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

1978)• Non-discrimination, physical accessibility, economic

accessibility and information accessibility (Committee on Economical, Social and Cultural Rights, UN 2000)

• Availability, utilization, relevance, effectiveness and equity (Morgan 2008)

• Availability, affordability and acceptability (McIntyre, 2009)• Approachability, acceptability, availability and

accommodation, affordability, appropriateness (Levesque 2013)

Systematic review and concept analysis

Objectives

• 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

Tools to measure access• 30 tools: individual/ patient level: patient, caregiver

questionnaires

• 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%

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70%

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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

supported this project