Does ability to access primary health care vary with personal and social characteristics?

Problem

Interventions to enhance access tend to benefit persons who are better-off rather than the disadvantaged, possibly due to socially-related differences in access abilities. The Patient-Centred Accessibility Framework suggests that variations in access to primary healthcare can be due to differences in how healthcare services are organized OR in the variations in the abilities of people to access care (ability to perceive need, to seek appropriate options, to reach services, to pay and to engage in a clinical encounter). Our participatory action-research program co-designed, piloted and evaluated interventions to increase access to comprehensive primary health care for socially vulnerable populations in six jurisdictions: three in Canada and three in Australia. We also aimed to explore how access abilities correlate with indicators of poor access and how they vary with personal and social characteristics.

Approach

Although the vulnerable populations and interventions were different in each site, all interventions used a common evaluation method. Pre-and post-intervention surveys incorporated the same: indicators of poor access (reported difficulties accessing care, emergency room use); proxy measures of access abilities and personal and social characteristics (financial status; education; social support; language proficiency; immigrant/refugee status; chronic illness burden). This is a pooled analysis of the baseline data in the 284 participants across the six study regions. We explored correlations between access abilities and self-reported access problems; then access abilities with personal and social characteristics.

Findings

Referring to the last 6 months, 38% of persons reported having difficulties with getting needed healthcare or advice, which in 2/3 resulted in forgone care; 29% of the participants reported using the emergency room, of which 42% attributed use to access difficulties. Lower scores for each of the access abilities are associated with statistically significant increase in the likelihood of reporting difficulties with access and use of the emergency room. There is no difference in access abilities by age, sex, chronic illness burden. Lower access abilities are associated (in decreasing order) with poor financial status, low social support, limited language proficiency, low education. When these social characteristics were summed into an index, higher social vulnerability correlates with lower ability to perceive (r=-0.25), to seek (r=-0.23), and to engage (r=-0.36, r=-0.23) and more experienced cost barriers (r=0.16) but not with ease of travelling to regular clinic (reach).

Consequences

Lower patient abilities to navigate successfully all the stages of the care-seeking trajectory is associated with difficulties with accessing care and potential overuse of emergency rooms. These limited access abilities are more evident in socially vulnerable populations – a clear example of healthcare inequity. Primary healthcare access can become more equitable and appropriate by organizing services to be more attentive to persons with poor access abilities, which is likely to benefit especially the socially vulnerable.