Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK This project involved the development and use of the method of Critical Interpretive Synthesis (CIS) This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually A more useful means of understanding access is offered by the synthetic construct of candidacy Candidacy describes how people's eligibility for healthcare is determined between themselves and health services It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole Both the method and the model should be evaluated in other contexts

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Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

The goal of this analysis is to determine the importance of geographic and spatial behavior factors in the health care utilization of the residents of rural communities. These geographic factors are part of a general conceptual framework of rural health care utilization. The health and health care of rural Americans are complex. Rural Americans are disadvantaged compared with their urban counterparts in several important ways that affect their health: they are disproportionately poorer, proportionately fewer are of working age, and they have less education (Ricketts 1999). The rural U.S. has 20 percent of the national population, but less than 11 percent of its physicians. Rural versus urban residents are more often uninsured (18.7 versus 16.3 percent), more likely to report being in fair or poor health, have restricted activity, and lower levels of access to a regular primary care provider (Ricketts 1999).

A major problem that rural dwellers face is access to care (Ricketts and Savitz 1994; Medicare Payment Advisory Commission 2001). Although access can be measured in many ways, geographic access is of primary concern in many rural areas. People who live in isolated places, relatively far from metropolitan areas or urban centers, often find it very difficult to contact health care personnel or facilities. In comparison with urban dwellers, rural residents have to travel farther to care and face other problems such as poor quality roads and lack of public transportation. These problems are well known and yet their solution eludes the efforts of the U.S. Congress, state legislatures, and regional governments (Ricketts 1999).

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The Effects of Geography and Spatial Behavior on Health Care Utilization among the Residents of a Rural Region

https://biblio.ugent.be/publication/315110/file/6786980.pdf

Socio-economic status of the patient and doctor-patient communication: does it make a difference?

The increasing availability of Geographical Information Systems (GIS) in health organisations, together with the proliferation of spatially disaggregate data, has led to a number of studies that have been concerned with developing measures of access to health care services. The main aim of this paper is to review the use of GIS-based measures in exploring the relationship between geographic access, utilisation, quality and health outcomes. The varieties of approaches taken by researchers concerned with teasing out the relative importance of geographical factors that may influence access are examined. To date, in the absence of detailed data on health utilisation patterns, much of this research has focused on developing measures of potential accessibility. This paper then critically evaluates the situation with regard to the use of such measures in a broad range of accessibility studies. In particular, there has been less research to date that examines the relationship between such measures and health outcomes. In the final sections of the paper, I draw on the review to outline areas where a broader research agenda is needed, particularly in relation to more recent innovations in health care delivery.

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A Literature Review of the Use of GIS-Based Measures of Access to Health Care Services

In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing importance of social inequalities in health care, an actualization of this review seemed appropriate. A systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. In this review social class was determined by patient's income, education or occupation. Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour. This review indicates that the literature on the social gradient in doctor-patient communication that was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize the importance of the reciprocity of communication. Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication. By increasing the doctors' awareness of the communicative differences and by empowering patients to express concerns and preferences, a more effective communication could be established.

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The social gradient in doctor-patient communication

Differences in levels of utilization vary and are a function of socio-economic and geographical factors. This paper presents the results of a questionnaire study involving twelve GP practices in Northamptonshire, UK, of factors which affect access and utilization in asthmatics and diabetics; these groups were selected to control for differences in utilization behaviour, as a result of different aetiologies. The questionnaire sought data on: residential location of patients, utilization characteristics of primary health-care, personal circumstances and mobility and hindrances to access and utilization. Key themes were identified relating to age, gender, social class, employment, ethnicity and proximity to the GP surgery. The young, elderly and females report higher rates of utilization, as do nonmanual workers and those who are unemployed. However, accessibility and utilization vary greatly in response to mobility and locational characteristics; these variations tend to be masked by data on overall rates of usage. Optimal scaling techniques were used to investigate the interactions between the factors affecting accessibility and utilization, and to characterize patients in terms of their levels of utilization. Results confirmed that current service provision afforded a differential level of service to patients, which does not directly reflect their level of need.

Ken S. Field

Papers

Socio-economic and locational determinants of accessibility and utilization of primary health-care.