Barreras y facilitadores de acceso a la atención de salud: una revisión sistemática cualitativa

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Abstract

OBJETIVO: Determinar si las barreras y los elementos facilitadores de acceso a la atención de salud son transversales a distintas poblaciones, países y patologías, e identificar en qué etapas del proceso de acceso a la atención sanitaria se presentan con más frecuencia. MÉTODOS: Revisión sistemática cualitativa de literatura publicada durante el período 2000-2010. Se consultaron seis fuentes internacionales: Fuente Académica, Medline en texto completo, Base de datos académica multidisciplinaria en texto completo (Academic Search Complete), PubMed, SciELO y LILACS. Se aplicaron criterios de valoración científica del Programa CASPe y la declaración STROBE. En paralelo se revisó literatura gris. RESULTADOS: Se seleccionaron 19 de 1 160 resultados de la revisión de artículos científicos, y 8 de 12 documentos de la revisión de literatura gris. Se identificaron 230 barreras y 35 facilitadores en países con diferentes contextos y grados de desarrollo. Las 230 barreras se clasificaron acorde al modelo de Tanahashi: 25 corresponden a la dimensión disponibilidad, 67 a accesibilidad, 87 a aceptabilidad y 51 a contacto. La mayor proporción de barreras correspondió a la dimensión de aceptabilidad y de accesibilidad. Los elementos facilitadores identificados tienen relación con factores personales, relación entre prestadores y usuarios, apoyo social, información sobre la enfermedad y adaptación de los servicios al paciente. CONCLUSIONES: La identificación de barreras y facilitadores se realiza mayoritariamente en personas que han contactado los sistemas sanitarios y en todas las etapas del proceso de acceso a la atención de salud. Se identificaron pocos estudios orientados a quienes no contactan los servicios. Las barreras y facilitadores identificados están socialmente determinados, y la mayoría son expresión de inequidades sociales que existen en los países y requieren una acción conjunta con otros sectores distintos de salud para ser reducidas o eliminadas.

Translated abstract

OBJECTIVE: To determine whether health care access barriers and facilitators cut across different populations, countries, and pathologies, and if so, at which stages of health care access they occur most frequently. METHODS: A qualitative systematic review of literature published between 2000 and 2010 was undertaken drawing on six international sources: Fuente Académica, MEDLINE (full-text), Academic Search Complete (a full-text multidisciplinary academic database), PubMed, SciELO, and LILACS. Scientific appraisal guidelines from the Critical Appraisal Skills Programme Español (CASPe) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were applied. Gray literature was also reviewed. RESULTS: From the review of scientific literature, 19 of 1 160 articles and 8 of 12 gray literature documents were selected. A total of 230 barriers and 35 facilitators were identified in countries with different contexts and degrees of development. The 230 barriers were classified according to the Tanahashi framework: 25 corresponded to availability, 67 to access, 87 to acceptability, and 51 to contact. Most of the barriers were related to acceptability and access. The facilitating elements that were identified had to do with personal factors, the provider-client relationship, social support, knowledge about diseases, and adaptation of the services to patients. CONCLUSIONS: The barriers and facilitators were seen mostly in people who initiated contact with the health systems, and they occurred at all stages of health care access. Only a few of the studies looked at people who did not initiate contact with the health services. The barriers and facilitators identified were socially determined and largely a reflection of existing social inequities in the countries. To reduce or eliminate them, joint action with other non-health sectors will be necessary.

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Most cited references 22

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Health service coverage and its evaluation.

T Tanahashi (1978)

Health service coverage is considered as a concept expressing the extent of interaction between the service and the people for whom it is intended, this interaction not being limited to a particular aspect of service provision but ranging over the whole process from resource allocation to achievement of the desired objective. For the measurement of coverage, several key stages are first identified, each of them involving the realization of an important condition for providing the service; a coverage measure is then defined for each stage, namely the ratio between the number of people for whom the condition is met and the target population, so that a set of these measures represents the interaction between the service and the target population. This definition of coverage allows for variations, which are called "specific coverage", by limiting the target population to specific subgroups differentiated by certain conditions related to service provision or by demographic or socioeconomic factors.The evaluation of coverage on the basis of these concepts enables management to identify bottlenecks in the operation of the service, to analyse the constraining factors responsible for such bottlenecks, and to select effective measures for service development.