Access to primary health care: a conceptual review and tool development Tim A. Holt Senior Clinical Research Fellow in Primary Care Health Sciences Oxford University, UK Deena Alasfoor Expert, Ministry of Health, Oman, and Masters Student, Oxford University, UK Nuffield Department of Primary Care Health Sciences Oxford University, UK
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Access to primary health care: a conceptual review and tool developmentTim A. HoltSenior Clinical Research Fellow in Primary Care Health Sciences Oxford University, UK
Deena AlasfoorExpert, Ministry of Health, Oman, and Masters Student, Oxford University, UK
Nuffield Department of Primary Care Health SciencesOxford University, UK
The Alma Atta Declaration 1978
• “Primary health care is essential health care made universally accessible to individuals and families…”
• Accessibility: “implies the continuing and organized supply of care that is geographically, financially, culturally and functionally within easy reach of the whole community”.
Universal Health Coverage
• WHO-2005: Access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access
• UN Sustainable Development Summit 2015: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
Oman
Access to primary health care in Oman
World Health Survey 2008: • Health care satisfaction rate: 71%• Satisfaction with ease of meeting health care provider: 67%
Al Balushi et al 2012: • Only 59.3% thought the distance to the hospital was suitable
Access conceptualization
Gulzar 1999Gulliford 2002
Ricketts and Goldsmith 2005 Levesque 2013
Dimensions of access • Geographical; financial, cultural and functional (Alma Atta
• To understand the concept of access to primary health care thorough a systematic review of published literature and concept analysis
• To develop an operational definition guided by the concept analysis
• To propose, through the concept analysis and a stakeholder consultation, a patient questionnaire as a tool to measure access to primary health care for evaluation in a future research project
Concept analysis approach(Morse 1995)
Concept delineation : two linked concepts
Concept comparison: Undeveloped and multiple
Concept clarification: mature but unclear
Concept correction: theory and application controversy
Concept identification: no conceptual development or theory
Inclusion criteria • Primary studies that measured or defined access• Setting was primary health care• Situation was not an emergency or crisis• Concept or discussion papers that included definitions of
access • Definitions listed• List of tools generated
RESULTS
Article publication dates
1978-1990 1991-2000 2001-20150%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Country of publication
Africa
Asia
Europe
North Americ
a
South Americ
a
Other countri
es
Multiple/ not s
pecified
0%10%20%30%40%50%60%70%80%90%
100%
Conceptualizing accessAttributes: Characteristics of the conceptAvailability, physical access, etc
Antecedents: Phenomena leading to access ‘seeking, screening, becoming ill’
Consequences: Outcomes occurring after health care is accessed
Percentages of articles investigating attributes of access
0%20%40%60%80%
100%
Percentage studying antecedents for access to health care
0%20%40%60%80%
100%
Percentages studying consequences
Individual
outcome/ im
proved healt
h
Satisfa
ction
Population outco
me/ reducti
on of dise
ase
No or unrelat
ed outcome
0%20%40%60%80%
100%
Patient 19%
The health service: 57%
Interaction: gets, obtains 60%
Pre-requisite 19%
Characteristics of the service 38% 7%
Definitions analysis
Principles of access derived from the concept analysis • Patient ability to obtain care• Primary care service capacity to provide
care• Absence of barriers to care• Fit between supply and demand
Proposed definition
“The ability to obtain health care when needed without financial,
organizational, cultural or geographical barriers”
BOUNDARY CONCEPTS
Quality and Utilization are problematic
Quality • Access is a component of care quality received by the
community (Donabedian 1988) • Quality is an important component of availability and
acceptability, as well as geographic and financial accessibility (Peters et al 2008)
BUT• Access and quality are at times conflicting dimensions of
primary care• e.g. Surgical services in one site or multiple sites? Quality vs
Access • Easier to measure separately
Utilization
Access: “…those dimensions which describe the potential and actual entry of a given population group to the health care delivery system” (Aday and Anderson 1981)
But is utilization: • An indicator?• An outcome?• Proof of adequacy of provision? • A reflection of patient satisfaction?
Utilization is an outcome of a complex range of structural, behavioral and social factors
• 23 tools: institutional level: number of visits, avoidable hospitalization rates, emergency departments use
• 1 tool: national level geographical access using Geographic Information Systems technique
The Questionnaire • Main source: QUALICOPC tool: most attributes identified in
the concept analysis are covered• Chicago Southeast Diabetes Community Action Coalition.
2006. Access to Healthcare Questionnaire-Short Version [Online].
• Shi, L., Starfield, B. & Xu, J. Validating the adult primary care assessment tool Journal of Family Practice 2001.
• Agency for Healthcare Research and Quality 2015. Surveys and tools to advance patient-centred care. US Department of Health and Human Services [Online].
• Adapted through consultation by the stakeholder group.
Stakeholder consultation• Fifteen participants recruited through seed/convenience and then snowball
sampling
• 3 service users• 3 policy makers• 4 public health practitioners• 3 researchers• 2 representatives of the Oman Public Health Society
• Asked to comment on elements of the concept of ‘access’ in primary care (suggested by the concept analysis) and to rank their importance
• Were the elements appropriate, relevant, important, and feasible?
• Second iteration conducted following the initial round
Importance of the attributes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Physical Access Q1: How did you commute to the health center/ facility?a) Car b) Walkingc) Public transport d) OthersQ2: How long did it take you to get to the health center/ facility?a) 0-30 minutes b)30 minutes-1 hourc) 1-3 hours d) More than 3 hoursQ3: In the past 12 months; did you cancel or delay a visit to the health center because you had no transport?a) Yes b) No Q4: In the past 12 months, did you cancel or delay a visit to the health center because you could not afford transport cost?a) Yes b) No
Access to information Q5: Does your doctor/ or healthcare facility call to inform you about your test results?a) Yes b) NoQ6: Did you get advice from the health center / practitioner about how to stay healthy?a) Yes b) NoQ7: Does your doctor advise you about your health concerns?a) Yes b) NoQ8: If you call your health facility for questions during office hours do you get an answer in the same day?a) Yes b) NoQ9: If you call your health facility for questions after working hours do you get answers in the same day?a) Yes b) No
Organizational Access Q10: When I call my GP, the time it takes to talk to someone:a) 0-10 minutes b) 10-30 minutes c) 30-60 minutesd) More than one hour e) It is not possible/ no one answers
Q11: I know how to get evening, night and weekend appointmentsa) Yes b) No
Q12: Did you need to make an appointment for this visit?a) Yes b) No
Q13: If you needed to make an appointment for this visit, how long did you wait for this appointment?a)1-2 days. b) 3-7 days.c)7-30 days. d) More than one month.
Organizational Access (cont’d)Q14 How long did you wait today between the time you arrived and the you were seen by a GP?
a) less than 25 minutes b) 15-30 minutes c) 30-45 minutesd) 45- 60 minutes e) More than an hour.
Q15: Were you referred to a specialist during the last 12 months?a) Yes b) No
Q16: If yes, how long did you have to wait for the appointment with the specialista) 1-2 days. b) 3-7 days.c)7-30 days. d) More than one month.
Affordability
Q17: In the past 12 months, did you postpone or abstain from a visit because you could not afford it?
a) Yes b) No
Q18: In the past 12 months, was there a time you did not take a medication because you could not afford it?a) Yes b) No c) I don’t remember
Cultural Acceptability Q19: Has a doctor talked to you in a language that you understand?a) Yes b) No
Q20: In the past, did you have difficulty understanding your doctor or healthcare professional?a) Yes b) No
Q21: Have you received written or other information about your illness?a) Yes b) No
Q22: When you are discussing your health conditions or concerns, do you always get an area where you have privacy?b) Yes b) NoQ23: In the past 12 months, have you ever been treated with disrespect during your visit to the health center?a) Yes b) No c) I don’t know
Service and medicine availability Q24: In the past 12 months has a doctor talked to you about medications you take, including ones by your doctor?a) Yes b) NoQ25: Do you have a health center, or personal GP or doctor that you consult?a) Yes b) NoQ26: During the last year were you prescribed a medicine that you did not get?a) Yes b) No c) I was not prescribed a medicineQ27: If the doctor asks you to do a blood or other test, is it always available at the health center?a) Yes b) No c) I was never asked to do blood testsQ28: If you need to see a dietitian, physiotherapist or other health professional; are they always available?a) Yes b) No c) I was never asked to see themQ29: During the last year, have you had difficulty getting medical treatment because there was no doctor or other health professional available?a) Yes b) No
Conclusions and further research Systematic review and concept analysis of available literature has clarified the
concept of primary care access and its components, although access to information remains unclear
It has supported the design of a new tool to measure access to primary health care, now requiring validation
Remaining research questions:
• Are the attributes independent? • Are any missing, or redundant? • Is the tool valid across different countries and health care settings?
Acknowledgement:We wish to thank the participants of the stakeholder consultation exercise and all the expert advisors that generously