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      An evaluation of access to health care services along the rural-urban continuum in Canada

      , 1 , 2 , 3

      BMC Health Services Research

      BioMed Central

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          Studies comparing the access to health care of rural and urban populations have been contradictory and inconclusive. These studies are complicated by the influence of other factor which have been shown to be related to access and utilization. This study assesses the equity of access to health care services across the rural-urban continuum in Canada before and after taking other determinants of access into account.


          This is a cross-sectional study of the population of the 10 provinces of Canada using data from the Canadian Community Health Survey (CCHS 2.1). Five different measures of access and utilization are compared across the continuum of rural-urban. Known determinants of utilization are taken into account according to Andersen's Health Behaviour Model (HBM); location of residence at the levels of province, health region, and community is also controlled for.


          This study found that residents of small cities not adjacent to major centres, had the highest reported utilisation rates of influenza vaccines and family physician services, were most likely to have a regular medical doctor, and were most likely to report unmet need. Among the rural categories there was a gradient with the most rural being least likely to have had a flu shot, use specialist physicians services, or have a regular medical doctor. Residents of the most urban centres were more likely to report using specialist physician services. Many of these differences are diminished or eliminated once other factors are accounted for. After adjusting for other factors those living in the most urban areas were more likely to have seen a specialist physician. Those in rural communities had a lower odds of receiving a flu shot and having a regular medical doctor. People residing in the most urban and most rural communities were less likely to have a regular medical doctor. Those in any of the rural categories were less likely to report unmet need.


          Inequities in access to care along the rural-urban continuum exist and can be masked when evaluation is done at a very large scale with gross indicators of rural-urban. Understanding the relationship between rural-urban and other determinants will help policy makers to target interventions appropriately: to specific demographic, provincial, community, or rural categories.

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          Most cited references 29

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          Socio-economic status and the utilisation of physicians' services: results from the Canadian National Population Health Survey.

          This paper assesses the extent to which Canada's universal health care system has eliminated socio-economic barriers in the use of physician services by examining the role of socio-economic status in the differential use of specific, publicly-insured, primary and specialist care services. Data from the 1994 National Population Health Survey, a nationally representative survey, were analysed using multiple logistic regression. In order to control for the association between primary and specialist utilisation, a two-staged least squares method was used for models explaining specialist utilisation. Health need, as measured by perceived health status and number of health problems, was found to be consistently associated with increased physician utilisation, for both primary and specialist visits. Whereas the likelihood of an individual making at least one visit to a primary care physician was found to be independent of income, those with lower incomes were more likely to be frequent users of primary care, that is, make at least six visits to a primary care physician. Even after adjusting for the greater utilisation of primary care services by those in lower socio-economic groups, and, therefore, their higher exposure to the risk of referral, the utilisation of specialist visits was greater for those in higher socio-economic groups. Canadians lacking a regular medical doctor were less likely to receive primary and specialist care, even after adjustments for socio-economic variables such as income and education. Although financial barriers may not directly impede access to health care services in Canada, differential use of physician services with respect to socio-economic status persists. After adjusting for differences in health need, Canadians with lower incomes and fewer years of schooling visit specialists at a lower rate than those with moderate or high incomes and higher levels of education attained despite the existence of universal health care.
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            Health inequalities and place: a theoretical conception of neighbourhood.

            In the past 10 years, interest in studying the relationship between area of residence and health has grown. During this period empirical relations between place and health have been observed at a variety of spatial scales, from census tracts to administrative units in metropolitan areas to whole regions, and for a variety of health outcomes. Despite the richness of the data, there are relatively few publications offering theoretical explanations for these observations, and a sound conception of place itself is still lacking. Using place as a relational space linked to where people live, work and play, this paper conceptualises the nature of neighbourhoods as they contribute to the local production of health inequalities in everyday life. In reference to Giddens' structuration theory, we propose that neighbourhoods essentially involve the availability of, and access to, health-relevant resources in a geographically defined area. Taking inspiration from the work of Godbout on informal reciprocity, we further propose that such availability and access are regulated according to four different sets of rules: proximity, prices, rights, and informal reciprocity. Our theoretical framework suggests that these rules give rise to five domains, the physical, economic, institutional, local sociability, and community organisation domains which cut across neighbourhood environments through which residents may acquire resources that shape their lifecourse trajectory in health and social functioning.
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              Neighborhood socioeconomic disadvantage and access to health care.

               T Kaneda,  B. Kirby (2005)
              Most research on access to health care focuses on individual-level determinants such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed care, however, has not received much attention. We address this gap in the literature by examining how neighborhood socioeconomic disadvantage is associated with access to health care. We find that living in disadvantaged neighborhoods reduces the likelihood of having a usual source of care and of obtaining recommended preventive services, while it increases the likelihood of having unmet medical need. These associations are not explained by the supply of health care providers. Furthermore, though controlling for individual-level characteristics reduces the association between neighborhood disadvantage and access to health care, a significant association remains. This suggests that when individuals who are disadvantaged are concentrated into specific areas, disadvantage becomes an "emergent characteristic " of those areas that predicts the ability of residents to obtain health care.

                Author and article information

                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                31 January 2011
                : 11
                : 20
                [1 ]Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto ON, M4N 3M5 Canada
                [2 ]Health System Performance Research Network, Department of Health Policy, Management, and Evaluation, University of Toronto, 155 College Street - 425, Toronto ON, M5T 3M6 Canada
                [3 ]Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore MD, 21205 USA
                Copyright ©2011 Sibley and Weiner; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Research Article

                Health & Social care


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