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      Factors associated with multiple barriers to access to primary care: an international analysis


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          Disparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems.


          In this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions.


          Overall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care.


          A greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed.

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          The online version of this article (10.1186/s12939-018-0740-1) contains supplementary material, which is available to authorized users.

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          Most cited references29

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          Patient-centred access to health care: conceptualising access at the interface of health systems and populations

          Background Access is central to the performance of health care systems around the world. However, access to health care remains a complex notion as exemplified in the variety of interpretations of the concept across authors. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services. Methods A synthesis of the published literature on the conceptualisation of access has been performed. The most cited frameworks served as a basis to develop a revised conceptual framework. Results Here, we view access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. In this framework, five corresponding abilities of populations interact with the dimensions of accessibility to generate access. Five corollary dimensions of abilities include: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage. Conclusions This paper explains the comprehensiveness and dynamic nature of this conceptualisation of access to care and identifies relevant determinants that can have an impact on access from a multilevel perspective where factors related to health systems, institutions, organisations and providers are considered with factors at the individual, household, community, and population levels.
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            Contribution of primary care to health systems and health.

            Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
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              The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study

              Background Canadians’ health care-seeking behaviour for physical and mental health issues was examined using the international Quality and Cost of Primary Care (QUALICOPC) survey that was conducted in 2013 in Canada. Method This study used the cross-sectional Patient Experiences Survey collected from 7260 patients in 759 practices across 10 Canadian provinces as part of the QUALICOPC study. A Responsive Care Scale (RCS) was constructed to reflect the degree of health care-seeking behaviour across 11 health conditions. Using several patient characteristics as independent variables, four multiple regression analyses were conducted. Results Patients’ self-reports indicated that there were gender differences in health care-seeking behaviour, with women reporting they visited their primary care provider to a greater extent than did men for both physical and mental health concerns. Overall, patients were less likely to seek care for mental health concerns in comparison to physical health concerns. For both women and men, the results of the regressions indicated that age, illness prevention, trust in physicians and chronic conditions were important factors when explaining health care-seeking behaviours for mental health concerns. Conclusion This study confirms the gender differences in health care-seeking behaviour advances previous research by exploring in detail the variables predicting differences in health care-seeking behaviour for men and women. The variables were better predictors of health care-seeking behaviour in response to mental health concerns than physical health concerns, likely reflecting greater variation among those seeking mental health care. This study has implications for those working to improve barriers to health care access by identifying those more likely to engage in health care-seeking behaviours and the variables predicting health care-seeking. Consequently, those who are not accessing primary care can be targeted and policies can be developed and put in place to promote their health care-seeking behavior.

                Author and article information

                Int J Equity Health
                Int J Equity Health
                International Journal for Equity in Health
                BioMed Central (London )
                20 February 2018
                20 February 2018
                : 17
                : 28
                [1 ]ISNI 0000 0004 0474 1797, GRID grid.1011.1, Australian Institute of Tropical Health and Medicine, , James Cook University, ; Townsville, QLD 4812 Australia
                [2 ]Bureau of Health Information, Level 11, 67 Albert Avenue, Chatswood, NSW 2067 Australia
                [3 ]ISNI 0000 0004 4902 0432, GRID grid.1005.4, Centre for Primary Health Care and Equity, , University of New South Wales, ; Sydney, NSW 2052 Australia
                [4 ]ISNI 0000 0001 2342 0938, GRID grid.1018.8, Australian Institute for Primary Care & Ageing, La Trobe University, ; Melbourne, VIC 3068 Australia
                [5 ]ISNI 0000 0004 1936 8649, GRID grid.14709.3b, Department of Economics and Department of Epidemiology, Biostatistics, and Occupational Health, , McGill University, ; 855 Sherbrooke St. West, Montreal, QC H3A 2T7 Canada
                [6 ]ISNI 0000 0000 9064 6198, GRID grid.86715.3d, Department of community health, , University of Sherbrooke, ; 150 Place Charles LeMoyne, Longueil, Québec, J4K 0A8 Canada
                [7 ]ISNI 0000 0004 1936 7857, GRID grid.1002.3, General Practice Research, School of Primary and Allied Health Care, , Monash University, ; 270 Ferntree Gull Rd Notting Hill, Melbourne, VIC 3168 Australia
                Author information
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 2 July 2017
                : 6 February 2018
                Funded by: FundRef http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Funded by: Australian Primary Health Care Research Institute, Australian National University (AU)
                Custom metadata
                © The Author(s) 2018

                Health & Social care
                primary care,accessibility of healthcare services,vulnerable groups,mental health,healthcare disparities


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