanted to but did not. The most common reason given for not complaining was that it was futile to do so. Lack of knowledge of how to make effective complaints which might contribute to the quality assurance cycle was evident. Conclusions: Rural consumers' disaffection with health complaints as a means to quality improvement poses a significant barrier to consumer engagement in quality assurance processes. Provider practices may need to change to regain community confidence in quality improvement processes.