A Realist Review of Access to Primary Care for Socio-economically Disadvantaged Older People in Rural Areas
Approximately 316,000 socio-economically disadvantaged older people live in rural areas in England. Previous research has identified this group as having poor access to primary care. Our aim was to use a realist review to explore the contexts that act as barriers and facilitators to accessing primary care for this group, understanding the underlying mechanisms, why they occur and how they are triggered. Realist reviews aim to answers questions such as ‘how?’, ‘why?’, ‘for whom?’, ‘in what circumstances?’ and ‘to what extent?’ programmes or interventions ‘work’.
An initial rough theory was generated based on prior knowledge and an initial scoping search. Subsequently MEDLINE and EMBASE electronic databases and grey literature (from inception to Dec 2014) were searched. Broad inclusion criteria were used to allow articles which were not specific, but might be relevant to the population of interest to be considered. All titles and abstracts were screened and articles included if they were judged to possibly contain relevant data. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded for concepts relating to context, mechanism or outcome in QRS NVivo. An overarching patient pathway was generated iteratively and used as the basis to explore contexts, causal mechanisms and outcomes.
3,065 titles and abstracts were screened leading to full text review of 196 articles of which 34 were excluded after assessment for relevance and rigour leaving 162 included. Most were from the USA or UK, were cross sectional in design and presented subgroup data by age, rurality or deprivation. From these studies a patient pathway was generated which included seven steps (problem identified, decision to seek help, actively seek help, obtain appointment, get to appointment, primary care interaction and outcome). The patient pathway is linear for simplicity, but it is clear that access to primary care is considerably more complex and dynamic. Important contexts were stoicism, education status, expectations of ageing, financial resources, understanding the health care system, access to suitable transport, capacity in primary care, the booking system and experience of health care. Prominent causal mechanisms were health literacy, perceived convenience, patient empowerment and responsiveness of the practice.
Socio-economically disadvantaged older people in rural areas face personal, community and health system barriers that limit their access to primary care. Initiatives should be targeted at modifiable contextual factors to help older people recognise problems, feel welcome, navigate the health care system, book appointments easily, access appropriate transport and have sufficient time with professional staff to improve their experience of health care, all of which will require dedicated primary care resources.