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

Assessment of out-of-pocket (OOP) expenditures on essential medicines for acute and chronic illness: a comparative study across regional and socioeconomic groups in India

BACKGROUND

Substantial out-of-pocket (OOP) expenditures push a large portion of the population below the poverty line, especially those residing in rural areas having low incomes. Individuals from economically disadvantaged states in India incur higher healthcare costs for hospitalization in public health centers than do those from more developed states. Economically poorer households in states such as Bihar and Odisha face significantly higher OOP expenditures for hospitalization in public health centers than do those in economically developed states such as Tamil Nadu.

OBJECTIVE

This study aims to compare households by using the wealth index and demographic factors concerning OOP expenditures on medicines for acute and chronic illnesses in Odisha, India.

METHODOLOGY

A cross-sectional household survey was adopted to conduct the research. Access to medicines focused on OOP expenditures in Odisha is being studied by purposively selecting six districts: Rayagada, Kalahandi, Angul, Keonjhar, Khordha, and Kendrapara. A total of 902 households were surveyed. A stratified random sampling procedure was adopted to select the locations and households. The survey took place from October 2021 to February 2022. The sampled respondents were investigated for acute and chronic illnesses. The software SPSS version 25 was used to analyze the data. The details of the expenditures for the past four weeks were compared with those of medicines and healthcare expenses. Households were categorized into wealthy, middle, and poor classes. The prevalence of acute and chronic illnesses was analyzed in light of the share of medicine expenditures to total household expenditures.

RESULTS

Out of 902 surveyed households, 173 (19.2%) spent out-of-pocket (OOP) money on medicines due to acute and chronic illnesses. Among the studied population, 23.7% were affected by acute illness, whereas 10.9% suffered from chronic illness. Wealthy households constituted most of the OOP expenditure (81 wealthy households), whereas 33 poor households also contributed to the OOP expenditure. According to the unadjusted odds ratio (UOR) analysis, wealthy households were 0.25 times less likely to spend more than 50% of their total monthly household budget on medicine than poor households (UOR = 0.25, 95% CI = 0.09-0.65). Similarly, ST households were 0.18 times less likely to spend more than 50% of their money on medicine from their budgets than SC households (UOR = 0.18, 95% CI = 0.04-0.72).

CONCLUSION

The present study again reveals that capital regions (metropolitan regions) are well protected against OOP expenditures on medicines, but tribal areas are still underserved. The odds ratio reveals a critical positive association between high OOP and poor economic status in households in Odisha. That association must be minimized or nullified for equitable economic and social development.

Non-clinical Psychosocial Mental Health Support Programmes for People with Diverse Language and Cultural Backgrounds: A Critical Rapid Review

Low accessibility to mainstream psychosocial services disadvantages culturally and linguistically diverse (CALD) populations, resulting in delayed care and high rates of unsupported psychological distress. Non-clinical interventions may play an important role in improving accessibility to psychosocial support, but what characterises best practice in this space remains unclear. This critical rapid review addressed this gap by searching for, and critically analysing, existing research on non-clinical psychosocial support services, drawing from a critical realist framework and Brossard and Chandler's (Brossard and Chandler, Explaining mental illness: Sociological perspectives, Bristol University Press, 2022) taxonomy of positions on culture and mental health. We searched PubMed, PsycInfo, LILACS, Scopus and Sociological Abstracts to identify non-clinical psychosocial support interventions for first-generation immigrant CALD populations delivered by lay-health workers. Thirty-eight studies were included: 10 quantitative, 7 mixed-methods and 21 qualitative. Most studies were conducted in North America (n = 19) and Europe (n = 7), with few conducted in low-income countries (Tanzania and Lebanon, n = 3 each, Kenya [n = 1]). Studies often focussed on specific interventions (e.g. psychoeducation) for targeted populations (e.g. refugees, Latinx immigrants); multimodal interventions (e.g. psychological support and food distribution) for broad populations were less common. Thirty-five different outcome scales were identified across quantitative and mixed-methods studies, with most covering depression, stress and trauma. Most studies identified significant improvements for at least one psychosocial outcome despite interventions being relatively short in sessions. Findings from qualitative studies highlighted varied engagement with theory-informed models of service, and identified important barriers to non-clinical psychosocial support services, including precarious resourcing. Our analysis suggests most studies were underpinned by split-relativist frameworks and focussed on interventions aimed at helping clients navigate the eurocentricity and complexity of mainstream services. Recognising the eurocentrism of universalist frameworks, working from a culturally relativist position, prioritising social determinants of health and using models that centre clients, flexibility, context, culture and community are likely to ensure best practice for non-clinical psychosocial support interventions.

Identifying barriers and potential solutions to improve equitable access to community eye services: an exploratory sequential mixed methods study protocol

INTRODUCTION

Access to care varies by sociodemographic group, with some groups facing higher barriers to care than others. This study will use novel methods to explore barriers and potential solutions as perceived by members of the population groups who are least able to access care. We aim to use rapid yet robust mixed methods that allow us to identify generalisable findings within each programme and testable service modifications to improve equitable access to care; delivering non-tokenistic findings within a matter of weeks.

METHODS AND ANALYSIS

This is a multiphased exploratory sequential mixed methods study. We will use the same approach in four different screening programmes, in Botswana, India, Kenya and Nepal. First, we will conduct interviews with people purposively selected from the sociodemographic subgroups with the lowest odds of accessing care within each programme. We will explore their perceptions of barriers and potential service modifications that could boost attendance at eye clinics among people from these 'left-behind' groups. We will use a deductive analytic matrix to facilitate the rapid analysis of qualitative data. Space will be made for the inductive identification of themes that are not necessarily captured in the framework. Sample size will be determined by thematic saturation. Next, we will conduct a survey with a representative sample of non-attenders from the same left-behind groups, asking them to rank each suggested service modification by likely impact. Finally, we will convene a multistakeholder workshop to assess each service modification based on ranking, likely impact, feasibility, cost and potential risks. The most promising service modifications will be implemented and evaluated in a follow-on randomised controlled trial, the methods for which will be reported elsewhere.

ETHICS AND DISSEMINATION

This project has been approved by independent research ethics committees in Botswana, Kenya, India, Nepal and the UK. We will disseminate our findings through local community advisory boards, national eye screening meetings, in peer-reviewed journals and at conferences.

Analysis of Maternity Rights Perception: Impact of Maternal Care in Diverse Socio-Health Contexts

Maternity rights are perceived and fulfilled differently according to women's psychosocial characteristics, leading to varying maternal experiences and outcomes. It is necessary to know the impact of cultural context, emotional well-being, and resource availability on the maternal woman's clinical care experience. The aim is to identify if these factors contribute to disparities in the perception of maternity rights fulfillment in Spain and Colombia. This retrospective observational study focused on women who received maternity-related healthcare in Spain or Colombia. A total of 185 women were included (Spanish = 53; Colombian = 132). Data collected included social and obstetric history, as well as psychological variables such as resilience, positive and negative affect, derailment, and maternity beliefs. The study also assessed women's knowledge of healthcare rights (MatCODE), perceptions of resource scarcity (MatER), and the fulfillment of maternity rights (FMR). C-section was more prevalent in Colombia, where women also scored higher on maternity beliefs as a sense of life and as a social duty compared to Spanish women. Conversely, FMR was higher in the Spanish context. Colombian women reported lower levels of social support and less involvement in medical decision-making. The FMR was positively correlated with positive affect, MatCODE, and MatER. Predictive modeling identified negative factors for FMR, including giving birth in Colombia (β = -0.30 [-0.58; -0.03]), previous miscarriage (β = -0.32 [-0.54; -0.09]), C-section in the most recent labor (β = -0.46 [-0.54; -0.0]), and higher MatER scores. Positive predictors included gestational age, maternal age, and previous C-section (β = 0.39 [0.11; 0.66]). The perception of the fulfillment of maternity rights depends on socio-healthcare contexts, women's age, obstetric history, and resources. It is suggested to apply culturally sensitive strategies focused on women's needs in terms of information, emotional and social support, privacy, and autonomy to manage a positive experience.

Impact of primary care benefits on healthcare utilisation and estimated out-of-pocket expenses in urban, rural and remote settings in the Philippines

BACKGROUND

This study aimed to determine the effects of primary care interventions on healthcare utilisation and estimated out-of-pocket (OOP) expenses in selected urban, rural and remote settings in the Philippines.

METHODOLOGY

Context-specific measures relating to expanding healthcare provider networks, augmenting the health human workforce and subsidising transportation costs were implemented to strengthen primary care systems. In this study, two key outcomes were monitored: (1) monthly healthcare utilisation measured by the total number of outpatient consultations per site and (2) change in OOP expenses from baseline to endline within a 1 year study period.

RESULTS

All sites had a positive trend in monthly outpatient consultations in healthcare utilisation over 1 year. The remote site had the steepest increase in outpatient consultations, with a 401% increase compared with the baseline during the peak of consultations at month 7. The urban site had a 62% increase in outpatient consultations from baseline to month 6, while the rural site had a 251% increase from baseline to month 11, which corresponded to the peak month in terms of the number of outpatient consultations. The rural site had the largest decrease in estimated OOP expenses (50.3% reduction, 95% CI -88 to -13), followed by the remote site (33.2% reduction, 95% CI -67,+1) and the urban site (16.0% reduction, 95% CI -65,+33).

CONCLUSION

The rural site showed a significant reduction in estimated OOP expenses and an increase in healthcare utilisation. The remote site had the steepest increase in utilisation, but the reduction in estimated OOP expenses was not statistically significant. The urban site experienced the lowest increase in utilisation, and the smallest reduction in estimated OOP expenses, which was also not statistically significant. Implementing primary care benefits will necessitate contextualised approaches to avoid the inadvertent aggravation of inequities in healthcare.

Migrant Health Country Profile tool (MHCP-t) for transforming health data collection and surveillance in the Middle East and North African (MENA) region: tool development protocol with embedded process evaluation

INTRODUCTION

The Middle East and North Africa (MENA) region is characterised by major health disparities and complex migration flows. Yet, because of a lack of epidemiological data, there is an urgent need to strengthen routine data collection around migrant health and to define key indicators towards migrant health monitoring. To address this problem, we aim to design and pilot test the Migrant Health Country Profile tool (MHCP-t) which can collate country-level data collection around migration health data, policies and healthcare provision.

METHODS AND ANALYSIS

The MHCP-t development is a stepwise process that will integrate a process evaluation model with active involvement and engagement of multilevel stakeholders. First, towards the generation of indicators, qualitative field activities will be conducted in different regions in Morocco, Tunisia and Egypt with migrants (n=50 per region), migrant community leaders (n=20 per region) and professionals working with them (n=20 per region). Deductive-inductive thematic analysis will be applied to the data collected. Results from the national qualitative studies and a series of systematic reviews in the MENA region will conclude with a first draft of tool indicators which will be reviewed by national and international experts using the Nominal Group Technique. The revised indicators will be entered into an electronic data capture system and the tool will be pilot-tested by applying a mixed-methods process evaluation to examine its relevance, comprehensiveness, comprehensibility and other practical issues, such as completion time and ease of responding. Mechanisms of change will be assessed on how the participative interactions towards the tool development can trigger change at national and regional levels.

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional review boards at the Hospital Clinic in Barcelona, Spain, the University of Sousse in Sousse, Tunisia, the University Hospital of Tanger, Morocco and Badr University of Cairo in Egypt. Findings will be disseminated in peer-reviewed journals and communications to national and regional congresses.

Investigating the relationship between unmet need and utilisation of health care in European countries

Access to health care is a multidimensional concept, influenced by individual and health system factors and the relationship between different access dimensions is not well understood. We used individual-level data from the 2019 wave of the European Health Interview Survey, covering 27 European Union member states, Iceland, and Norway (n = 269,799 individuals) and country-level data from the Eurostat, OECD and World Bank databases to explore this important research gap. We investigated six outcome measures: unmet need due to long wait, distance, affordability of medical care, and affordability of prescribed medicines, and the utilisation of general practitioner, or specialist care. We investigated the relationship between these outcomes and individual characteristics using a multilevel multivariate logit random effects model, which allowed us to model outcomes simultaneously. After controlling for individual socio-economic position, health status and health behaviour, we assessed the correlation between outcomes at individual and country levels to gain insight into the relationship between different dimensions of access. We investigated the association between each outcome measure and health system characteristics including health expenditure, physician density and primary care gatekeeping as well as macroeconomic characteristics (income and income inequality) using multilevel logit random effects models. We found that people with lower self-reported health status, multimorbidity and limitations due to health problems were more likely to report unmet need and utilisation. Higher household income was negatively associated with unmet need and positively associated with utilisation. After controlling for individual characteristics, correlations between unmet need and utilisation were very low (under 10%) at individual level. At country level, there was a negative correlation between unmet need due to the affordability of prescribed medicines and GP (-49%), and specialist (-42%) care. Individuals in countries that incentivised or required a referral from primary to specialist care were less likely to report use of specialist care. Our findings emphasise that unmet need and utilisation measure different dimensions of access, thus underscoring the importance of employing complementary measures of access to health care.

April 15th war and hemodialysis patients in Sudan: a cross-sectional study

BACKGROUND

On April 15th, 2023, intense clashes involving heavy weapons and airstrikes occurred between the Sudanese Armed Forces (SAF) and the paramilitary Rapid Support Forces (RSF) in Khartoum, the capital of Sudan, leading to the displacement of almost 8.1 million people. The ongoing armed conflict in Sudan has led to a worsening humanitarian catastrophe, posing serious challenges to the country's health-care system and even its collapse. Healthcare facilities have been severely affected, with barely one-third of hospitals operating in conflict zones. Hemodialysis patients are among the most affected by this war's aftermath, which ranges from obvious dangers like violence-related injuries and deaths to more indirect effects like the suspension of access to preventive and curative medical care.

METHODS

This was a descriptive cross-sectional multicenter health facility-based study aiming to study the impact of the April 15 war on hemodialysis patients in Sudan. The study was conducted in five centers in four different states in Sudan, including Gezira State, Red Sea State, River Nile State, and Kassala State. The study included 316 participants. Data was collected using structured interviews guided by a questionnaire. The questionnaire encompassed five primary domains: demographic data, healthcare access (Levesque's Conceptual Framework of Access), physical implications, psychological impact (Generalized Anxiety Disorder scale and Patient health questionnaire), and quality of life (Kidney disease quality of life 36 scales). Statistical Package for the Social Sciences (SPSS) version 26 was used for data analysis.

RESULTS

This study involved 316 participants, with an average age of 47.14 and 63.9% being males. After the war, 74.7% reported being unemployed. 30.1% of participants had to flee their homes, and 18.7% had a renal ailment limiting their travel. Among the components of healthcare access affordability, it received the lowest score (5.6 out of 10). More than half of the participants were unable to maintain their regular hemodialysis sessions (56.9%) throughout the war, and 65.2% of the participants developed medical complications as a result. The GAD assessment showed 62.7% of participants had significant anxiety symptoms, while 40.5% had significant depression symptoms.

CONCLUSION

Hemodialysis patients' suffering has increased as a result of the war. Hemodialysis patients experience severe mental health problems in addition to physiological problems, including depression and anxiety, as a result of internal displacement and their inability to continue regular hemodialysis sessions. The study advocates for the implementation of a permanent ceasefire in conflict zones to ensure the delivery of critical humanitarian medical aid, particularly hemodialysis care. The study encourages stronger advocacy for hemodialysis in war-torn areas as well as collaboration with international organizations to provide such specialized care. Finally, it encourages the use of telemedicine services as a backup plan to provide continuous hemodialysis consultation and care in the event of conflict disruptions.

Exploring barriers to accessing health care services by young women in rural settings: a qualitative study in Australia, Canada, and Sweden

BACKGROUND

The aim of this study is to explore young rural women's perceived barriers in accessing healthcare services with a focus on the interrelation between three marginalization criteria: age (youth), gender (female), and place of residence (rural areas) in Australia, Canada, and Sweden.

METHODS

Using a qualitative interpretive approach, we conducted semi-structured in-depth interviews with 31 young women aged 18 to 24 in selected rural communities. Data collection took place from May 2019 to January 2021, and the qualitative data were analyzed using NVivo software.

RESULTS

Self-perceived barriers for access to healthcare services among young women living in rural and remote areas encompass various challenges across individual, institutional, and structural levels. Individual barriers include limited knowledge about available health services, negative attitudes toward healthcare, psychological discomfort when seeking assistance, and economic affordability issues. Institutional challenges involve limited healthcare resources, gender insensitivity among providers, judgmental attitudes from healthcare staff, inadequate time management of services, and a lack of privacy and confidentiality within facilities. Structural barriers further compound these issues through socio-cultural and gender norms, insufficient coverage of universal health insurance, low budget allocations for health facilities in rural and small urban areas, and the geographic distance to healthcare providers. Addressing these multifaceted barriers is crucial to improving healthcare access for rural population.

CONCLUSIONS

Appropriate strategies and policies must be introduced to promote access to healthcare services in rural and remote areas even in most high-`income countries.

Migrant women's perception toward cervical and breast cancer screening in Türkiye: a qualitative analysis

INTRODUCTION

This study aims to investigate the knowledge, attitudes, and behaviors of Syrian migrant women regarding breast and cervical cancer screenings in the Sultanbeyli district of Istanbul.

METHODS

The women were recruited from Extended Migrant Health Centre, which is a primary health care institution in Istanbul. In August 2024, face-to-face interviews were conducted using an open-ended, semi-structured question form administered by a nurse experienced in qualitative research. Sociodemographic information, their thoughts on cancer, information on the types of cancers screened and sources of information, their participation in cancer screenings, and their perspectives on cancer screenings were asked.

RESULTS

In depth interviews were conducted with 40 migrant women. Four main themes and thirteen sub-themes were identified. These themes include "Opinions about the cancers and information about the cancer screenings" "Attitudes about the cancer screening program" "Perspectives on preventive measures against cancers" and "Problems in access to health services". Women mostly described cancer as a serious, incurable, and fatal disease. Despite this perception, almost half of the participants had not attended cancer screening programs. The majority said they did not undergo screening because they had no symptoms. The other main barriers for participation included lack of knowledge, fear of receiving a negative result, or fear of the procedures involved.

CONCLUSIONS

Based on this study, migrant women have low level of attendance to breast and cervical cancer screening programs. Besides, they lack adequate information about breast cancer and cervical cancer, the screening protocols and preventive measuremets.

Exploring the barriers to cervical screening and perspectives on new self-sampling methods amongst under-served groups

BACKGROUND

Cervical screening rates have fallen in recent years in the UK, representing a health inequity for some under-served groups. Self-sampling alternatives to cervical screening may be useful where certain barriers prohibit access to routine cervical screening. However, there is limited evidence on whether self-sampling methods address known barriers to cervical screening and subsequently increase uptake amongst under-screened groups. Addressing this research gap, the study aims to understand experiences during and barriers to attending cervical screening for under-screened groups and; explore the views of individuals eligible for screening towards self-sampling (vaginal swabbing and urine sampling) as alternative screening methods and how this may address existing barriers to screening.

METHODS

We draw on three integrated theoretical frameworks (access to primary care services, intersectional and feminist perspectives) to examine participants' barriers to screening and views toward self-sampling methods. We undertook primary qualitative data collection (interviews and focus groups) with 46 participants, facilitated by collaborations with the VCSE sector which successfully enhanced reach to under-served communities.

RESULTS

Known barriers to cervical screening persist for under-screened participant groups, but we also find numerous examples of good practice where some participants' needs were met throughout the screening process. Both positive and negative experiences tend to centre around experiences with healthcare professionals, with negative experiences also centring around the use of the speculum. Self-sampling methods (vaginal swab and urine collection) were positively received by participants, and may address some existing barriers through the proponents of enhanced choice - between method and location (which also dovetailed with convenience) leading to greater empowerment. The removal of the speculum and lack of invasive examination by a healthcare professional was also positively received.

CONCLUSIONS

Whilst barriers to cervical screening remain for under-served groups, examples of good practice are prevalent. Such examples should be implemented more widely to ensure consistency in patient experience and to ensure needs are better met for under-served groups. The introduction of self-sampling alongside traditional methods may reduce barriers to screening, and may boost screening rates for under-screened groups but only if they are implemented with appropriate information and sufficient communication. Failure to implement self-sampling without these considerations may threaten to undermine the identified and important benefits of self-sampling methods.

Building knowledge to improve access to inclusive and equitable care for trans and gender-diverse survivors of sexual assault and intimate partner violence: a qualitative research protocol

INTRODUCTION

Intimate partner violence (IPV) and sexual assault are pervasive public health and human rights concerns that disproportionately impact trans and gender-diverse (TGD) individuals. Experiences of cisgenderism and transphobia, compounded by racism and other forms of discrimination and structural violence, can hinder access to appropriate supports in a safe and non-stigmatising environment across a variety of sectors, including but not limited to healthcare, social services, criminal justice, and legal. TGD individuals may also have unique health and social needs requiring support that is not yet in place. Recent research has identified the need to better understand barriers to accessing support for TGD survivors of IPV and sexual assault as a top priority. This study aims to address this need for evidence to facilitate improved access to inclusive and equitable services for TGD survivors.

METHODS AND ANALYSIS

This qualitative study will involve semi-structured interviews with approximately 60 adult TGD survivors of IPV and/or sexual assault who wanted to access, attempted to access, or used services. A diverse array of participants from across Canada will be recruited via purposeful and snowball sampling through partner organisations, Peer Leader Advisors and their networks, as well as promotion in physical and virtual spaces (eg, flyers and social media). An interview guide was developed based on Levesque's access to care model. Virtual interviews will be thematically analysed using Braun and Clarke's iterative phases of reflexive thematic analysis. An intersectionality lens will be applied throughout the research process.

ETHICS AND DISSEMINATION

Research Ethics Board approval was obtained from Women's College Hospital (WCH REB #: 2023-0033-E). Findings will be shared in peer-reviewed publications, at academic conferences, and through the burgeoning trans-LINK Canada Network WebPortal (https://www.translinknetwork.com/) using a variety of media, including newsletters, infographics, and webinars.

Structural barriers and facilitators to accessing HIV services for marginalized working populations: insights from farm workers in South Africa

Farm workers are vulnerable working populations who face significant inequalities in accessing health services, including those for human immunodeficiency virus (HIV) prevention, treatment and care. This descriptive phenomenological study aimed to explore farm workers' experiences when accessing HIV services and was conducted in Limpopo province, South Africa. Eighteen in-depth interviews were conducted in four health facilities from two districts, and two focus group discussions were conducted in one of the farms within the province. Purposive sampling and systematic random sampling were used to select study participants. A deductive thematic approach was used to analyse data, informed by the social-ecological model of health. The results reveal that farm workers perceive multiple interdependent factors that inhibit or enable their access to HIV healthcare services. Key barriers to HIV healthcare were transport affordability, health worker attitudes, stigma and discrimination, models of HIV healthcare delivery, geographic location of health facilities and difficult working conditions. Key facilitators to HIV healthcare included the availability of mobile health services, the presence of community health workers and a supportive work environment. The findings suggest disparities in farm workers' access to HIV services, with work being the main determinant of access. We, therefore, recommend a review of HIV policies and programmes for the agricultural sector and models of HIV healthcare delivery that address the unique needs of farm workers.

Impact of a Virtual Care Navigation Service on Member-Reported Outcomes Among Lesbian, Gay, Bisexual, Transgender, and Queer Populations: Case Study

Background

While the significance of care navigation in facilitating access to health care within the lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) communities has been acknowledged, there is limited research examining how care navigation influences an individual's ability to understand and access the care they need in real-world settings. By analyzing private sector data, we can bridge the gap between theoretical research findings and practical applications, ultimately informing both business strategies and public policy with evidence grounded in real-world efficacy.

Objective

The objective of this study was to evaluate the impact of specialized virtual care navigation services on LGBTQ+ individuals' ability to comprehend and access necessary care within a national cohort of commercially insured members.

Methods

This case study is based on the experience of commercially insured members, aged 18 or older, who used the LGBTQ+ Health Care Navigation (LGBTQ+ Navigation) service by Included Health between January 26 and July 31, 2023. Care coordinators assisted members by connecting them with vetted identity-affirming in-network providers, helping them navigate and understand their LGBTQ+ health benefits, and providing education and advocacy for clinical and nonclinical needs. We examined the impact of navigation on 5 member-reported outcomes. In addition to reporting the proportion who agreed or strongly agreed, we calculated an impact score that averaged assigned numerical values to all 5 question responses (1=strongly disagree to 5=strongly agree) for each respondent. We used ANOVA with Tukey post hoc tests and t tests to explore the relationships between the impact score and member characteristics, including optional self-reported demographics.

Results

Out of 4703 LGBTQ+ Navigation cases, 7.53% (n=354) had member-reported outcomes. A large majority of LGBTQ+ members agreed or strongly agreed that care navigation resulted in less stress (315/354, 89%), less care avoidance (305/354, 86.2%), higher confidence in finding an identity-affirming provider (327/354, 92.4%), improved ability to comprehend health care information (312/354, 88.1%), and improved ability to engage with providers (308/354, 87%). The average impact score was 4.44 (SD 0.69), with statistically significant differences by gender identity (P=.003), race (P=.01), ethnicity (P=.008), and pronouns (P=.02). The scores were highest for members with multiple gender identities (mean 4.56, SD 0.37), and members who did not provide their race, ethnicity, or their pronouns (mean 4.55, SD 0.64). Impact scores were lowest for transgender members (mean 4.11, SD 0.95).

Conclusions

The LGBTQ+ Navigation service, by enhancing members' comprehension and use of necessary care, demonstrates potential public health utility and value. Continuous evaluation of navigation services can serve as a supplementary tool for employers seeking to promote health equity and improve belonging among employees. This is particularly important as discrimination and stigma against LGBTQ+ communities persist in the United States. Therefore, scalable and system-level changes that use navigation services are essential to reach a larger proportion of the LGBTQ+ population.

Development and pilot testing of INTERVENER, a web-based tool to match barriers to the cancer continuum organization to evidence-based interventions

BACKGROUND

Barriers to the cancer continuum organization and interventions to approach them have been identified; however, there is a lack of a tool matching them. Our aim was to develop a web-based tool to identify the main barriers to the process of the cancer continuum organization, and propose matched evidence-based interventions (EBI) to overcome them.

METHODS

A questionnaire on barriers at six steps of the process of the cancer continuum organization was answered by collaborators. Each question included several options of barriers to be ranked. Barriers were organized in a framework based on the Tanahashi conceptual model, and were categorized in these dimensions: availability of services, accessibility, affordability, acceptability, user-provider interaction, governance, protocols and guidelines, information system, and quality assurance. Systematic searches were conducted on interventions for breast, cervical and colorectal cancer. Interventions were matched with the barriers they helped to overcome, and were classified in one of these groups for each barrier and cancer site: EBI as a single strategy, EBI within a multicomponent strategy, limited-evidence interventions, and macro level approaches. Barriers and interventions were matched on a web-based tool named INTERVENER, that allows the selection of up to 3 barriers for each step. It displays the visual representation of the selected barriers, the size of each dimension being proportional with the importance of that dimension as a barrier. Experts on different aspects of screening and cancer sites provided feedback on the tool. Collaborators from 41 countries worldwide tested it.

RESULTS

The tool matched 81 barriers with over 60 interventions. Collaborators reported the webpage to be organized logically (N = 17, 94%) and clearly formatted (N = 15, 83%). The tool was found useful for conducting a situational analysis of the barriers to cancer screening (N = 16, 89%), facilitating discussion with stakeholders on prioritization of interventions (N = 15, 83%), and planning their implementation (N = 15, 83%).

CONCLUSION

This tool supports countries in conducting a systematic assessment of barriers, including their prioritization, and identifying EBI to overcome them, ultimately facilitating reduction of health inequalities. This tool can support governments, policymakers, managers, and healthcare providers to make better informed decisions to improve their cancer screening programmes.

Model to explain dental visit for children aged 0 to 5: Scoping review of birth cohorts

INTRODUCTION

Health services accessibility is a multidimensional concept. An early-life dental visit could improve child dental health. Through birth cohorts, it is possible to identify health conditions and pathways of exposure that occur earlier in life. The aim of this study is to propose a theorical model to explain the use of dental care for children with primary teeth, based on results from birth cohorts.

METHOD

3 databases were queried: PubMed, Embase and Dentistry & Oral Sciences Source. Eligible articles presented data on children's dental visits, with at least one follow-up visit between birth and the child's 6th birthday and based on birth cohorts.

RESULTS

We identified 649 articles in biomedical literature databases. After exclusions, we read 136 abstracts, and finally 36 articles in their full length. A total of 22 articles were included in the analysis, from 15 countries on 5 continents. The mains proximal factors for access to dental care for preschool children are related to caregivers' perception of children's oral health and its impacts on quality of life. These perceptions are influenced by the child's oral health, the child's and mother's use of healthcare, and the healthcare organization. Dental fear seems to be another proximal factor. However, family social background seems to be an enabling moderator for dental visits.

CONCLUSION

The scoping review allowed us to develop a model that explains dental visits for children aged 0-5 years as a multifactorial process influenced by caregivers' perceptions of the child's oral health, the family's quality of life, and the child's dental anxiety.

Patients' Use of e-Consultations as an Alternative to Other General Practitioner Services: Cross-Sectional Survey Study

BACKGROUND

e-Consultations, defined as asynchronous text-based messaging, have transformed how patients interact with their general practitioner (GP). While e-consultations can improve patient access to GP care, concerns about increased workload for GPs are raised.

OBJECTIVE

This study aimed to address three research questions: (1) For what purpose and with what expectations do patients initiate e-consultations? (2) If e-consultations had not been available, what alternative actions would the patient have taken? and (3) How are the alternative actions associated with patient and e-consultation characteristics?

METHODS

A cross-sectional study was conducted through a web-based survey on Helsenorge. Helsenorge is the national citizen portal for digital health services in Norway, including e-consultations with the GP. All users who sent e-consultations through Helsenorge were invited to participate between January and February 2023. The survey addressed questions on users' expectations and experience with e-consultations. The association between patient and e-consultation characteristics and alternative actions to e-consultations were analyzed using multinomial logistic regression.

RESULTS

Overall, 13,011 users answered the survey. The most common reason for initiating an e-consultation was requesting a sick certificate (4940/13,011, 38%). Overall, 68.7% (8802/13,011) of respondents expected an answer within 24 hours, and 17.7% (2310/13,011) anticipated that the GP would ask them to attend a physical examination. If e-consultations had not been available, 45.5% (5917/13,011) of respondents would have booked a GP appointment, and 44.9% (5846/13,011) would have called the front desk. Users who expected a quicker response (odds ratio [OR] 1.64, 95% CI 1.46-1.85) and were less concerned about their health issues (OR 1.29, 95% CI 1.18-1.40) were more likely to call the front desk. Only 2.5% (323/13,011) of respondents would have contacted out-of-hours services. Users with longer travel time to the GP office (OR 6.08, 95% CI 3.46-10.66) and with a new health problem (OR 2.71, 95% CI 2.09-3.51) were more likely to choose this option. In addition, 4.7% (609/13,011) of the users would not have sought help if e-consultations had not been available. Younger patients (OR 2.16, 95% CI 1.38-3.37) and those with a longer travel time to the GP office (OR 2.19, 95% CI 1.27-3.80) or a new health issue (OR 1.74, 95% CI 1.43-2.12) had higher odds for not seeking help.

CONCLUSIONS

e-Consultations were often the patients' first choice of access route, and users expected a fast response. e-Consultations were mostly perceived as an alternative to GP appointments or calling the front desk. Patients with lower availability to the GP office had higher odds of using e-consultations as an alternative to out-of-hours service or waiting and not seeking GP care. Guidance for patient use should be developed to ensure appropriate and safe use. Further research should assess the effect of e-consultations on health outcomes and efficiency.

Innovations that helped with accessing and delivering primary care for infants and young children during COVID-19

BACKGROUND

For children under age six, regular preventative primary care is needed for administration of vaccinations, surveillance of development, and early diagnosis and intervention for any potential health conditions or developmental delays. The COVID-19 pandemic created many barriers to providing and accessing primary care. While many studies have explored these barriers, it is important to understand how primary care adapted to ensure these crucial early-years appointments were not missed throughout the pandemic. The objective of this study, therefore, was to discover innovative programs or services that were used, and suggestions for programs or services that could have been implemented, to facilitate delivery of, and access to, primary care for young children during the COVID-19 pandemic (March 2020-May 2023).

METHODS

This qualitative descriptive study used a survey and semi-structured interviews to discuss primary care programs or services with parents or caregivers of children who were under the age of 6 during the pandemic and with primary care providers who deliver care to young children. The survey was sent to parent groups and primary care providers across the Canadian provinces of Ontario and Quebec from May to October 2023. Survey participants who indicated interest in further participation were subsequently contacted for an interview. Results were analyzed using content and thematic analyses.

RESULTS

102 individuals (33 primary care providers and 69 parents or caregivers) responded to the survey and of those, 19 participated in the interviews. Six themes emerged from the innovative services or procedures that were discussed: Prioritization of young children; Creation or modification of primary care spaces; Clear decision-making guidelines; Virtual care integration; Proactive communication; and Interdisciplinary collaboration.

CONCLUSIONS

This qualitative study explored some creative and positive solutions to the struggle of providing and accessing primary care for young children during the COVID-19 pandemic. The results from this research highlight the importance of flexibility and innovation within the primary care system, especially under circumstances of sudden and unexpected increases in barriers to providing and accessing care. On-going development of innovations that improve communication, take a more collaborative approach, and adapt systems, spaces, and methods will improve primary care access and delivery.

CLINICAL TRIAL NUMBER

Not applicable.

Population-based cancer screening access needs of disabled people: A qualitative evidence synthesis

BACKGROUND

Cancer is one of the most common causes of mortality among disabled people, and population-based screening is an effective method to identify some cancers early; however, its uptake is lower among the disabled population. There is a lack of evidence regarding why they access less, and their need to access population-based screening programmes.

AIM

To synthesise evidence of the experience of accessing population-based screening programmes for disabled people.

METHOD

A qualitative evidence synthesis (QES) was carried out by searching electronic databases including Medline, CINAHL, Web of Science Core Collection, and Scopus. Grey literature was also searched for. The search yielded 32 relevant publications.

RESULTS

The findings are based on Levesque's conceptual framework. Several factors affect the accessibility of screening services, including people's perceptions, family support, affordability, literacy, and accessibility.

CONCLUSION

Screening services need to acknowledge the needs of disabled people and integrate reasonable accommodations to facilitate their needs.

Determinants of health seeking behaviour in South Sudan: a cross-sectional household survey

BACKGROUND

Access to healthcare is a major challenge in South Sudan, but evidence on the factors influencing health seeking behaviour (HSB) and the magnitude of their effect is limited. This study aims to identify which determinants are associated with seeking care for perceived health needs and with seeking care at private or public healthcare facilities in South Sudan.

METHODS

A cross-sectional household survey was conducted in three purposefully-selected states (Central Equatoria, Western Equatoria and Warrap). A multi-stage, cluster sampling design was used. Univariable and multivariable logistic regression models were computed to explore the relationships between seeking care for perceived health needs and choice of facility, and individual and household characteristics based on an adapted Levesque framework.

RESULTS

We identified that individuals who obtained medication (OR 2.45, 95% CI 1.15-5.23), obtained and paid for medication (OR 4.26, 95% CI 2.08-8.74), lived in Western-Equatoria (OR 9.05, 95% CI 2.35-34.54), and were aware of community health workers (CHWs) (OR 1.70, 95% CI 1.08-2.67), were significantly more likely to seek care for a perceived health need. Individuals who obtained and paid for medication (OR 3.03, 95% CI 1.59-5.81) and who lived further from a public health centre (OR 1.19, 95% CI 1.09-1.31) were more likely to seek care at a private facility, while individuals who had used the provider before (OR 0.52, 95% CI 0.34-0.78), lived in Western Equatoria (OR 0.24, 95% CI 0.13-0.46), lived in a rural household (OR 0.40, 95% CI 0.23-0.70) and had a longer travel time to the visited health facility, were less likely to seek care at a private facility.

CONCLUSIONS

Survey respondents' state of residence and awareness of CHWs were associated with health seeking, while their state of residence, age, whether they paid for medication or not, travel time and distance to facilities were associated with choice of facility. Our results suggest differences in patterns of HSB between states, but studies with larger sample sizes are needed to analyse this. Furthermore, qualitative studies into access to healthcare in South Sudan could help characterise the nature of determinants and their relationship.

Demographic and clinical impact on preoperative BREAST-Q ePROM completion and baseline outcomes in women undergoing breast cancer surgery: a quantitative descriptive study at a Danish university hospital

OBJECTIVES

This study aimed to investigate patients' use of electronic Patient-Reported Outcome Measures (ePROMs) and understand the demographic and clinical factors that may be correlated with patient responses to the BREAST-Q at the preoperative stage of breast cancer. The BREAST-Q is a PROM in questionnaire format, developed and validated to assess satisfaction and quality of life for breast surgery patients.The hypothesis tested is that considering disparities in geography, age and education among responders is essential for capturing a diverse patient population in future Patent-Reported Outcome Measures initiatives, examining how these characteristics are associated with Patent-Reported Outcome Measures utilisation and outcomes.

DESIGN

Quantitative descriptive study.

SETTING

Electronic Patient-Reported Outcome Measures were collected between 6 September 2021 and 5 September 2022 from patients recruited from an outpatient clinic at a Plastic- and Breast Surgery Department at a University Hospital in Denmark.

PARTICIPANTS

Participants include a total of 629 Danish-speaking women diagnosed with breast cancer and scheduled for breast cancer surgery, with a final participation rate of 468.

INTERVENTION

Preoperative ePROMs and demographic data were collected between September 2020 and 2021 through patients' secure national digital post-box.

MAIN OUTCOME MEASURES

Demographic variables of both responders and non-responders were assessed using t-tests, Mann-Whitney U tests and χ2 tests. Linear regression models were employed to determine the demographic variables associated with BREAST-Q subscale scores.

RESULTS

The response rate for ePROMs was 72.5% with a median age of responders at 62 years. Older patients reported lower breast satisfaction (unadjusted coefficient bu=-0.26 (95% CI -0.44; -0.07), p=0.006) but better physical well-being (adjusted coefficient ba=0.23 (0.08; 0.37), p<0.001). Lower educational achievement was correlated with reduced breast satisfaction and psychosocial and sexual well-being; for example, patients with a master's/doctoral level education scored 14.29 points higher in psychosocial well-being (95% CI 6.50; 22.07, p<0.001) compared with those with lower secondary education. Cohabiting patients reported psychosocial well-being scores approximately four points higher than those living alone (ba=3.91 (0.06; 7.75), p=0.046). Body mass index (BMI) was negatively associated with sexual well-being, with a 0.75-point decline per additional BMI point (ba=-0.75, (-1.12; -0.37), p<0.001).

CONCLUSIONS

The present study demonstrates a positive attitude towards completing BREAST-Q as ePROMs among women diagnosed with breast cancer in the investigated region in Denmark. However, completion rates for ePROMs varied by demographic factors such as age, marital status and access to healthcare. Younger, more educated, married patients with lower BMI who lived near major cities were more likely to report better pretreatment outcomes.

'The lights are on, and the doors are always open': a qualitative study to understand challenges underlying the need for emergency care in people experiencing homelessness in rural and coastal North East England

Introduction

People experiencing homelessness have high rates of emergency care attendance compared with the general population. This study explores the factors underlying the need for emergency care services among people experiencing homelessness in rural and coastal areas of North East England.

Methods

The study was conducted in Northumberland and North Tyneside (North East England). One-to-one semistructured interviews were conducted with people experiencing homelessness. Interviews and focus groups were undertaken with frontline staff from housing associations, police, ambulance services, emergency care, primary healthcare, mental health services and alcohol and drug recovery services. Discussions centred on emergency care experiences, reasons for access and underlying health and social needs.

Results

Participants included 20 people experiencing homelessness (aged 18-56, 70% male) and 18 service professionals (aged 20-56, 56% female). Emergency care was often viewed by participants as an accessible safe place. Four key themes were found in this rural and coastal context: accessibility challenges due to limited public transport and geographic isolation; fragmented support exacerbated by widely dispersed services; service restrictions and limited alternatives having particular impact where options are few and prioritisation of immediate needs influenced by limited local resources.

Conclusion

Challenges in accessing primary healthcare and social care, alongside varying levels of timely support and understanding of individual contexts, can contribute to the increased use of emergency care for people experiencing homelessness in rural and coastal areas. Integrating services with a focus on flexibility could be crucial for addressing the needs of these populations. This involves adapting to the unique circumstances of multiple deprived groups who lack access to community support.

Patient Factors Associated with Access to Outpatient Pediatric General Surgical Care in a Rural State

BACKGROUND

We sought to understand factors impacting timely access to outpatient pediatric general surgical care in a largely rural state.

METHODS

We conducted a multi-site retrospective cohort study, evaluating patients <18 years referred for outpatient pediatric general surgical evaluation from 11/1/2017-7/31/2022. Outcomes included obtaining an appointment, completing an appointment, and undergoing an operation. Time to appointment and operation were calculated. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between patient factors and the primary outcomes, as well as delay to appointment.

RESULTS

Of 5270 patients, mean age was 7.1 years (SD = 6) with 59% male. All patients obtained an appointment; 85% (n = 4498) completed an appointment within one year. Forty percent (n = 2092) underwent an operation. Mean times from referral to appointment and operation were 22.5 (SD = 33.4) and 81.5 days (SD = 137.5), respectively. Patients who identified as African American/Black (OR = 1.94, p < 0.001), had self-pay (OR = 6.33, p < 0.001), or lived >100 miles away (OR = 1.55, p < 0.001) were more likely to not complete appointments. Patients with high household income (OR = 0.70, p = 0.009) and private insurance (OR = 0.60, p < 0.001) were less likely to not complete appointments. Delay to appointment was associated with race (p = 0.020). Patients with private insurance (p < 0.001) and higher income (p = 0.020) were more likely to undergo operation.

CONCLUSION

Fifteen percent of patients referred for outpatient pediatric general surgical evaluation did not complete an appointment within one year. Race, household resources, insurance, and travel distance were associated with completing appointments. Information about groups that have disparate access to care will inform interventions to improve this access.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE

III.

Advancing Antenatal Care in Ethiopia: The Impact of Tele-Ultrasound on Antenatal Ultrasound Access in Rural Ethiopia

Introduction: Access to antenatal ultrasound is limited in low-income countries such as Ethiopia. Virtual care platforms that facilitate supervision and mentoring for ultrasound scanning may improve patient access by facilitating task-sharing of antenatal ultrasound with midlevel providers. The purpose of this study was to assess the feasibility of a large volume tele-ultrasound program in Ethiopia, its impact on antenatal care (ANC) and patient access, and its sustainability as it transitioned from a pilot project to a continuing clinical program. Methods: Health care providers at two health centers in the North Shoa Zone, Ethiopia, performed antenatal tele-ultrasound exams with remote guidance from obstetricians located in urban areas. Data regarding ANC and ultrasound utilization, participant travel, ultrasound findings, specialist referrals, and participant experience were collected through a mobile app. Results: Between November 2020 and December 2023, 7,297 tele-ultrasound exams were performed. Of these, 489 tele-ultrasound exams were performed during the period of data collection from October to December 2022. The availability of tele-ultrasound at the two health centers significantly reduced participant travel distance (4.2 km vs. 10.2 km; p < 0.01; one-way distance). Most participants (99.2%) indicated the tele-ultrasound service was very important or important, with high levels of satisfaction. Clinically significant findings were identified in 26 cases (5.3%), leading to necessary referrals. Conclusion: This study demonstrated the feasibility of a large volume tele-ultrasound program in Ethiopia, its impact on improving the quality of ANC, and its sustainability. These findings lay a foundation upon which low-income countries can develop tele-ultrasound programs to improve antenatal ultrasound access.

Transforming Occupational Therapy for the 21st Century PAIRE: Recognize Privilege, Acknowledge Injustice, and Reframe Perspective to Reach Equity

Theories, models, and frameworks provide the foundation for occupational therapy education, research, and clinical practice. While most have a systems approach focus, other factors, such as societal influences and structural inequities, also contribute to health. Using a cross-sectional design, this study identified the gaps in occupational therapy models of practice and presents a novel approach, the PAIRE (Recognize Privilege, Acknowledge Injustice, and Reframe Perspective to Reach Equity) Model. PAIRE is focused on achieving occupational equity through the reciprocal and intersectional impact of the provider/team, the person/people seeking occupational therapy, and the occupation-in-context, with continuous influences of access, context, and justice. We describe the components of PAIRE and illustrate its functionality in education, research, and clinical practice contexts as well as case examples.

Exploring access to community neurorehabilitation for people with progressive neurological conditions: a qualitative study

PURPOSE

Community neurorehabilitation enables people with progressive neurological conditions (PNCs) to manage their symptoms to live an active, fulfilling life; however, it is not accessible to all. This study explored the factors influencing access to community neurorehabilitation in Northern Ireland from the perspective of people with PNCs and their carers.

METHODS

Eleven people living with a PNC and three carers took part in virtual focus groups. Data was thematically analysed using the framework method.

RESULTS

Access to neurorehabilitation was described as a staged journey, driven by people with PNCs, and impacted by interactions with others. Four themes were identified: the person in the driving seat, describing the value of person-centred care and the need for proactivity; the traffic lights, depicting the role and influence of health care professionals (HCPs); the need for direction; and roadworks and roadblocks, identifying additional barriers to access. In addition, six fundamentals of good access were identified.

CONCLUSIONS

This study adds depth to our understanding of the complexity, and the roles and needs of people with PNCs and HCPs, in accessing community neurorehabilitation. Further research is needed to determine how best to empower people to access rehabilitation.

Strengthening implementation of integrated care for small and nutritionally at-risk infants under six months and their mothers: Pre-trial feasibility study

An integrated care pathway to manage small and nutritionally at-risk infants under 6 months (u6m) and their mothers (MAMI Care Pathway) is consistent with 2023 WHO malnutrition guidelines and is being tested in a randomised controlled trial (RCT) in Ethiopia. To optimise trial implementation, we investigated contextual fit with key local stakeholders. We used scenario-based interviews with 17 health workers and four district managers to explore perceived feasibility. Eighteen policymakers were also surveyed to explore policy coherence, demand, acceptability, evidence needs, opportunities and risks. The Bowen feasibility framework and an access to health care framework were adapted and applied. Health workers perceived the MAMI Care Pathway as feasible to implement with support to access services and provide care. The approach is acceptable, given consistency with national policies, local protocols and potential to improve routine care quality. Demand for more comprehensive, preventive and person-centred outpatient care was driven by concerns about unmet, hidden and costly care burden for health services and families. Inpatient care only for severe wasting treatment is inaccessible and unacceptable. Support for routine and expanded components, especially maternal mental health, is needed for successful implementation. Wider contextual factors may affect implementation fidelity and strength. Policymakers cautiously welcomed the approach, which resonates with national commitments, policies and plans but need evidence on how it can work within varied, complex contexts without further system overstretch. A responsive, pragmatic randomised controlled trial will generate the most useful evidence for policymakers. Findings have informed trial preparation and implementation, including a realist evaluation to contextualise outcomes.

Unpacking access barriers through the health providers' lens among the Arab Bedouin population in Israel

The Arab Bedouin ethnic minority is considered one of the most vulnerable populations in Israel due to socio-cultural factors that affect their healthcare utilization patterns. By adopting the intersectionality perspective, this research aims to identify gaps and barriers to Bedouins' healthcare services (HCS) utilization, as perceived by healthcare professionals (HCP) serving this community. A qualitative study was conducted from June 2019 to January 2022, involving in-depth semi-structured interviews with thirty-two HPCs working in hospitals and community health centers/clinics in Bedouin villages and towns in Southern Israel. Reflective Thematic Analysis (RTA) was used to analyze the collected data, and trustworthiness was ensured through audit, reflexivity, and peer debriefing. Findings revealed that healthcare professionals noted gaps that hinder HCS accessibility and utilization. This study found that the intersection of physical, financial, language, health literacy, and gender barriers with issues of trust, stigma, and deep-rooted socio-cultural norms and beliefs affect Bedouin healthcare accessibility. Additionally, Bedouin women are particularly vulnerable subgroups who were impacted differently by these barriers. In conclusion, our research highlights the necessity of targeted interventions to improve healthcare access for Bedouin minority populations, particularly tailoring HCS to the women subgroup within the Bedouin community. Suggested interventions include health literacy-enhancing educational initiatives, addressing medication affordability, and approaches to mitigate cultural and gendered hindrances to HCS. These insights have broader relevance for shaping health policies and strategies that bridge healthcare disparities among global minority populations.

[Barriers to accessing abortion care: an analysis from the perspective of unintended pregnant women-findings from the ELSA study]

INTRODUCTION

Barriers to accessing abortion care can delay access to services, which can lead to delayed abortion and health risks. Barriers include geographical accessibility, confidentiality, waiting times, stigmatization, poor or inaccessible information and the cost of abortion. This article examines barriers to accessing abortion care in Germany. This includes barriers in the availability and accessibility of care services, access to information, costs associated with abortion and organisational barriers.

METHODS

The analyses are based on data from an online cross-sectional survey of 594 women in Germany who had an unwanted pregnancy terminated, which was conducted as part of the ELSA Study in 2021 and 2022.

RESULTS

The findings indicate that access to abortion care in Germany is associated with various barriers for many women. Of the respondents, 80.1% reported at least one barrier to accessing abortion, 65.5% reported more than two barriers and 40.5% reported three or more barriers. In particular, the non-disclosure of the procedure and the associated fear of stigmatisation represented hurdles for many participants.

DISCUSSION AND CONCLUSION

The results of the study underline the need to improve access to safe abortions. Reducing access barriers therefore includes the decriminalisation of abortion, a comprehensive care structure, financial support services, improved information services and the reduction of stigmatisation and discrimination.

Understanding reasons for delay in diagnosis of leprosy in Pakistan: A qualitative study

BACKGROUND

Recent epidemiological data shows significant rates of grade 2 disability at point-of-diagnosis among new leprosy cases in Pakistan. This indicates a feature of extensive diagnostic delay; the disability burden appears unmoving and disproportionate to the falling leprosy incidence rates. Therefore, this study was required to understand reasons for delay in diagnosis and treatment of leprosy.

METHODS

A qualitative design of 7 semi-structured interviews was employed to reveal perceptions and understandings of various leprosy stakeholders in Pakistan, termed "leprosy experts". Subsequent inductive analysis was used to identify themes and subthemes concerned with delay in the diagnosis and treatment of leprosy.

RESULTS

Leprosy experts identified three main areas, or domains, to which delay can be attributed: 1. Awareness and beliefs about leprosy, within the general population, 2. Knowledge and clinical experience of leprosy, among healthcare professionals, 3. Leprosy control program infrastructure, allocation of resources and institutional funding. These domains were each viewed as consequent to the larger theme of 'low-endemicity'. Strong correlations between diagnostic delay and socioeconomic status, gender, geography and health system challenges, were also mentioned, and which intersected the three major themes.

CONCLUSION

Reasons for diagnostic delay are evident in all tiers of the healthcare hierarchy in Pakistan. Thus, an approach at multiple levels is justified, to improve the general awareness of leprosy, education of healthcare professionals, and organizational structuring. Additionally, cultural features relevant to different communities in Pakistan which might be different from other care access frameworks demonstrated a need for further study into the health beliefs of Pakistani patients in a wide range of communities.

Barriers and facilitators for healthcare access among immigrants in Japan: a mixed methods systematic review and meta-synthesis

Background

While Japan provides universal healthcare, immigrants may experience hampered access to healthcare. A comprehensive review of immigrant healthcare access is also lacking. This systematic review aims to examine barriers and facilitators of healthcare access among immigrants in Japan.

Methods

We searched for literature published in English and Japanese until January 9, 2024. Studies were included if they assessed factors influencing any stage of immigrants' healthcare access, such as perceiving needs, seeking, reaching, utilizing healthcare and the consequences of healthcare, as defined by the Levesque framework. We performed a thematic analysis to further identify categories (PROSPERO: CRD42023418554).

Findings

After screening 2791 articles, we identified 67 studies (40 quantitative, 23 qualitative, 4 mixed methods) meeting eligibility criteria. Limited healthcare information led immigrants to seek alternative information sources and affected immigrants' perceived healthcare needs. Longer duration of stay improved access to healthcare information. Cultural and healthcare system differences affected healthcare seeking. Reaching and utilizing healthcare were hindered by heavy workloads, undocumented status, financial hardship, and limited insurance but were facilitated by support from family and friends. The healthcare system was often insufficient to support immigrants' language and cultural needs leading to dissatisfaction and poor compliance.

Interpretation

Findings highlight the critical importance of a multidimensional approach to support immigrants in Japan, ranging from improving healthcare information access to creating immigrant-friendly health systems. More research is needed on the healthcare access among vulnerable immigrants, such as undocumented and low-skilled labor immigrants and children.

Funding

No specific funding source supported this study.

Digging for Literature on Tailoring Cultural Offers With and for Older People From Ethnic Minority Groups: A Scoping Review

Introduction

Social prescribing addresses non-medical issues (e.g., loneliness, financial worries, housing problems) affecting physical and/or mental health. It involves connecting people to external support or services, including 'cultural offers'-events, groups and activities run within or by cultural organisations. Such offers need to be acceptable and accessible to diverse populations if forming part of a social prescription.

Methods

A scoping review was conducted to identify what existing literature, conducted in the United Kingdom, tells us about tailoring cultural offers for older people (aged 60+ years) from ethnic minority groups. Relevant literature was searched for on electronic databases, through Google, via a questionnaire to cultural organisations and by contacting the study's advisory group.

Results

Screening of 906 references-59 of which were read as full documents-resulted in six sources being included in the review. Some cultural activities described within them were run in traditional cultural spaces (e.g., museums, art galleries). Others were held in community centres. Data suggested that attending with others could reduce concerns about belonging. Barriers to engagement included low energy, language, poor confidence, accessing transport and unfamiliarity with a setting and/or activities. Provision of familiar food could help make people feel welcomed.

Conclusions

Reviewed papers showed that consulting with target groups is important to ensure that activities are inclusive and sympathetically delivered. The review also highlighted a paucity of published research on the topic; this means that cultural providers have little evidence to draw on when developing cultural offers for older people from ethnic minority groups.

Quality of care for chronic conditions: identifying specificities of quality aims based on scoping review and Delphi survey

There is a growing need to implement high quality chronic care to address the global burden of chronic conditions. However, to our knowledge, there have been no systematic attempts to define and specify aims for chronic care quality. To address this gap, we conducted a scoping review and Delphi survey to establish and validate comprehensive specifications. The Institute of Medicine's (IOM) quality of care definition and aims were used as the foundation. We purposively selected articles from the scientific (n=48) and grey literature (n=26). We sought papers that acknowledged and unpacked the plurality of quality in chronic care and proposed or utilised frameworks, studied their implementation, or investigated at least two IOM quality care aims and implementation. Articles were analysed both deductively and inductively. The findings were validated through a Delphi survey involving 49 international chronic care experts with varied knowledge of, and experience in, low-and-middle-income countries. Considering the natural history of chronic conditions and the journey of a person with a chronic condition, we defined and identified the aims of chronic care quality. The six IOM aims apply with specific meanings. We identified a seventh aim, continuity, which relates to the issue of chronicity. The group endorsed our specifications and several participants gave contextualised interpretations and concrete examples. Chronic conditions pose specific challenges underscoring the relevance of tailoring quality of care aims. The next steps require a tailored definition and specific aims to improve, measure and assure the quality of chronic care.

From feeling depressed to getting diagnosed: Determinants of a diagnosis of depression after experiencing symptoms

BACKGROUND

Receiving a formal diagnosis for a depressive disorder is a prerequisite for getting treatment, yet the illness inherently complicates care-seeking. Thus, understanding the process from depression symptoms to diagnosis is crucial.

AIMS

This study aims to disentangle (1) risk factors for depression symptoms from (2) facilitators and barriers to receiving a diagnosis after experiencing depression symptoms.

METHOD

We used data from the German Socio-Economic Panel. Within a sample of 40,238 individuals, we investigated factors predicting depression symptoms, assessed with the SF-12 Mental Component Summary score. Additionally, within a subsample of 3,444 individuals with depression symptoms, we analyzed factors associated with receiving a first-ever diagnosis in the subsequent year. These factors included health status, demographics, socioeconomic characteristics, personality traits, and health infrastructure.

RESULTS

Depression symptoms were associated with chronic physical conditions, female gender, middle age, living alone, fewer close friends, being unemployed or not working, lower income, lower agreeableness, conscientiousness, or extraversion, and higher neuroticism. Additionally, poorer overall mental and physical health, female gender, older age, unemployment, and neuroticism were positively associated with receiving a formal diagnosis. Access to general practitioners and psychotherapists was not associated with receiving a formal diagnosis.

CONCLUSIONS

Our results replicated previous research on risk factors for depression symptoms. Moreover, some risk factors for experiencing symptoms (female gender, middle age, unemployment, and higher neuroticism) subsequently also facilitated receiving a formal depression diagnosis. Thus, this study underscores the importance of considering the chronological sequence in the process from depression symptoms to diagnosis.

Accessibility and Quality of Palliative Care-Experience in Primary Health Care

Background and Objectives: Palliative care is a very important part of medicine, aimed at ensuring an improvement in quality of life and a reduction in distressing symptoms in patients with serious, incurable, progressive diseases. The issues of the accessibility and quality of these services should be a focus for health policymakers and researchers, although it is acknowledged that a significant portion of the public has not heard about this service. For this reason, it is important to investigate the experience of the accessibility and quality of palliative care services in primary healthcare facilities. Materials and Methods: A quantitative study was conducted in institutions providing outpatient and inpatient palliative care services. A total of 784 patients and 219 family members participated in the study. Participants expressed their opinions through a questionnaire containing 24 statements, to which they responded by indicating their level of agreement on a Likert scale. The collected data were analyzed using statistical analysis software. Results: Palliative care services are widely available in large cities, but their accessibility is very limited in small towns and rural areas. Patients and their families are not familiar with the concept of palliative care, often equating it with the provision of treatment and nursing services, and they see the support of clergy as unnecessary. Although patients and their families rate the quality of the services received positively, they note shortcomings related to communication among staff. Conclusions: Palliative care services are provided within the primary healthcare system by specialists with qualifications regulated by legislation; however, patients do not see the need to receive assistance from clergy members. Based on the study results, it can be concluded that in Lithuania, the accessibility of palliative care is ensured in larger cities but is insufficient in smaller towns and rural areas. Patients tend to rate indicators reflecting the quality of palliative care services positively; however, they are not convinced that these services improve their quality of life.

Medicaid‑Insured Children with Medical Complexity in a Rural State

OBJECTIVE

To describe children with medical complexity (CMC) in Montana according to their clinical characteristics, rurality, and distance from specialty care, and to assess for disparities in geographic access to specialty care for American Indian children.

METHODS

In this cross-sectional study, we categorized children in 2016-21 Montana Medicaid claims data using the Pediatric Medical Complexity Algorithm and compared the associations of medical complexity and demographic traits using chi-square tests. Using a database of providers, we calculated drive times from children's residences to the nearest pediatric subspecialist and calculated bootstrap confidence intervals for the difference in median driving distances by complexity and race.

RESULTS

Among 126,873 children, 23% lived in rural areas and 20% were reported as American Indian. In all, 10,766 children (8.5%) had complex chronic conditions (children with medical complexity, CMC), and 27,431 (21.6%) had noncomplex chronic conditions. Medical complexity was associated with age, race, ethnicity, sex, Children's Health Insurance Program enrollment, disability, and rurality. CMC had shorter median drive times to care than children with noncomplex medical conditions and children without chronic conditions (28 vs 34 and 43 minutes, 95% confidence intervals of differences 4-9 and 6-11). At each level of medical complexity, the median distance from care was greater for American Indian children than children of other races.

CONCLUSIONS

Although CMC tend to live closer to specialists than other children, many CMC live far from subspecialty care. American Indian children live farther from specialists than other children, regardless of complexity. Future work should support access to care for rural and American Indian CMC.

"Equity" in genomic health policies: a review of policies in the international arena

Introduction

The field of genomics is rapidly evolving and has made significant impact on the diagnosis and understanding of rare and genetic diseases, in guiding precision medicine in cancer treatment, and in providing personalized risk assessment for disease development and treatment responses. However, according to the literature, there is widespread socio economic and racial inequities in the diagnosis, treatment, and in the use of genomic medicine services. This policy review sets out to explore the concept of equity in access to genomic care, the level of inclusion of equity and how it is addressed and what mechanisms are in place to achieve equity in genomic care in the international health policy.

Methods

A systematic search for genomic policies was conducted using 3 databases. In addition, General and Specific Policy Repositories, Global Consortia in Genomic Medicine, WHO Collaborating Centers in Genomics, Australian Genomics, Public Policy Projects, Global Genomic Medicine Consortium (G2MC), G2MC conference Oct 2023 and National Human Genome Research Institute databases were searched using the inclusion and exclusion criteria. Seventeen policies were selected and analyzed using the EquiFrame.

Results

The Core Concept of access is highly cited in most of the selected policies. The CCs that are covered to a lesser degree are participation, quality, coordination of services, cultural responsiveness and non-discrimination. The CCs of liberty and entitlement are not addressed in any of the selected policies. The coverage of vulnerable communities in the policies varies from country to country.

Discussion

Genomic health science is rapidly evolving and presents a major challenge for policies to remain current and effectively address new discoveries in the field. There is a relative dearth of policies that focus on clinical genetic services which may reflect a gap in policy and policy research translation and implementation. Recommendations for countries, irrespective of their economic and social contexts, include conducting regular policy reviews to accommodate the advances in genomics field and inclusion of specific mechanisms to achieve equity in genomic health. Insights and experiences in achieving healthcare equity in HICs and LMICs can offer valuable lessons for each other.

Facilitating oral healthcare for children with disabilities in the Kingdom of Saudi Arabia: a qualitative exploration of the perceptions of parents and professionals

BACKGROUND

Children with disabilities worldwide experience disparities in oral health. Parents and children encounter challenges in accessing quality dental care. Similar challenges are experienced in Saudi Arabia. This study aimed to explore the barriers and facilitators of oral healthcare for children with disabilities in Saudi Arabia.

METHODS

This was an ethnographic study. The sample size was 25 participants, comprising of 12 pediatric dentists and 13 parents of children with disabilities. Data were collected through in-depth interviews, employing a topic guide. A pre-defined analytical framework was developed from the study objectives and framework analysis used to analyse data.

RESULTS

The study identified significant barriers and facilitators to oral healthcare for children with disabilities. Barriers included long travel distances, inadequate clinic facilities, a shortage of specialist pediatric dentists, inefficiencies in referral systems, and financial constraints. Other challenges were related to physical barriers in clinics, cultural norms, and socioeconomic inequalities. Facilitators, though fewer, included personal connections, specialized disability friendly clinics, and the Priority Card Program, albeit with limited effectiveness. Suggestions for improvement highlighted the need for better training for dental professionals, enhanced clinic accessibility, and greater financial support for families.

CONCLUSION

Accessibility of dental care for children with disabilities in Saudi Arabia remains a significant challenge due to systemic barriers and individual-level obstacles. The study underscores the need for policy reforms, enhanced professional training, and the improvement of physical and financial accessibility to dental services. Addressing these issues through comprehensive educational programs and targeted interventions is essential for reducing oral health disparities and improving care for children with disabilities.

Health System Factors Influencing the Integration of Pre-Exposure Prophylaxis into Antenatal and Postnatal Clinic Services in Cape Town, South Africa

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is an effective and safe option to prevent HIV acquisition and vertical HIV transmission in pregnant and breastfeeding women. Understanding health system factors influencing the integration of PrEP into care for pregnant and breastfeeding women is key to increasing access. We explored managers' and health care workers' (HCWs) experiences with integrating PrEP into antenatal care and postnatal care services in primary health care clinics in Cape Town, South Africa.

METHODS

This exploratory qualitative study used codebook thematic analysis, where HCWs were purposively, heterogeneously sampled from an implementation science study. Semistructured individual interviews were conducted with 9 managerial-level staff, and 3 focus group discussions were conducted with HCWs (nurses, midwives, and HIV counselors) providing PrEP (6-7 HCWs per group) between November 2022 and January 2023 (N=28). Interview guides covered health system facilitators, barriers, and recommendations. The Health Systems Dynamics framework guided data analysis and presentation of results.

RESULTS

PrEP integration into antenatal care services was described as acceptable and feasible; however, changes to HIV testing policy and indicators in breastfeeding women are needed to integrate PrEP into postnatal clinics, together with identification of mother and baby as a dyad in visits. Results showed that supportive policies facilitated wider, simplified PrEP provision. The availability and accessibility of prescribing nurses and lay HIV counselors, PrEP (both within facilities and in communities), and information about PrEP for implementers and pregnant and breastfeeding women will be pivotal to facilitating integration.

CONCLUSION

Facilitators for PrEP integration include task-shifting PrEP education and identification of women for PrEP initiation to HIV counselors, changes to national guidelines defining who can prescribe PrEP, revision and integration of PrEP training for HCWs, community-level interventions for PrEP demand creation and stigma reduction, and provision of differentiated PrEP delivery options.

Service Delivery Redesign for Noncommunicable Disease Management: Assessment of Needs and Solutions Through a Co-Creation Process in Argentina

INTRODUCTION

In Argentina, the implementation of a national strategy to reduce the prevalence of noncommunicable diseases (NCDs) has been hampered by challenges at the provincial level. We aimed to design a new model of care for NCDs at the primary care level by conducting a multimodal system assessment and co-design of potential solutions in the province of Mendoza.

METHODS

We carried out a mixed-methods study with 7 components: evaluation of patterns of care, patient focus groups, cross-sectional standardized population-based phone survey, an electronic cohort follow-up of patients with type 2 diabetes, in-depth interviews with stakeholders, a knowledge test for health care providers on chronic condition management, and a Delphi consensus to provide recommendations from stakeholders.

RESULTS

Focus group and in-depth interviews revealed access to primary health care for NCDs was associated with problems with long waiting times and time-consuming procedures for referral to laboratory tests, hospital care, and provision of medication. Mental health care services were particularly limited. Survey respondents (N=1,190) were predominantly covered through public (41%) or social security sectors (54%); 41% fell in the lowest income group. Contact with the health system was high (5.7 annual visits), but 19.7% reported unmet health care needs. Public sector providers perceived they provided high-quality care despite insufficient material and human resources. Within the social security sector, the main challenge was insufficient staff, particularly affecting mental health care. Health care providers showed a higher percentage of correct answers to depression-related questions, but worse results were seen in hypertension and diabetes care. Actions supported by evidence and expert agreement were identified for implementation to guide future system changes.

CONCLUSION

Our research highlights the potential for Argentina's primary care system to initiate transformative, system-level changes aimed at improving health outcomes. We propose an innovative methodological assessment and co-design for improving primary care.

Care providers' view of the barriers in providing care for adolescents with emotional and behavioral problems

Objectives

Emotional and behavioral problems (EBP) during adolescence are a major public health issue due to its high prevalence and long-lasting consequences. The knowledge of the barriers in providing psychosocial care can be a starting point for subsequent efficiency improvement. Therefore, the aim of this study is to assess which barriers do care providers experience while providing psychosocial care for adolescents with EBP.

Methods

We performed a qualitative assessment that was embedded in the Slovak Care4Youth study mapping the system of care provided for adolescents with EBP. We conducted 25 semi-structured individual and group interviews with a total of 49 care providers from 17 institutions that provided preventive counselling, social, and mental healthcare for adolescents with EBP. We focused on the care provider's perception of barriers in providing care for these adolescents. The interviews were audiotaped and transcribed verbatim. We coded the data using the consensual qualitative research approach in combination with conventional content analysis.

Results

We found that care providers experienced several barriers in providing care for adolescents with EBP which relate to six themes-legislative framework and legislative changes; financing of the care system; coordination of care; workforce development, education, methodical guidance and supervision; personnel and institutional capacities; and administrative burden.

Conclusion

Addressing these barriers within the care system from the "front line" perspective provides clues to efficiently improve the psychosocial care for adolescents with EBP. According to the care providers, the organization and financing of the care system requires adaptation; the burden of the care providers should be reduced; and care providers require quality practical education, training, and methodological guidance.

Challenges in accessing health care services for women and girls with disabilities using a humanitarian physical rehabilitation program in Lebanon: a mixed method study

BACKGROUND

Achieving equitable healthcare access for persons with disabilities is vital, as they often face various barriers that impact their health and well-being. Recognizing the importance of gender equity, this study aims to explore the specific barriers faced by women and girls with disabilities in accessing quality healthcare services in Lebanon.

METHODS

A mixed-method sequential explanatory approach was employed. Initially, a retrospective descriptive study analyzed data from the International Committee of the Red Cross (ICRC)-supported physical rehabilitation programme (PRP) database. Subsequently, in-depth interviews were conducted to delve into factors influencing gender-disproportionate service users and to uncover barriers to accessing healthcare. Levesque et al.'s 'Conceptual framework on healthcare access' was used to organize and map the results.

RESULTS

The quantitative analysis of service utilization at ICRC PRP centers from 2015 to 2022 revealed significant gender disparities, with males comprising 66.6% of service users compared to 33.4% females. This trend was consistent across age categories, nationalities, and clinical conditions. Healthcare access for women and girls with disabilities was found to be inadequate across all five dimensions of the Levesque framework: adequacy, accessibility, affordability, appropriateness, and availability, as well as their corresponding abilities. While certain challenges such as transportation, financial constraints, inadequate infrastructure, and limited information on available services were common to both genders, gender-specific barriers primarily included societal norms, safety concerns during unaccompanied visits to healthcare facilities, limited access to societal information, economic disparities, preferences for female healthcare providers, and the need for privacy during consultations.

CONCLUSION

This study underscores key barriers hindering healthcare access for women and girls with disabilities in Lebanon, necessitating tailored interventions. Gender-specific challenges, including societal norms and safety concerns, require targeted solutions for improved access and outcomes. This study serves as a call to action for stakeholders at various levels to collaborate and implement concrete measures to bridge the gap in healthcare access and ensure that no one is left behind.

Parents' and informal caregivers' experiences of accessing childhood vaccination services within the United Kingdom: a systematic scoping review of empirical evidence

BACKGROUND

Despite repeated calls to action and considerable attention, childhood vaccination uptake has declined for a thirteenth consecutive year in the United Kingdom (UK). Increasingly, stakeholders are advocating for research which goes beyond vaccine hesitancy and explores service accessibility in greater depth. This scoping review aims to identify and critically assess how accessibility is being conceptualised and investigated with a view to informing future research. Research, that in turn, will dictate the interventions pursued to improve vaccination coverage.

METHODS

A detailed search strategy was implemented across seven databases to identify research exploring parents' experiences of accessing childhood vaccination services within the UK. The analysis explored the studies in relation to their conceptualisation of access, methodology, reported results, and recommendations for research or practice using a combination of descriptive qualitative content analysis, typologies, and frequency counts. Methods and reporting adhered to the 'JBI Manual for Evidence Synthesis' and the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews'.

RESULTS

Forty-five studies were included in the analysis. Studies claimed to consider only attitudinal constructs (4%) or did not discuss access at all (33%) despite findings, in part, including access related issues. Remaining studies used the term access in passing or ambiguously (24%), distinguished between attitudes and access in-text (27%), and a minority of studies utilised a theoretical framework which acknowledged accessibility (13%). The focus on access to information (92% of studies) was disproportionately large compared to other domains of accessibility such as availability (11%), affordability (13%), and proximity (16%). Of the seven identified intervention studies, five were centred on information provision.

CONCLUSION

Accessibility is poorly conceptualised within most of the research conducted on childhood immunisation uptake within the UK. This, in part, is because exploring accessibility was not an explicit objective of many of the studies included in the review. It is vital that the accessibility of childhood vaccination services is given greater priority and appropriately defined in empirical research. Otherwise, researchers run the risk of limiting the scope of their findings based on their own conceptual ideas regarding the drivers of poor uptake rather than the lived reality of parents.

"When in Rome…": structural determinants impacting healthcare access, health outcomes, and well-being of South Asian older adults in Ontario using a multilingual qualitative approach

With the increase in international migration, the need for an equitable healthcare system in Canada is increasing. The current biomedical model of healthcare is constructed largely in the Eurocentric tradition of medicine, which often disregards the diverse health perspectives of Canada's racialized immigrant older adults. As a result, current healthcare approaches (adopted in the US and Canada) fall short in addressing the health needs of a considerable segment of the population, impeding their ability to access healthcare services. This study aimed to identify and understand the structural and systemic factors that influence healthcare experiences and well-being among South Asian older adults in Ontario, addressing a significant gap in empirical and theoretical knowledge in the Canadian context. We conducted in-depth individual and dyadic interviews (n = 28) utilizing a descriptive multilingual cross-cultural qualitative approach. Through this research, participants expressed that their understanding of well-being does not align with that of their healthcare providers, resulting in unmet health needs. Our study uses an intersectional lens to demonstrate participants' perceptions of virtual access to care and systemic factors, such as mandatory assimilation and whiteness as a taken-for-granted norm impacting the health and well-being of South Asian older adults. The findings of this research can offer valuable insights to healthcare providers and policymakers in developing culturally competent practices, guidelines, and training policies that effectively address the healthcare needs of the South Asian population in Canada.

Factors associated with the uptake and utilisation of diabetic retinopathy screening services in sub-Saharan Africa: A scoping review

INTRODUCTION

Diabetic Retinopathy (DR) is a microvascular complication of chronic Diabetes that can lead to visual impairment if left untreated. While concerted efforts have been made to develop screening modalities to facilitate the early detection of Diabetic Retinopathy in sub-Saharan Africa, little is known about the factors impacting the optimal use of these screening services. This paper aims to identify and highlight factors associated with the access of Diabetic Retinopathy screening services from patient and service provider perspectives.

METHODOLOGY

This scoping review was conducted using the Arksey and O'Malley (2005) framework. A comprehensive search of peer-reviewed articles and grey literature was conducted from May 2023 to June 2023. Electronic databases searched include Medline, Embase, PubMed, CINAHL Complete, APA PsycINFO, Web of Science, and African Journal Online (AJOL). Two reviewers independently screened the retrieved records for eligibility, and relevant data was extracted from the included studies. A descriptive overview of key findings was provided, and the 5As conceptual framework of access to healthcare was used to map the identified factors.

RESULTS

The search strategy yielded 873 records. Of those, 19 studies met the criteria for inclusion. Health literacy and duration of Diabetes were reported in 12 and 9 studies as the most common factors associated with DR screening services access. Similarly, age at onset and inadequate referral by healthcare providers were cited as significant determinants of DR screening access in 7 studies, respectively.

CONCLUSION

The 5As framework of access to healthcare aids our understanding of factors associated with the access of DR screening from patient and service provider standpoints. To address these issues, there is a need for more research on this topic to design effective DR screening services in the region.

How I approach intersectionality in hematopoietic stem cell transplantation

ABSTRACT

In the context of health care, intersectionality refers to a framework that focuses on the ways in which multiple axes of social inequality intersect and compound at the macro and micro levels to produce a broad range of unequal health outcomes. With the aid of tools such as the wheel of power and privilege, this framework can help identify systemic biases hidden in plain sight in the routine diagnostic, therapeutic, and prognostic paradigms used in clinical practice. Hematopoietic stem cell transplantation is a high-cost, highly specialized complex procedure that exemplifies the impact of intersectional identities and systemic biases in health care systems, clinical research, and clinical practice. Examples include the derivation of clinical algorithms for prognosis and risk assessments from data with limited representation of diverse populations in our communities. Transplant clinicians and teams are uniquely positioned to appreciate the concept of intersectionality and to apply it in clinical practice to redress inequities in outcomes in patients with marginalizing social determinants of health. An intersectional approach is the most efficient way to deliver effective and compassionate care for all.

Utilization, Satisfaction, and Clinical Outcomes of People of Color and White Adults Using an Employer-Sponsored Digital Mental Health Platform

Evaluating digital mental health services across racial and ethnic identities is crucial to ensuring health equity. We examined how People of Color (POC) and White adults were using and benefiting from an employer-sponsored digital mental health platform. A sample of 947 adults (42% POC) consented to an observational study and completed surveys on their identities and mental health outcomes at baseline and three-month follow-up. We examined care preferences, utilization, therapeutic alliance with mental health providers, and changes in outcomes among POC and White adults. At baseline, there were no race or ethnicity differences in preferred topics of focus (p = 0.36), rates of depression, anxiety, or loneliness (ps > 0.35), or self-reported well-being or stress (ps > 0.07). POC adults were more likely to prefer one-on-one care than White adults (p = 0.02). After 3 months of care utilization, there were no differences in therapeutic alliance (p = 0.52), use of therapy, coaching, or self-guided digital resources (ps > 0.47), or in the likelihood of improving, recovering, or maintaining clinical symptoms or psychosocial factors (ps > 0.07). Utilization, satisfaction, and clinical effectiveness were similar between POC and White adults, indicating the platform may offer comparable experiences. Evaluating utilization and outcomes among POC communities is necessary to inform consumers and help developers assess if innovations are fostering health equity.

"Youth are experts in what they need": experiences and best practice in co-designing and implementing Fast-PrEP, a novel PrEP service for adolescents and youth in Cape Town, South Africa

Introduction

Defining the prevention needs, motivations, and gender dynamics influencing adolescent and young people's (AYP's) healthcare access is a key component to successful PrEP (pre-exposure prophylaxis for HIV prevention) implementation. WHO encourages a strong people-cantered approach to healthcare delivery, and this is particularly emphasized for HIV services. Enhanced youth engagement is needed to ensure that interventions are tailored to the specific needs and preferences of youth populations.

Description

Fast-PrEP is an implementation science project providing PrEP (oral, vaginal ring, and injectable) to adolescents and young people (15-29 years old) in Cape Town, South Africa. In 2020, during the planning phase of this project, a Youth Reference Group (YRG) was established to guide, co-create, monitor, and evaluate the implementation of PrEP delivery. From March to October 2023, we conducted four focus group discussions with thirty YRG members, and seven interviews with project implementers (including clinical and research staff). This study aimed to explore real-time experiences of young people and staff members and provide recommendations for best practices when setting up and engaging with YRGs.

Findings

Overall, young people described their experience of being involved in the YRG as empowering. Young people felt that their voices and needs were valued when seeing their input put into action or witnessing their designs in demand creation campaigns. Young people felt that being consulted was not for tokenistic reasons, but their contribution was valuable and considered young people's sexual health needs. Best practices included involving the YRG in every aspect of the project design and implementation, being flexible around young people's schedules, and having engagements in spaces that are easily accessible and safe for key populations. Staff recommended upskilling the youth members in knowledge around HIV and certain 'soft skills' such as building self-confidence and communication skills. It was also recommended that all research and clinical staff need ongoing training and sensitization on the importance and value of youth engagement.

Conclusion

The involvement of young people in the co-creation of Fast-PrEP services in all phases of service provision, has been effective in assisting to provide youth appropriate PrEP services.

Financial barriers to primary health care in Aotearoa New Zealand

BACKGROUND

In Aotearoa New Zealand, co-payments to see a general practitioner (GP, family doctor) or collect a prescription are payable by virtually all adults.

OBJECTIVE

To examine the extent to which these user co-payments are a barrier to accessing health care, focussing on inequities for indigenous Māori.

METHODS

Pooled data from sequential waves (years) of the New Zealand Health Survey, 2011/12 to 2018/19 were analysed. Outcomes were self-reported cost barriers to seeing a GP or collecting a prescription in the previous year. Logistic regression was used to estimate odds ratios (ORs) of barriers to care for Māori compared with non-Māori, sequentially adjusting for additional explanatory variables.

RESULTS

Pooled data included 107,231 people, 22,292 (21%) were Māori. Across all years, 22% of Māori (13% non-Māori) experienced a cost barrier to seeing a GP, and 14% of Māori (5% non-Māori) reported a cost barrier to collecting a prescription. The age- and wave-adjusted OR comparing Māori/non-Māori was 1.71 (95% confidence interval [CI]: 1.61, 1.81) for the cost barrier to primary care and 2.97 (95% CI: 2.75, 3.20) for the cost barrier to collecting prescriptions. Sociodemographics accounted for about half the inequity for both outcomes; in a fully adjusted model, age, sex, low income, and poorer underlying health were determinants of both outcomes, and deprivation was additionally associated with the cost barrier to collecting a prescription but not to seeing a GP.

CONCLUSIONS

Māori experience considerable inequity in access to primary health care; evidence supports an urgent need for change to system funding to eliminate financial barriers to care.

Food insecurity is associated with greater difficulty accessing care among people living with HIV with or without comorbid non-communicable diseases in western Kenya

INTRODUCTION

The relationship between food insecurity and access to healthcare in low-resource settings remains unclear. Some studies find that food insecurity is a barrier to accessing care, while others report that food insecurity is associated with a greater need for care, leading to more care utilisation. We use data from the Harambee study in western Kenya to assess the association between food insecurity and difficulty accessing care among people living with HIV (PLWH) with or without comorbid non-communicable diseases (NCDs).

METHODS

The Harambee study is a cluster randomised trial that tested the effectiveness of delivering integrated HIV and NCD care for PLWH. In this cross-sectional analysis, we examined baseline data from Harambee participants to investigate the relationship between household food insecurity and difficulty accessing care, using multivariable logistic regression models, controlling for sociodemographic factors and care satisfaction. We tested for effect measure modification by gender and household wealth and stratified analyses by NCD status.

RESULTS

Among 1039 participants, 11.1% reported difficulty accessing care, and 18.9% and 51.9% of participants had moderate and severe food insecurity, respectively. Among those with difficulty accessing care, 73.9% cited transportation issues as the major barrier. Difficulty accessing care was greater with higher levels of food insecurity: among participants with low, moderate and severe food insecurity, 5.9%, 9.7% and 14.4% reported difficulty accessing care, respectively. After adjusting for confounders, severe food insecurity was independently associated with difficulty accessing care (adjusted OR=2.5, 95% CI 1.4 to 4.4). There was no statistical evidence for effect measure modification by gender or wealth.

CONCLUSIONS

We found that greater food insecurity was associated with greater difficulty accessing care among PLWH with or without NCDs in rural western Kenya. These findings suggest that addressing social determinants of health may be necessary when implementing integrated HIV and NCD care programmes.