Access To Primary Health Care Research Articles

Improving access to primary health care: a cross-case comparison based on an a priori program theory

BackgroundInequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative.MethodsIMPACT’s evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results.ResultsEach site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors.DiscussionThe model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways.ConclusionsAll the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of ‘cases’.

Improving primary health care through partnerships: Key insights from a cross-case analysis of multi-stakeholder partnerships in two Canadian provinces.

Background and AimsMulti‐stakeholder partnerships offer strategic advantages in addressing multi‐faceted issues in complex, fast‐paced, and rapidly‐evolving community health contexts. Synergistic partnerships mobilize partners' complementary financial and nonfinancial resources, resulting in improved outcomes beyond that achievable through individual efforts. Our objectives were to explore the manifestations of synergy in partnerships involving stakeholders from different organizations with an interest in implementing organizational solutions that enhance access to primary health care (PHC) for vulnerable populations, and to describe structures and processes that facilitated the work of these partnerships.MethodsThis was a longitudinal case study in two Canadian provinces of two collaborative partnerships involving decision makers, academic representatives, clinicians, health system administrators, patient partners, and representatives of health and social service organizations providing services to vulnerable populations. Document review, nonparticipant observation of partnerships' meetings (n = 14) and semi‐structured in‐depth interviews (n = 16) were conducted between 2016 and 2018. Data analysis involved a cross‐case synthesis to compare the cases and framework analysis to identify prominent themes.ResultsFour major themes emerged from the data. Partnership synergy manifested itself in the following: (a) the integration of resources, (b) partnership atmosphere, (c) perceived stakeholder benefits, and (d) capacity for adaptation to context. Synergy developed before the intended PHC access outcomes could be assessed and acted both as a dynamic indicator of the health of the partnership and a source of energy fuelling partnership improvement and vitality. Synergistic action among multiple stakeholders was achieved through enabling processes at interpersonal, operational, and system levels.ConclusionsThe partnership synergy framework is useful in assessing the intermediate outcomes of ongoing partnerships when it is too early to evaluate the achievement of long‐term intended outcomes. Enabling processes require attention as part of routine partnership assessment.

ACCESS TO PUBLIC HEALTH SERVICES FOR DIFFERENT GROUPS OF RURAL POPULATION IN RUSSIA

During the COVID-19 pandemic, the problems of accessibility of primary health care and quality health services for rural residents are exacerbated. The purpose of the article is to conduct comparative studies of the access to public health services of rural medical posts (RMPs), polyclinics, specialized medical facilities for different groups of the rural population of Russia. The results of the studies showed that the majority of rural residents living in small remote settlements request medical assistance at the RMPs. Among those who requested medical assistance, 70.7% were over 45 years old, and 43.9% were pensioners. Most of them have low requirements for medical assistance. They are primarily interested in the services provided for free. Younger rural residents (35.2% under the age of 45 years) request medical assistance at polyclinics, 47.8% of them are self-employed, and about 71.1% are low-income groups. The main reasons for applying for paid medical care, they call the lack of specialists in public institutions. Visitors to specialized centers have the highest requirements for the quality of medical services received. The maximum share belongs to young people (24.4% of people aged 16-30 and 20.3% aged 31-45), about 60.5% have jobs, 40.6% have incomes higher than the subsistence level. They are more likely than others to seek paid medical services. The main reason for choosing commercial institutions is the belief that paid medical services are of better quality. The construction of multidimensional distributions was performed using the statistical processing package STATISTICA Advanced for Windows 10.0.

Spatial Accessibility of Primary Health Care in Rural Areas in Poland.

The aim of the study was to assess the spatial accessibility of basic and universal healthcare (understood as primary healthcare (PHC) facilities) in rural statistical localities in Poland. Data from the National Health Fund, Central Statistical Office, National Register of Geographic Names and OpenStreetMap were used in the research. The research was carried out on the basis of modelled distance from the rural statistical localities to the nearest PHC facility. The methods used included network analysis, characteristics of normal point distribution, Theil index, and spatial autocorrelation. Areas where the greatest shortages of access to PHC facilities occurred were indicated on the basis of the analysis of their clustering density. The average distance from rural statistical localities in Poland to PHC facilities is about 5 km. Slightly more than 70% of the distance values are within one standard deviation of the mean. Better access to the examined healthcare facilities is available in the southern and central parts of Poland, while northern and eastern Poland, as well as the border areas, suffer from lower accessibility. Poor access to PHC occurs first of all at the border of Greater Poland Voivodeship with the Kuyavian–Pomeranian Voivodeship, on the border of the Lodz Voivodeship, in Masovian and Swietokrzyskie Voivodeship, and in the ring surrounding Warsaw, as well as in the Pomeranian Voivodeship. The research findings can be used to develop strategies to improve the accessibility of primary care facilities in rural areas.

Meeting the healthcare needs of overseas Chinese students at UK universities

Individuals from China comprise the largest cohort of international students in the UK, making up almost one quarter of those coming to the country to study. The large Chinese student population at UK universities means there are considerable numbers each year who require access to student primary healthcare.This article describes a literature and narrative review that aimed to critically review the evidence concerning whether the primary healthcare needs of overseas Chinese students studying at UK universities are being met. Three themes were identified: primary healthcare accessibility and potential barriers for overseas Chinese students; health-seeking behaviour and health needs; and cultural and spiritual foundations of health needs and trusted health-seeking frameworks.

The quality of alternative models of primary health care and morbidity and mortality in Brazil: a national longitudinal analysis

BackgroundEvidence is limited on health benefits from quality improvement of primary healthcare (PHC) in low- and middle-income countries (LMICs). This study investigated whether increasing PHC quality in Brazil with highly-skilled health professionals and integrated community health workers (CHWs) was associated with reductions in hospitalizations and mortality beyond benefits derived from increasing access. MethodsAnnual municipal-level data for 5,411 municipalities between 2000 and 2014 were analysed using fixed effects panel regressions. PHC quality was measured as: i) the proportion of consultations provided by highly-skilled health professionals (doctors and nurses); and ii) the proportion of visits provided by CHWs from multidisciplinary PHC teams. Models assessed associations between PHC quality and hospitalization and mortality from diabetes, cardiovascular disease (CVD), tuberculosis, leprosy, perinatal and maternal causes, and adjusted for PHC access, utilisation, presence of secondary care services, and socioeconomic factors. FindingsA one percentage point increase in the proportion of consultations provided by highly-skilled health professionals was associated with 0•019 fewer deaths from diabetes per 100,000 population (95%CI: -0•034, -0•003; p-value: 0.0167) and 0•029 fewer hospitalizations per 100,000 from leprosy (95%CI: -0•055, -0•002; p-value: 0.0321). A one percentage point increase in the proportion of care provided by CHWs from multidisciplinary PHC teams was associated with 0•025 fewer deaths from CVD per 100,000 (95%CI: -0•050, -0•001; p-value: 0.0442) and 0•148 fewer maternal hospital admissions per 100,000 (95%CI: -0•286, -0•010; p-value: 0.0356). No significant associations were found for the other twenty pairs of exposures and outcomes analysed. InterpretationInvesting in higher-quality PHC models with highly-skilled health professionals and integrated CHWs can deliver reductions in mortality and hospitalizations in LMICs. FundingNone.

Accessibility of primary healthcare in low and middle income countries: a systematic review

Background: Accessibility to healthcare is the capability of a population to obtain a specified set of healthcare services. There is a direct link between the distance patients travel to access health and the reduction of ill health and suffering in a country. This has an important impact on the quality of life of people. Objective: To find the spatial or geographic determinants of accessibility of primary healthcare provision in low and middle income countries during last two decades. Methods: Systematic review was done according to PRISMA guidelines. Data bases used were Google scholar, PubMed and Science direct. We found ten different studies from eight different economic groups of countries. Accessibility of primary healthcare in low and middle Income countries published during the period of last two decades were included using the key words like Spatial Accessibility;Geographical Accessibility; Primary Health Care; Primary Care; Low and middle income countries. The countries included were Afghanistan, Bangladesh, Bhutan, Democratic Republic of Congo, India, Indonesia, Sudan, Mozambique /Rural Africa. Two studies each from India and Mozambique (Rural Africa) were included. The categorization as low and middle income counties was as per World Bank classification. Results: We found that accessibility to primary healthcare was worse in low income countries like Afghanistan, Mozambique and South Sudan where more than two third of the population lived in underserved or difficult to access areas while rest of the countries, which come under category of lower middle income countries, more than half of the population lived in underserved or difficult to access areas.] Conclusion: Health care ease of access is a single most important component for equitable and adequate health system. Guaranteeing a healthcare system which is easily accessible to the people is a basic consideration for public health policy makers, policy implementers and academicians.

Meaningful and deep community engagement efforts for pragmatic research and beyond: engaging with an immigrant/racialised community on equitable access to care

Primary healthcare access is one of the crucial factors that ensures the health and well-being of a population. Immigrant/racialised communities encounter a myriad of barriers to accessing primary healthcare. As...

How Brazilians access Primary Health Care: evolution and adversities in recent times (2012-2018)

The scope of this study is to analyze access to primary care in Brazil between 2012 and 2018, taking into consideration the availability of services and the physical-structural, temporal and organizational characteristics of the primary care units and teams, highlighting the main advances and obstacles to their enhancement in different contexts. It involved a descriptive cross-sectional and longitudinal study, with a quantitative approach based on secondary data from the National Program for the Improvement of Access and Quality of PC and population coverage data from the Ministry of Health. A total of 15,378 teams were selected and data screened from 59,354 users relating to the teams selected for 2012, and 56,369 users for 2018. Improvements were noted with respect to service availability and in terms of physical and architectural structure; the majority of the teams implemented and/or qualified the reception to spontaneous demand, including emergency care, improved the ways of organizing the agenda to foster a more integrated contact between users and health professionals and qualified the ways of scheduling and reduced the waiting times between scheduling and care. However, the persistence of recurring problems that need to be addressed to improve access to primary care in the country was detected.

Community-Driven Prioritization of Primary Health Care Access Issues by Bangladeshi-Canadians to Guide Program of Research and Practice.

Research around probable solutions to immigrants accessing health care in Canada is not extensive, and the perspective of immigrant communities on priorities and potential solutions has not been captured effectively. The purpose of this article is to describe a research initiative that involved grassroots community members as producers of research priorities on primary care access issues. This study aimed to seek input from an immigrant community in Calgary, Canada. Members of the Bangladeshi community of Calgary were asked through a survey to rank 10 predefined primary care access topics as to what they felt constituted priorities for solution-oriented research (1, highest; 10, lowest). We used frequencies and percentages to describe the participant demographics. Ratings of preferred research themes were analyzed on the basis of relative weighted priority rank. We received 432 responses: 51.2% female; 58.9% aged 36 to 55 years; 90.5% had university-level education; 46.2% immigrated to Canada between 10 and 19 years ago; 82.5% employed full/part-time or self-employed. Lack of resources, lack of knowledge, health care cost, and workplace-related barriers were among the top-ranked topics identified as solution-oriented research priorities. Through partnerships and reciprocal learning, public input can increase insider perspectives to help develop interventions that align with the needs of community members.

Reasons for never receiving a pap test among Brazilian women: National health survey.

To identify reasons among Brazilian women for never having a Pap test. We designed a cross-sectional study that used data from the National Health Survey. Two thousand four hundred and two women 25-64 years old who never had a pap test. Variables were age, race, education, marital status, housing condition, primary health care access, health insurance, self-perceived health, and social support network. We calculated the prevalence of different reasons and odds ratios for each. The most frequent reason for never having a test were linked to women thinking the test was unnecessary (42.3%) which had a significant association with marital status (OR=1.52; 95% CI=1.07-1.91), age (OR=1.56; 95% CI=1.21-1.99), area of residence (OR=1.15; 95% CI=1.02-1.39), having a health insurance (OR=1.18; 95% CI=1.01-1.36), and self-perceived health (OR=1.42; 95% CI=1.28-1.56). The second most frequent reason was not knowing they needed a test (22.9%) which was associated with age (OR=1.95; 95% CI=1.74-2.16) and self-perceived health (OR=1.56; 95% CI=1.33-1.80). The findings suggest lack of knowledge about cervical cancer and its prevention among Brazilian women. We consider it essential that the health service can provide the test, as well as the necessary guidelines for raising the awareness of the target audience.

Bill introduced to make mental health visits more affordable

The Primary and Behavioral Health Care Access Act would require insurance to cover three primary care visits and three outpatient mental health or substance use disorder treatment visits per year without charging patients out‐of‐pocket costs.

Measuring geospatial healthcare access to primary level facilities in Mexico: a GIS-based diagnosis analysis.

To describe a general overview of health services delivery in Mexico and geospatially analyze the current distribution and accessibility of Primary Health Care (PHC) facilities to contribute to new approaches to improve healthcare planning in Mexico. We performed a spatial analysis of official data to analyze current distances from health facilities to population, to determine the underserved areas of health services delivery in three selected states using a ranking of indicators. We estimated service area coverage of PHC facilities with road networks of three Mexican states (Chiapas, Guerrero, and Oaxaca). Our estimations provide an overview of spatial access to healthcare of the Mexican population in Mexico's three most impoverished states. We did not consider social security nor private providers. Geospatial access to health facilities is critical to achieving PHC and adequate coverage. Countries like Mexico must measure this to identify underserved areas with a lack of geospatial access to healthcare to solve it. This type of analysis provides critical information to help decision-makers decide where to build new health facilities to increase effective geospatial access to care and to achieve Universal Health Coverage.

Optimising geographical accessibility to primary health care: a geospatial analysis of community health posts and community health workers in Niger

BackgroundLittle is known about the contribution of community health posts and community health workers (CHWs) to geographical accessibility of primary healthcare (PHC) services at community level and strategies for optimising...

Inpatient Facility Distribution and Primary Healthcare Centers Demand Based on Location-Quotient in Bali within 2015-2019 Period

The study of access to primary healthcare centers (PHCs) in the middle region of Indonesia, including Bali, is scarce. A study on primary healthcare access is worth undertaken in this region because it is usually given less attention regarding its fair distribution of healthcare facilities in relation to their population. This study aimed at determining geographical distribution and concentration of PHCs facility and demand in Bali Province. This study focused on the inpatient facility and demand of PHCs in relation to population. Data of PHCs’ inpatient facility and demand of each regency/city and population data were obtained from Bali Health Profile of 2015 to 2019. Location quotients (LQ) of inpatient facility and inpatient demand for each regency/city were calculated to determine the spatial concentration of the two variables compared to the provincial average. Our study found that there was variation in facility and demand for inpatient care in PHCs in Bali. A low level of inpatient facility and demand was seen in Regency of Buleleng, Denpasar, and Gianyar, while a high level of facility and demand for inpatient facility was observed in Regency of Jembrana, Tabanan, Klungkung, and Karangasem. A unique finding was also noticed in Bangli Regency, where the inpatient facility of PHC was high, while the inpatient demand was low. This might indicate a need for evaluation of the inpatient facility of PHC in this Regency.
 Keywords: Access to healthcare, Bali, inpatient care, puskesmas, primary healthcare centers.

Why do patients leave the Pediatric Emergency Department and what happens to them?

The dropout rate is an important indicator of the quality of emergency services. The authors intend to evaluate factors that influence abandonments in the Pediatric Emergency Department (PED) and to assess outcome and destination of the highest triage leveled patients. Retrospective analysis of the abandonment cases occurring between 2014 and 2016 in a tertiary hospital, including sociodemographic characterization, temporal factors, triage level, referral from other health services, waiting time and patient attendance. The outcome of the highest triage level was also accessed. In the three years analyzed, there were 240171 PED visits, with an abandonment rate of 2.57%. PED abandonment was influenced by higher patient attendance and waiting time, a younger age, and less urgent triage level. Only 1.78% of the urgent or emergent patients (level three or two) abandoned the PED. Of these, 44% sought medical care in the next five days, 41% of which in private institutions, 40% in public hospitals and 19% in primary care. Only 0.81% of those were hospitalized. The majority of patients who leave the PED do not correspond to urgent cases. Health education awareness campaigns, clinical counseling platforms (online or phone services) and the improved accessibility of primary health care may optimize the usage of health resources. The reinforcement of the teams in times of greater affluence may contribute to decrease the rate of abandonment.

Older people and rural eHealth: perceptions of caring relations and their effects on engagement in digital primary health care.

BackgroundThe aim of this article is to describe older people’s perceptions of caring relations in the context of rural eHealth, as well as to explore how such relations can facilitate engagement in digital primary health care. There is an ongoing implementation of eHealth in Western health care, and rural areas and older people are specifically targeted. eHealth is said to be a solution to emergent problems and a technology that will facilitate people’s opportunities to achieve good and equal health. From this perspective, it is crucial that older people engage in eHealth services, but there are barriers for use, and care providers need to adapt to the preferences of older people.MethodsSemi‐structured interviews with 19 individuals aged 61‐85 were conducted. The participants were using digital services at two primary healthcare centres located in northern Sweden. Qualitative content analysis was used. An important theoretical tenet was that older people’s perceptions of and engagements in eHealth are affected by the specific rural conditions. Ethical approval for the study has been obtained.ResultsThe analysis rendered a total of three themes: in‐person interaction was central to people’s perceptions of good caring relations; patient–nurse relations were particularly emphasised; and caring relations in rural eHealth appeared to be multi‐directional and fuelled by a shared sense of rural community. Altogether, this facilitated participants’ engagement in local eHealth initiatives.ConclusionseHealth is an opportunity for primary health care and for rural communities. However, the results provide insight into matters that can affect the quality, access, and equality of rural primary health care. Participants’ engagement in eHealth was almost always facilitated by close caring relations with local Registered Nurses. Digital care needs to be approached as a combination of digital and in‐person presence. Separating digital and physical task assignments among different personnel could make older people refrain from seeking health care.

Knowledge assessment and barriers to cancer screening among Ghanaian community pharmacists.

Though there are controversies, cancer screening has been suggested to decrease mortality. Over the years, the most accessible primary healthcare provider; the community pharmacist, has developed an interest in being part of cancer screening activities and prevention of a wide range of other non-communicable diseases. To achieve this, community pharmacists need a working knowledge of the basic screening test and recommendations. Also, it's important to acknowledge the barriers that may prevent the implementation of cancer-screening efforts at the community pharmacy. This study aims to determine the knowledge and barriers to cancer screening among Ghanaian community pharmacists. Knowledge and barriers to cancer screening was assessed using an online questionnaire in 435 community pharmacists. Descriptive statistics and Pearson's chi-squared tests were used to analyze the data. The reliability and validity assessment of the questionnaire after data collection revealed a Cronbach's alpha value of 0.82 for knowledge on cancer screening. The SD and mean age of study participants were 2.48 ± 20.08. Only 25.7% of the participants had good knowledge. The most identified barrier was the lack of established guidelines (60.9%). There was no association between participants' demographics and their knowledge scores. Community pharmacists can potentially have a large impact on early detection of cancer through screening. However, they have to improve their knowledge on general screening guidelines and be aware of available educational resources to increase their knowledge. It is also important for all stakeholders to come together to establish local screening modalities and recommendations for the country.

Hospitalization for ambulatory care sensitive conditions: What conditions make inter-country comparisons possible?

Hospitalizations for ambulatory care sensitive conditions have been extensively used in health services research to assess access, quality and performance of primary health care. Inter-country comparisons can assist policy-makers in pursuing better health outcomes by contrasting policy design, implementation and evaluation. The objective of this study is to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing these types of hospitalizations across countries. A conceptual framework for inter-country comparisons was drawn based on a review of 18 studies with inter-country comparison of ambulatory care sensitive conditions hospitalizations. The dimensions include methodological choices; population’s demographic, epidemiologic and socio-economic profiles and features of the health services and system. Main factors include access and quality of primary health care, availability of health workforce and health facilities, health interventions and inequalities. The proposed framework can assist in designing studies and interpreting findings of inter-country comparisons of ambulatory care sensitive conditions hospitalizations, accelerating learning and progress towards universal health coverage.

Overcoming the Challenges Faced by Immigrant Populations While Accessing Primary Care: Potential Solution-oriented Actions Advocated by the Bangladeshi-Canadian Community.

Introduction:Immigrants continue to face significant challenges in accessing primary healthcare (PHC) that often negatively impact their health. The present research aims to capture the perspectives of immigrants to identify potential approaches to enhance PHC access for this group.Methods:Focus group discussions (FGDs) were conducted among a sample of first-generation Bangladeshi immigrants who had experience with PHC in Canada. A total of 13 FGDs (7 among women, 6 among men) were conducted with 80 participants (women = 42, men = 38) in their preferred language, Bangla. We collected demographic information prior to each focus group and used descriptive statistics to identify the socio-demographic characteristics of participants. We applied thematic analysis to examine qualitative data to generate a list of themes of possible approaches to improve PHC access.Results:The focus group findings identified different levels of approaches to improve PHC access: individual-, community-, service provider-, and policy-level. Individual-level approaches included increased self-awareness of health and wellness and personal knowledge of cultural differences in healthcare services and improved communication skills. At the community level, supports for community members to access care included health education workshops, information sessions, and different support programs (eg, carpool services for senior members). Suggested service-level approaches included providers taking necessary steps to ensure an effective doctor-patient relationship with immigrants (eg, strategies to promote cultural competencies, hiring multicultural staff). FGD participants also raised the importance of government- or policy-level solutions to ensure high quality of care (eg, increased after-hour clinics and lab/diagnostic services).Conclusions:Although barriers to immigrants accessing healthcare are well documented in the literature, solutions to address them are under-researched. To improve healthcare access, physicians, community health centers, local health agencies, and public health units should collaborate with members of immigrant communities to identify appropriate interventions.