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

Bridging the distance: understanding access to healthcare through stories from Gwich'in medical travellers in Northwest Territories

In northern Canada, medical travel - the movement of patients to a larger centre to access healthcare services outside their home community - is a dominant feature of the healthcare system. This qualitative study explored the medical travel experiences of Gwich'in living above the Arctic Circle in the Gwich'in Settlement Area in Northwest Territories (NT). Data collection in 2020 comprised storytelling sessions with 10 Gwich'in medical travellers (6 female, 4 male). Using inductive and deductive methods with continual critical reflexivity, and guided by Gwich'in values, concerns about access to healthcare were found to be at the heart of each story. A broad conceptualisation of access was applied to understand and interpret the results according to six dimensions: accessibility, availability, affordability, adequacy, acceptability, and awareness. Situated within a context of colonialism, structural inequities and other factors relevant across the Circumpolar North, the results suggest that the NT medical travel policy framework provides only partial access to care. This article illustrates a need for healthcare and other government systems to think about policy and programmes in a more wholistic, equitable and relationship-centred way, which would help not only to bridge distances across geography, but also between peoples.

Navigating Mental Health Frontiers: A Scoping Review of Accessibility for Rural LGBTIQA+ Communities

Mental healthcare for LGBTQIA+ populations in rural areas remains unequal, despite societal progress toward inclusivity. This review examines the specific obstacles faced in rural areas, such as limited services, workforce deficiencies, and travel burdens for treatment, which exacerbate existing mental health inequities. By following the Joanna Briggs Institute methodology, an exploration of SCOPUS, EBSCO Host (All), and Ovid databases yielded 2373 articles. After careful screening, 21 articles from five countries were selected, primarily using qualitative interviews and quantitative online surveys. Analysis through the Lévesque framework reveals the complex challenges faced by LGBTQIA+ individuals in rural mental healthcare. Discrepancies in approachability, acceptability, availability, affordability, and appropriateness were identified. Geographical isolation, discrimination, and a lack of LGBTQIA+-attuned professionals further compound these issues. Societal stigma, discrimination, and economic constraints hinder individuals from accessing and engaging in mental health services. This study highlights the need for purposeful interventions to improve rural mental health access for sexual and gender minorities.

Experience of contraceptive care by midwives for nonpostpartum individuals in the Netherlands: A mixed methods study

Since 2015, Dutch midwives have been authorised to prescribe all contraception. Initially providing contraceptive care to postpartum clients, they increasingly offer it to anyone. It remains unknown how this broader population experiences this care. Therefore, this mixed methods study aims to explore experiences of nonpostpartum individuals receiving contraceptive care from Dutch primary care midwives. At 15 practices in the Netherlands, participants were recruited to complete a survey and participate in an in-depth semi-structured interview, both based on Levesque's Conceptual Framework of Access to Health. Univariate and multivariate logistic regression analyses were applied to survey data (n = 91) and thematic analysis to interview data (n = 10). Most survey participants (87.8 %) received an intrauterine device during their appointment. A majority (58.2 %) rated their care a 10 out of 10. Giving full marks was significantly associated with a higher perceived income (adjusted OR = 3.19, 95 % CI = 1.21-8.81, p = 0.021), adjusted for appointment type and time since appointment. Participants reported receiving understandable information, being taken seriously, and having enough time during their appointment. Interviews revealed that participants especially appreciate how midwives make them feel at ease, midwives' expertise, and the convenience of access. To conclude, given the positive experiences reported by nonpostpartum individuals with contraceptive care from midwives, efforts should be made to improve task sharing and to increase awareness of midwives as contraception providers. Future research should compare care experiences across all types of providers (including midwives, general practitioners, abortion doctors, and gynaecologists) amongst a more representative population.

Does access to medicines differ from access to healthcare? Experiences of barriers to medicines access by people facing social disadvantage

BACKGROUND

Levesque et al.'s widely-cited five dimensional model of access to healthcare has been used in a variety of contexts, including access to medicines. However the model is based on healthcare, i.e., facilities where health professionals work. We examined whether there were other important features of access to medicines, not captured by this model.

METHODS

A longitudinal qualitative study was conducted, repeatedly interviewing 21 households about their lives and access to medicines, over the course of a year. Participants were Māori, Pacific, former refugee, or New Zealand Europeans with limited incomes. Analysis was thematic and inductive.

RESULTS

Our participants experienced a number of barriers to accessing medicine, some of which do not fit comfortably within existing models of access to healthcare. For example, communication difficulties with healthcare staff (lack of appropriateness of care), had implications for medicine-taking after participants got home. Confusion about medicines identity, purpose and possible side effects, led to poorer access or under-use of prescribed medicines. Communication problems were particularly acute for former refugee participants. For them, communication in pharmacies was impossible because of lack of interpreters, severely restricting the information they had access to, and increasing the use of other less reliable sources of information. Crime, fear of crime, and the justice system also impacted on access in a variety of ways.

CONCLUSION

Because medicines are portable, physical objects taken at home, the effects of appropriateness of healthcare are played out in the home. Aspects of the wider, non-healthcare environment also impact on access to medicines in unexpected ways.

Exploring network relations between healthcare access and utilisation in individuals with rare diseases

Background

Rare diseases affect fewer than one in 2000 people and impact approximately 400 million individuals globally. High costs, uncoordinated care, and inadequate provider knowledge pose challenges to rare disease care. We aimed to examine the relationship between healthcare access and utilisation among rare disease patients in Switzerland.

Study design

A cross-sectional survey was conducted with 314 individuals with a rare disease.

Methods

Participants completed the Perception of Access to Healthcare Questionnaire (PAHQ) and provided data on healthcare utilisation (institutional and provider levels). Network analysis assessed nodes were based on expected influence (EI), predictability, and bridge centrality (BC).

Results

Four PAHQ subscales (acceptability, availability, adequacy, and awareness) exhibited higher EI and predictability. Conversely, accessibility and affordability of healthcare services had lower EI and predictability scores. In terms of healthcare utilisation, hospitals, private practices, general practictioners (GPs), mental health professionals, and emergency services demonstrated elevated EI and predictability. Specialists and holistic healthcare providers exhibited lower EI and predictability. Affordability, disease course, as well as hospital, and GP utilisation had elevated BC values and emerged as key connectors between access and utilisation.

Conclusion

This study illuminates the intricate dynamics of healthcare experiences for patients with rare diseases. This work validates network analysis as a valuable tool for examining healthcare systems. Findings can inform policies that address challenges faced by this vulnerable population, namely care integration for individuals with an unstable disease course.

Inclusive healthcare for people with intellectual disabilities: The impact of labelling and biomedical causal beliefs

BACKGROUND

People with intellectual disabilities often face inequalities in healthcare, including a lack of sensitivity on the part of healthcare professionals who are less able to identify and recognise these people's health needs despite the desire to make healthcare accessible.

AIMS

This study examined the links between variables related to intellectual disability literacy and variables related to stigma which may be related to healthcare professionals' sensitivity to the health needs of people with intellectual disabilities.

METHOD AND PROCEDURE

An online cross-sectional survey was conducted with 163 healthcare professionals. Participants were randomly assigned to one of the following vignettes, with two presentation conditions (labelled or unlabelled) and two gender conditions (male or female), and the participants were asked to complete an intellectual disability literacy scale (IDLS, Scior & Furnham, 2011).

RESULTS

Only 31 % of healthcare professionals in the unlabelled condition recognise a neurodevelopmental disorder. Furthermore, the label predicts an attribution of biomedical causal beliefs and fewer environmental causal beliefs than the unlabelled condition. Moreover, the belief in a biomedical cause predicts a reduction in social distance. Finally, gender and label seem to affect social distance.

CONCLUSIONS AND IMPLICATIONS

Healthcare professionals are not sufficiently aware of intellectual disability (i.e., recognition of symptoms, causes of the disorder). These findings seem all the more important given that our results indicate that attributing a biomedical cause to a person's situation helps reduce social distance, which is an essential element in caring for people. It therefore seems essential to promote practices aimed at improving access to inclusive healthcare.

[Barriers and facilitators to the use of mental health prevention programs among preschool- and elementary school-aged children]

BACKGROUND AND AIMS

Emotional and behavioural problems occur frequently in childhood and are usually associated with burdens on children, families, and society. Preventive interventions could reduce these burdens, but are rarely used despite their availability and effectiveness. The aim was to identify general, individual, structural, and family-related barriers/facilitators to potential and actual participation in prevention programs.

METHODS

As part of a prospective implementation study, n = 3,231 project folders were handed out to parents in 28 paediatric practices in Dresden and surrounding area during routine health check-ups (U9-U11) for children aged 5 to 10 years. In addition to screening for mental health problems, a questionnaire was used to identify potential barriers/facilitators to participation in prevention programs. Of n = 2,844 families agreeing to participate in the study n = 2,122 (74.6 %) completed the questionnaire at least partially. Regression analyses were used to test associations between potential barriers/facilitators and actual participation in (a) a pre-intervention interview (PII; in order to check indications with the program provider) or (b) the prevention program among children with a prevention recommendation.

RESULTS

Of the participating families, 1.8 % reported that they had already participated in a prevention program to improve mental health or had received a recommendation for it before. 59.5 % of the families expressed their general interest in such programs, and 95.7 % would participate if their paediatrician recommended it. At the structural level, a lack of knowledge about mental health prevention programs was identified as a barrier to potential participation; as only 9.2 % of the families were aware of such programs before participating in the study. 65.8 % of all the families considered full reimbursement of the participation fees after paying in advance a prerequisite for their potential program participation, and 56.7 % wanted to receive a voucher from their health insurance fund entitling them to participate without prepayment. At the individual level, the parents' attitude towards the usefulness of prevention programs predicted the actual utilisation of the PII after the paediatrician's recommendation. At the structural level, the acceptance of longer travel times (up to 60 minutes) as well as the assumption/reimbursement of the entire course fees were relevant predictors. Furthermore, male sex (of the children) and higher screening scores were also important predictors at the family-related level. After the PII, the only factor associated with actual participation in prevention programs was efficient public transport accessibility.

DISCUSSION

In order to increase participation in prevention programs, funding to cover participation fees should be secured through health insurance funds. In addition, advertising and educational measures in the public as well as by paediatricians in the context of screening could raise the awareness of and improve attitudes towards useful programs. Implementing the programs in children's environments could reduce structural barriers and create equal opportunities for participation.

Barriers and Facilitators to Comprehensive Pediatric Sickle Cell Care: A Qualitative Study

BACKGROUND

Children with sickle cell disease (SCD) require comprehensive care to prevent and treat serious and life-threatening complications and to access disease-specific treatment approaches that can improve outcomes. This study characterized barriers and facilitators to care for SCD in the context of the Conceptual Framework of Access to Care Model.

METHODS

This qualitative descriptive study was conducted using semi-structured interviews with 27 patient/caregivers focused on sickle cell anemia (SCA; a subtype of SCD). Data were analyzed using directed content analysis with the model above as the initial coding framework.

RESULTS

Themes were identified among healthcare system and patient/community-level factors. Healthcare system facilitators predominated themes, with a focus on the extent to which the healthcare services provided were a good match for the family and available and accommodating to patient and family needs. Additional facilitators at the patient/community level focused on whether patients and families could perceive and seek out, reach and pay for, and engage with healthcare. Barriers reflected the opposite experiences, with negative or challenging healthcare experiences and adverse social determinants of health interfering with access to care.

CONCLUSIONS

Barriers and facilitators were mapped to the Conceptual Framework of Access to Care Model, with facilitators playing a more substantial role than barriers in access to comprehensive care among children with SCA and their caregivers. A focus on optimizing facilitators at both the healthcare system and patient/family level may have a considerable impact on improving access to and engagement in care.

"Quick, simple, and friendly": Understanding the acceptability and accessibility of a nurse and peer-led, mobile model of hepatitis C care adjacent to community corrections in Australia

BACKGROUND

People on community corrections orders are at high-risk for hepatitis C but opportunities for hepatitis C care may be missed due to poor integration of prison-based healthcare. The C No More study is a pilot feasibility study of point-of-care hepatitis C testing and rapid treatment initiation delivered adjacent to community corrections settings in Melbourne, Australia, via a mobile, nurse and peer-led, low-threshold model of care.

METHODS

We conducted a mixed methods evaluation using Levesque's Conceptual Framework of Access to Health to understand participants' experiences and perspectives on the accessibility of this model of care. Interviewer-administered surveys were conducted with all participants after enrolment and initial testing, and qualitative in-depth interviews were conducted with a sample of those who completed the survey.

RESULTS

500 participants completed the survey, and 20 participants undertook in-depth interviews. Both quantitative and qualitative results indicated that participants found the C No More service approachable and accessible due to the informal outreach setting, the involvement of peer workers, and the convenient location of service delivery. Participants reported feeling comfortable seeking care in the van and found the service appropriate and easy to engage with due to the fingerstick point-of-care testing and individualised support provided by the nurse.

CONCLUSION

Multiple elements of the C No More model increased client-perceived service accessibility, including being located close to government services, point-of-care testing, and the person-centred, peer-based and non-judgemental nurse-led care provided. This study supports the implementation of other peer and nurse-led models of hepatitis C care in similar settings.

A Mixed-Methods Approach to Assessing Barriers and Facilitators to Cancer Genetics Care in Black and Latino/a Individuals Impacted by Pancreatic Cancer: The Racial/ethnic Equity in GENetic Education, Risk Assessment, and TEsting (REGENERATE) Study

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) disproportionately impacts Black and Latino/a communities, who are less likely to receive genetic counseling/testing referrals, hindering early cancer detection/prevention access. This study aims to determine the barriers/facilitators to PDAC genetics care/surveillance among Black and Latino/a populations.

METHODS

This is a concurrent mixed-methods study that utilized electronic surveys and semi-structured focus groups/in-depth interviews (02/14/2022-12/21/2022). This was a volunteer sample of Black or Latino/a general participants with a personal or family history of PDAC and community leaders serving these groups. Participants discussed barriers/facilitators to PDAC cancer genetics care/surveillance. Health literacy, cancer worry, medical trust, and inherited cancer risk were assessed using electronic surveys. Discussions were recorded, transcribed, and analyzed using a content analysis approach. Chi-square tests, two-sample t-tests, and one-way analysis of variance were used to evaluate survey data using R v4.3.2.

RESULTS

55 participants (n = 27 general participants, 28 leaders) completed surveys. 27 (49%) self-identified as Black and 23 (42%) as Latino/a. Leaders (74%) reported higher levels of perceived medical mistrust among their communities than general participants (Trust in Physician Scale mean/SD 29.9/4.2 vs. 38.4/5.2, p < 0.001; Medical Mistrust Index = 18.8/4.2 vs. 24.4/3.6; p < 0.001, respectively). General participants self-reported higher digital health seeking capabilities than leaders' perception of that skillset (p < 0.001). 24 of these participants completed a focus group/in-depth interview, emphasizing informed discussions with a trusted/established provider.

CONCLUSIONS

Individuals impacted by PDAC are open to genetics care and desire resources to promote PDAC surveillance. It is also crucial that leaders and providers be engaged to facilitate access to this care.

Access to mental health care for Black and Latino teens with anxiety and depression: a qualitative study

BACKGROUND

Anxiety and depression are common mental disorders among children and their prevalence has increased in recent years. Unfortunately, some children do not have access to mental health care. Black and Latino children have been reported to be more likely to have unmet mental health care needs than other racial or ethnic groups. This study sought to identify the influential factors in accessing mental health care for Black and Latino teens with anxiety or depression in Milwaukee, Wisconsin, and identify recommendations to improve access for this group.

METHODS

Ten qualitative, key informant interviews were conducted between February 2022 and January 2023 and analyzed using thematic analysis as the research approach.

RESULTS

Study findings were categorized into six themes:(1) Mental health during the COVID-19 pandemic, (2) First points of contact, (3) Preferences for mental health professional characteristics, (4) Adequate care: Culturally-appropriate, trauma-informed, and family-centered, (5) Community awareness of mental health and resources available, (6) Availability of mental health services.

CONCLUSIONS

Recommendations for public health policy and practice to increase access for these groups are discussed.

Perceptions of providers and unhoused patients on access to eye care in Santa Clara County: A qualitative study

SIGNIFICANCE

Perspectives on eye care barriers differ between low-income patients and vision care providers. Comparing these views provides valuable insight into strategies for addressing disparities in underserved communities, especially in regions with significant income inequality and opportunity gaps.

PURPOSE

The aim is to identify obstacles that prevent individuals who are unhoused, have low income, or are publicly insured in Santa Clara County from accessing basic refractive eye exams and corrective glasses.

METHODS

Patients aged ≥18 years with low income presenting to a free vision care clinic in Northern California (n = 15) and vision care providers who primarily work with underserved patients in Santa Clara County, California (n = 11) participated in one-on-one phone interviews. Interviews were transcribed and analyzed.

RESULTS

Most participants (87% patients and 82% providers) say that basic vision care (refractive eye exam and eyeglasses) in Santa Clara County is unaffordable and that in-person eye exams can be physically inaccessible (67% patients and 91% providers) due to busy work schedules or limited access to transportation. However, patient and provider perspectives on intrinsic barriers to accessing eye care diverge. In total, 73% of providers stated that limited health literacy contributed to lower utilization of routine vision care, while 47% of patients cited limited empathy from providers as responsible for their negative experiences and dissatisfaction with care.

CONCLUSIONS

In Santa Clara County, patients with low income and their providers both identify similar external barriers to basic vision care: high costs, inadequate insurance coverage, and limited services. However, patients and providers may disagree on intrinsic barriers to accessing care. Suggestions for improving access to vision care include more help from healthcare coordinators, better information about affordable services, improved vision insurance, and mobile healthcare options.

Barriers and Facilitators to Accessing Mental Health Supports Among Black Perinatal Women: Application of the Patient-centered Access Framework

Black perinatal women experience high rates of mental health disorders including depression and traumatic stress disorders, but also face significant disparities in access to mental health treatment. We conducted focus groups with 43 Black perinatal women in the Southeastern U.S. to understand barriers and facilitators that affect their access to mental health services during pregnancy and post-partum as well as recommendations to promote culturally response trauma screening and services. This study leveraged Levesque's patient-centered access framework to inform coding and analysis. Barriers to access and corresponding recommendations were identified among all five dimensions and abilities of the patient-centered access framework. Medical mistrust was a key theme that spanned several dimensions-including the likelihood of seeking care and comfort disclosing mental health concerns to a provider. Study recommendations included the need for provider training on delivering trauma-informed, culturally responsive care, increased transparency about trauma screeners to mitigate patient mistrust, and the establishment of integrative care approaches to reduce time and cost barriers to accessing mental health supports.

Developing an intervention to improve early infant HIV diagnosis service uptake among postpartum women in Malawi's primary healthcare using a co-designing approach with stakeholders

Low health service use by women and infants after birth limits early infant HIV diagnosis (EID). From August 2021 to December 2022, we collaborated with 44 healthcare workers (HCW), service users, and non-governmental organisation stakeholders from seven public facilities and five non-governmental organisations in Blantyre, building on a previous study. We analysed context-specific problems in EID services and co-designed a context-appropriate enhanced health system intervention to improve the uptake of six weeks' EID services in primary health facilities in Blantyre, Malawi, using qualitative methods and co-designing workshops. The Behaviour Change Wheel, Theoretical Domain Framework and Consolidated Framework for sustainability constructs in healthcare guided the workshops. Reflexive thematic analysis of the data showed that stakeholders found that EID services were sub-optimal and identified challenges to service provision in 5 key areas: (1) client identification, (2) context-appropriate client-centred service integration, (3) HCW coordination and accountability, (4) HCW capacity building for optimal service delivery, and (5) intervention sustainability. Specifically, client and HCW stigma perceptions, referral gaps, resource challenges, HCW lack of time and poor documentation affected client identification; HCW clustered work shifts to extend off-duty periods, failure to synchronise client appointments, and lack of resources were barriers to client-centred integrated services; dysfunctional teams, minimal supervision and misconduct among HCW impacted coordination and accountability; and lack of information sharing and limited training reduced HCW capacity for service delivery. Context-appropriate stakeholder informed co-design initiatives to address identified challenges included: clients' unique identifiers, booking systems, strengthening leadership, data validation, care pathways, and facility-based training. We recommend evaluating these initiatives in low resource settings as they have potential to address the identified EID service implementation gaps and significantly improve the EID of HIV in contexts of greatest need.

Relationships between substance use treatment facilities and alcohol-attributable mortality across U.S. counties

BACKGROUND

Formal substance use treatment is a key resource for recovery among people with alcohol use disorders. Limited county-level availability of substance use treatment facilities may restrict access to care and ultimately contribute to worsening health outcomes and mortality. However, it is unknown whether the availability of such facilities is associated with county-level alcohol-attributable mortality risk.

METHODS

We used Bayesian hierarchical Poisson spatial regression models to assess the relationship between population-weighted county-level treatment facility availability and rates of (1) fully chronic alcohol-attributable mortality, (2) alcohol poisonings, and (3) suicides by exposure to alcohol in 2019-2020. Localized treatment facility availability was calculated using a weighted method incorporating Census block group-level population counts. We adjusted for county-level demographic and socioeconomic factors, hospital density, population density, overall mortality rate, densities of mental health practitioner offices, U.S. Census region, year, and season.

RESULTS

There was county-level heterogeneity in the availability of substance use treatment facilities, with northeastern county treatment facility densities at least twice as high as other regions. Higher county-level densities of treatment facilities were related to increased county-level risk for chronic fully alcohol-attributable deaths and alcohol poisonings but not suicides by exposure to alcohol.

CONCLUSIONS

Availability of substance use treatment facilities and the services they offer is heterogeneous across U.S. counties. The positive relationship between population-weighted county-level densities of treatment facilities and chronic fully alcohol-attributable mortality and alcohol poisonings may suggest that treatment facilities are placed in areas of greatest demand; yet, population-level needs may not fully met by these facilities.

Barriers to seeking consultation at public service and medical facilities among pregnant and postpartum women in Japan: a cross-sectional study

Background

Pregnant and postpartum women often experience parenting problems which may affect their mental health and children's health and development. However, their ability to seek consultation at public service or medical facilities remains unclear. This study aimed to identify the characteristics associated with women who refrain from visiting these facilities for consultation and their reasons for it.

Methods

This cross-sectional internet-based survey was conducted in Japan between July and August 2021, involving 7,326 women (1,639 pregnant and 5,687 postpartum women). The study outcome was defined as refraining from seeking consultation on family or parenting issues at public service or medical facilities despite a perceived need. We identified women's characteristics associated with refraining from consultation using multivariable logistic regression and conducted a descriptive analysis of 13 listed reasons for refraining from the consultation.

Results

The percentage of women who reported refraining from seeking consultation at public service or medical facilities was 8.6% and 5.1%, respectively. Common factors associated with refraining from seeking consultation at these facilities included having a child(ren) and being in the postpartum period, low health literacy, lack of partner support, and current disability. "Difficulty taking child(ren) to the consultation" and "uncertainty about the seriousness of the problem" were major reasons for refraining from consultation.

Discussion

Healthcare workers at public service and medical facilities should offer prenatal education on the importance of seeking help. An online consultation service and an improved facility environment may mitigate women's perceived barriers to seeking consultation.

Barriers to accessing medications for opioid use disorder among rural individuals

BACKGROUND

Individuals with opioid use disorder living in rural areas face barriers to accessing medications for treatment (MOUD), including finding prescribing clinicians and difficulties with transportation. This study sought to describe self-reported barriers to MOUD access in rural areas and associations between desired MOUD type and barriers encountered or perceived.

METHODS

We performed a cross-sectional study of Rural Opioid Initiative participants who ever used opioids and sought MOUD treatment, who were surveyed from 2018 to 2020 about access to MOUD. Multivariable logistic regressions explored the association between MOUD type and barriers while controlling for age, gender, race, and study site.

RESULTS

Of 2906 participants who used opioids and sought MOUD, 826 (28.4 %) were unable to access MOUD. In logistic regression models, lack of transportation was a more common barrier for those seeking methadone versus sublingual buprenorphine (adjusted odds radio [aOR] 1.87, 95 % confidence interval (CI) 1.24-2.81). A long wait list was more common for those seeking injectable naltrexone than sublingual buprenorphine (aOR 1.68, 95 % CI 1.05-2.69). Lack of doctors or programs and affordability were more common for those seeking injectable versus sublingual buprenorphine (aOR 7.84, 95 % CI 4.87-12.63 and aOR 1.89, 95 % CI 1.26-2.83, respectively).

CONCLUSIONS

Access barriers vary by MOUD type for rural individuals with OUD. Compared to sublingual buprenorphine, methadone access was hindered more by transportation difficulties, while injectable long-acting buprenorphine was hindered more by affordability and finding a doctor or program. These barriers highlight the need to de-regulate and expand locations for methadone access and prescribing, and to improve affordability and prescriber uptake of newer MOUDs, such as injectable buprenorphine.

Understanding patient perceptions of access to healthcare centers in one of the major cities of Afghanistan

Access to healthcare services is an important aspect in providing health care, but there is little information about the perception level of people who have come to healthcare centers about access to services in Herat, Afghanistan. The aim of this study was to investigate the perception level of people referred to healthcare centers in Herat in 2024. The study was a cross -sectional study and participants (n = 420) included individuals aged 18-65 to Herat healthcare centers. The cluster sampling method was that each of the 31 service centers was considered. Modified Penchansky and Thomas's (2015) Theory of Access questionnaire was used to collect data from a sample of people referred to medical centers in Herat. The results demonstrated that the perception level of clients significantly varied across different variables such as age, gender, economic conditions, job status, education level, and marital status. The mean scores for the perception level of various variables including accessibility, acceptability, affordability, accommodation, awareness, and availability were reported as 65.86, 30.48, 52.48, 64.05, 73.11, and 63.31, respectively. The results indicated that perception level was the highest for awareness and after it accessibility, and affordability, respectively. Moreover, education level and job status had a statistically significant effect on perception level (P-value < 0.05). This study revealed the importance of considering demographic characteristics when assessing the level of peoples' perceptions of access to health care services. Improving access to health care services requires a comprehensive understanding of the various factors that influence levels of perception. Addressing these factors can help to increase the quality and effectiveness of providing health services in Herat city.

Meaningful Patient Partnerships: A Qualitative Study of Patient Perspectives and Shared Decision-Making Regarding Glaucoma Surgery

PURPOSE

Patient centred-care is key to successful clinical outcomes and meaningful clinician-patient relationships. Accordingly, a comprehensive understanding of patient perspectives is essential to aligning the clinician's focus and patient's goals. However, our understanding of patients' perceptions of glaucoma surgery and involvement in surgical decision-making has not kept pace with the rapid treatment advances in the field and move towards earlier surgery with the advent of minimally-invasive glaucoma surgery devices. The purpose of this study was to understand the perspectives and priorities of people with glaucoma when considering glaucoma surgery through qualitative analysis of semi-structured interviews.

DESIGN

Qualitative study.

PARTICIPANTS

Individuals diagnosed with glaucoma, above 18 years of age, and able to communicate effectively in English. Interviews were conducted with 40 participants; 23 participants who had undergone glaucoma surgery and 17 who had not.

METHODS

Interviews were conducted over telephone, using an interview guide developed in consultation with people with glaucoma and surgeons. The cohort was purposely sampled to ensure representation across age, sex, socioeconomic status, remoteness, glaucoma severity, clinic settings, and treatment histories. Transcripts were iteratively analysed to identify key themes pertaining to perceptions of glaucoma surgery and involvement in decision-making.

MAIN OUTCOME MEASURES

Surgical perception and involvement themes, including barriers and bridges to confidence in glaucoma surgery.

RESULTS

Six key themes were identified: (1) patients feeling rushed; (2) onus on the patient to seek information; (3) undercurrents of anxiety; (4) perceptions of surgery shaped by understanding and expectations of the disease and its treatment paradigm; (5) trust in surgeon imbuing confidence in surgery, and; (6) empowerment through understanding of alternatives. Key barriers to patient involvement included patient anxiety, time pressures (real or perceived), and perceived urgency of intervention.

CONCLUSIONS

Shared decision-making in glaucoma surgery remains aspirational. This study provides valuable insights into patient perceptions of glaucoma surgery, which can help inform patient-centred care. Readily applicable 'practice points' are proposed to optimise patient involvement and empowerment.

Supporting safe disclosure of sexual violence in healthcare settings: findings from a realist evaluation applying candidacy theory through a trauma-focused lens

OBJECTIVES

Most people who have experienced sexual violence (SV) will disclose the event(s) to someone. Key recipients of disclosure are those working in healthcare, and using sexual and reproductive health services can be an important step in accessing necessary medical care and being signposted to other services. Accessing this care and disclosing SV can be challenging. Evidence is lacking about how best to create a safe environment for disclosure to take place, how services can make changes to better facilitate this experience and what changes matter most.

DESIGN

Realist evaluation.

SETTING

Sexual and reproductive health settings.

PARTICIPANTS

1-1 interviews with service users who have disclosed SV (n=18), three focus groups with healthcare professionals and survey respondents (n=2007).

OUTCOME MEASURES

Initial programme theories of what works, for whom and in what context were tested and refined with empirical data from a national survey, 1-1 interviews and focus groups. The final steps are presented here, bringing strands of the study together and informed using substantive theory.

RESULTS

The key steps in using healthcare on disclosure of SV relate to self-identification as a worthy candidate irrespective of background or presentation, ensuring empowerment during navigation of services, initial access to sexual healthcare made straightforward, validation by healthcare professionals when receiving disclosures, choice and control for service users during a collaborative interaction with healthcare professionals and aftercare that reflects needs particularly of minoritised groups.

CONCLUSIONS

We propose a novel way of considering Dixon-Woods' candidacy theory seen through a trauma-informed lens for healthcare following SV, and how, by holding a trauma-informed lens to candidacy, steps of healthcare access and utilisation can be framed to ensure a safer environment for disclosure. This modified substantive theory marks the chosen endpoint of the realist evaluation and provides a transferable programme theory that can be considered in other settings.

Using geographic information systems to map eye care service distribution in rural and remote Western Australia

BACKGROUND

Many rural residents face barriers to eye care access. Government workforce data show a maldistribution of eye care providers in Western Australia however, no detailed information is available on regional coverage within the state. This study aimed to identify and map all eye care services in rural and remote Western Australia and to calculate the regional workforce rates.

METHODS

A survey was sent to all optometry and ophthalmology practices in rural and remote Western Australia with questions on practitioner and equipment availability. Information on visiting services was captured directly through organisations as well as the survey. Geographic information systems were used to map service locations, calculate coverage of services relative to the population, and calculate full-time equivalent (FTE) per 100,000 of the population for each profession.

RESULTS

A total of 58 optometry practices, 8 ophthalmology practices, 113 visiting optometry services and 43 visiting ophthalmology services in rural and remote Western Australia were identified and mapped. Most of the population (97.2%) lived within 100 km of an eye care service. Overall FTE per 100,000 for optometry and ophthalmology were 12.1 and 2.4, respectively. Regional FTE per 100,000 ranged from 2.1 to 19.5 for optometry and 0 to 4.2 for ophthalmology.

CONCLUSIONS

The results show broad coverage of visiting services but highlights regional discrepancies in optometry and ophthalmology workforce rates, with several regions failing to meet FTE recommendations.

Relationship between experiencing a challenge or delay accessing contraception and contraceptive self-efficacy: Data from a 2022 nationally representative online survey

BACKGROUND

Previous research has found self-efficacy is associated with reproductive health behaviors and outcomes. However, few studies have quantitatively examined the relationship between barriers accessing contraception and self-efficacy. In addition, existing population-level metrics of contraceptive access tend to focus on method availability, uptake, and use, rather than people's self-defined needs and preferences. This study uses person-centered metrics to assess the relationship between experiencing a recent challenge or delay obtaining desired contraception and two measures of contraceptive self-efficacy.

METHODS

In 2022, we fielded a nationally representative survey in English and Spanish using NORC's AmeriSpeak panel, surveying non-sterile 15- to 44-year-olds assigned female sex at birth in the U.S. We describe common challenges and delays obtaining contraception and present the distribution of experiencing a challenge or delay obtaining contraception by key sociodemographic and reproductive health characteristics. We also conduct logistic regression analyses to investigate associations between experiencing a challenge/delay and two measures of contraceptive self-efficacy: confidence in obtaining a desired method when wanted and perceived ease of switching methods when wanted.

RESULTS

Among the analytic sample of respondents who had ever used or tried to obtain a contraceptive product, device, or procedure (unweighted n = 2,771), about 14% experienced a challenge/delay obtaining desired contraception in the past year. The most common reasons for challenges or delays were related to logistics (transportation, childcare, scheduling; 38.2%) and cost/insurance coverage (35.8%). Among those who experienced a challenge/delay obtaining desired contraception (unweighted n = 301), higher proportions were younger, identified as non-heterosexual, had lower educational attainment, and could afford smaller emergency expenses compared to the subgroup that did not experience a challenge/delay. Experiencing a challenge/delay was associated with decreased odds of feeling very or somewhat confident in obtaining a desired method (aOR 0.14; 95% CI 0.07, 0.25) and decreased odds of feeling it would be very or somewhat easy to switch contraceptive methods (aOR 0.48; 95% CI 0.33, 0.71).

CONCLUSIONS

Eliminating barriers to contraceptive care is crucial to achieving person-centered access. Our research suggests that experiencing a challenge/delay has implications not only for recent contraceptive access but also influences self-efficacy, potentially inhibiting future ability to obtain and use desired contraception.

Impact of Health All-in-One Machines on access to healthcare of rural areas in China: an interrupted time series analysis

BACKGROUND

Smart healthcare systems are expected to have a positive impact on addressing challenges in healthcare. However, the real-world adoption and widespread integration of Smart healthcare systems still face many barriers, and their clinical utility lacks empirical research with large sample sizes, particularly in rural areas. The aim of this study is to evaluate the impact of a new smart healthcare system, the Health All-in-One Machines (HAMs), on improving the health services in rural areas of China.

METHODS

The data included health services information from 1,866 village clinics in Hainan, China, covering the period November 30, 2020, to April 30, 2023. The impact of Health All-in-One Machines on access to healthcare was measured using four outcome indicators: the number of patient visits, medical revenue, pharmaceutical revenue, and medical expense per patient. We conducted a three-phase interrupted time series study to explore the effects of the Health All-in-One Machines intervention on these indicators across two distinct periods: the second phase (26 weeks, adaptation period) and the third phase (74 weeks, full-scale implementation period).

RESULTS

The interrupted time-series analysis revealed that the Health All-in-One Machines intervention had no significant impact on outcome indicators comparing the pre-intervention period to the adaptation period. However, from the adaptation period to full implementation, significant impacts were observed. Specifically, notable level changes were observed: the number of patient visits increased by 37.85% (p < 0.01), medical revenue increased by 54.03% (p < 0.001), pharmaceutical revenue increased by 32.84% (p < 0.05), and medical expense per patient increased by 2.368 CNY (p < 0.001). Additionally, a significant trend change was observed in medical expense per patient, with a decrease of 0.15 CNY per week (p < 0.05).

CONCLUSIONS

This study provides empirical evidence of some positive changes in the Health All-in-One Machines intervention on the outcome indicators regarding the access to healthcare. Moreover, our analysis indicates that the Health All-in-One Machines intervention would at least take longer to take effect when implemented in large-scale rural healthcare institutions. The findings from this study provide insights for future delivery and policy making of Smart healthcare systems in rural areas.

Parents' experiences of accessing childhood vaccination services in England: A qualitative longitudinal cohort study

BACKGROUND

In England, declining childhood vaccine uptake and related inequalities are causes for concern. Existing evidence suggests challenges accessing services contribute to this decline. This is particularly true for parents facing socioeconomic disadvantage. This study aimed to explore parents' experiences of the vaccination process to generate recommendations for improving the accessibility of childhood vaccination services.

METHODS

A longitudinal cohort study was established in May 2023. Sequential interviews were conducted with 22 parents from the birth of their child as they progressed through the vaccination pathway. Data collection comprised life journey interviews and diary keeping. Data were analysed using temporal thematic analysis.

RESULTS

Four vaccination trajectories were observed collectively referred to as the 4S Vaccination Trajectory Framework: supported (n = 9), struggled (n = 10), stalled (n = 2), and shunned (n = 1). Three main temporal themes were identified which accounted for the diverging vaccination trajectories: booking systems, the unexpected (e.g., how General Practices managed parents who were late or missed their appointment), and vaccine information provision. For example, many within the 'struggled' trajectory, initiated contact with their General Practice and had considerable difficulty securing appointments due to inflexible booking systems.

CONCLUSIONS

To address declining vaccination coverage within England it is vital that vaccine accessibility is improved and that services meet parents' needs. This study deepens our understanding of accessibility issues with the vaccination service and discusses implications for policy and practice.

Measuring person-centred care in the mission, vision, and core value statements of Canadian healthcare organizations

BACKGROUND

Person-centred care (PCC) has been shown to improve health outcomes. The inclusion and incorporation of person-centredness in care has been a growing priority for healthcare organizations across Canada.

METHODS

Person-Centred Care Quality Indicators (PC-QI) evaluate to what extent various PCC elements have been integrated into healthcare organizations. Using the first PC-QI, content analysis was performed on the mission, vision, and core value statements of 54 healthcare organizations to assess whether PCC is being included as a strategic and decision-making priority in the Canadian healthcare system.

RESULTS

Fifty-three healthcare organizations (98%) included at least one domain of PCC in their statements. The three most frequent were compassionate care (85%), trusting relationship with providers (70%), and co-designed care (56%). There was no presence of affordable care.

CONCLUSION

Canadian healthcare organizations are working towards promoting and implementing a culture that prioritizes some elements of PCC in the care of patients.

Factors influencing intentional non-utilization of healthcare: a study using the Andersen model

Objective

This study aims to investigate the factors influencing residents' healthcare utilization behavior and provide a scientific basis for enhancing the overall efficiency of healthcare utilization.

Methods

A comprehensive analysis was conducted using data from the China General Social Survey (CGSS) project. Exploratory Factor Analysis (EFA) and Structural Equation Modeling (SEM) were utilized to examine the influences and interrelationships of the three core factors of the Andersen Healthcare Utilization Model (Predisposing Factors, Enabling Resources, and Need), as well as the two extended factors (health behaviors and Medical-service Experience), on residents' decisions regarding the utilization of healthcare services.

Results

A total of 2,230 participants were enrolled in this study. Most were male (55.74%), were married (85.38%), and had junior- and senior-high school educations (45.29%). Mean age was 52.39 years, and 56.32% of participants reported an annual income of <30,000 RMB. EFA distilled influencing factors into four domains: Predisposing and Enabling, Need, Health Behaviors, and Medical-service Experience. The results of the revised SEM indicated that the influence coefficients of Predisposing and Enabling, Need, and Medical-service Experience on Decision to Utilize Health Services (DUHS) were 0.095, -0.104, and 0.093 respectively. Mediation effect test results demonstrated that the indirect effects of Predisposing and Enabling, Need, and Health Behaviors on DUHS were -0.098, 0.024, and -0.017, respectively, all of which were statistically significant. Finally, the fit indices of the modified model indicated an acceptable model fit.

Conclusion

This study showed that unmarried individuals with lower income and job instability exhibit reduced healthcare utilization due to economic barriers and lack of social support. Furthermore, medical service experience is another crucial factor affecting health service utilization. Notably, our findings suggest the need for targeted interventions, including enhanced insurance coverage, improving the quality of medical services and health education campaigns to mitigate disparities in access to health services.

Martin R, La Foucade A, Sarti FM. Determinants of Patients' Perception of Primary Healthcare Quality: Empirical Analysis in the Brazilian Health System

Background/Objectives: Primary healthcare (PHC) plays a central role in the promotion of universal healthcare coverage within the Brazilian health system. Nevertheless, inequalities across municipalities represent substantial barriers to achieving equity in access to health, particularly due to disparities in the quality of healthcare delivered to patients. Thus, the study aimed to investigate factors associated with perception of PHC quality among adult individuals using private and public facilities within the Brazilian health system. Methods: The empirical approach was based on quantitative analysis of cross-sectional data from five nationally representative surveys conducted by the Brazilian Institute for Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE) in 1998, 2003, 2008, 2013, and 2019. Pairwise comparisons and marginal analyses allowed for the assessment of differences in patients' perception of healthcare quality according to source of funding and type of healthcare quality. A logistic regression model was estimated to identify factors associated with the perception of good quality of care. Model discrimination, calibration, and goodness-of-fit were assessed to ensure the robustness of analyses. Results: The results indicate that patients' satisfaction was positively associated with level of implementation of the national program based on payment for performance in public healthcare facilities, PMAQ-AB (OR = 3.376; p < 0.001), self-assessment of good health status (OR = 3.209; p < 0.001), and healthcare financed through health insurance (OR = 2.344; p < 0.001). Contrarily, receiving healthcare in a public facility (OR = 0.358; p < 0.001) was negatively associated with the evaluation of good quality. Conclusions: The findings showed that patients' perception of quality of care presents significant associations with patients' health characteristics, healthcare funding source, and implementation of the PMAQ-AB. Furthermore, patients generally perceived lower healthcare quality in public facilities. The study indicates the need for evidence-based decision-making in public policies of health, particularly regarding further advances in payment for performance programs designed to foster improvements in quality of care within public PHC facilities in Brazil.

How has the integration of midwives into primary healthcare settings impacted access to care? A qualitative descriptive study from Ontario, Canada

PROBLEM

Most primary health care settings in Canada do not offer midwifery care. Midwifery remains poorly understood in Canada by some members of the public and healthcare providers.

BACKGROUND

Most midwives in Canada work in community-based midwifery-led continuity of care models that are not integrated into interprofessional primary healthcare settings.

AIM

To investigate perceptions of how integrating midwives into primary health care teams impacts access to care.

METHODS

We conducted a qualitative descriptive study of expanded midwifery care models in Ontario, Canada. We completed 28 semi-structured interviews with midwives, other healthcare providers, healthcare administrators and policy makers. Interviews were audio recorded, transcribed, and then coded using open coding followed by axial coding in NVivo. We used Levesque et al.'s (Int J Equity Health 12:18, 2013) conceptualization of access to care to inform the interview questions and organize our findings.

FINDINGS

We identified themes related to each of Levesque et al.'s supply side dimensions of access to care. Integrating midwives increased visibility and trust of the profession (approachability and acceptability), decreased access barriers such as travel time and cost (affordability), increased collaboration between healthcare providers (appropriateness), and ensured more timely and available care (availability and accommodation).

DISCUSSION

Integrating midwives into primary healthcare settings can improve access to care, particularly for groups underserved by midwives. Integrating midwifery-led care within interprofessional teams can also enhance care appropriateness for equity-deserving populations.

CONCLUSION

While stand-alone community-based midwifery care remains effective and efficient, policy makers should consider creating or expanding funding that supports the further integration of midwives into primary healthcare teams.

A framework for patient access management: consensus from a Delphi panel of US health system leaders

BACKGROUND

Patient access management in the ambulatory setting is important for health systems as waits and delays lead to reduced health outcomes, inequity, and poor patient experience. Health systems may benefit from a framework that catalogs the determinants of access management in the ambulatory setting to deliver timely care to all patients.

METHODS

The aim of this research is to define patient access and document the determinants of patient access management through a consensus from a two-stage Delphi panel of access leaders in US academic health systems and children's hospitals.

RESULTS

The study demonstrates a patient-centered definition of patient access management focusing on the delivery of timely, simple, connected access to care. Twelve major determinants were identified for patient access management: executive leadership support, dedicated access leadership, system strategy prioritization, data collection and analysis, contact center management, capacity management, appointment availability, appointment accuracy, measurable and defined goals, simplification of system for patients, timely offering of care, and patient-clinician connection. The determinants were applied to a framework using the Donabedian model. Frameworks may improve validity and reliability in performance improvement activities.

CONCLUSIONS

Health systems may benefit from prescriptive strategies to identify, diagnose, resource, and address the determinants that constitute patient access management. Additional research is warranted to understand each determinant.

Contraceptive practices in Québec in relation to immigration: A cross-sectional analysis of data from the Québec Population Health Survey

OBJECTIVES

This study aimed to examine the association between immigration status and women's contraceptive practices based on population data from government surveys.

METHODS

A secondary data analysis was conducted on the Quebec Population Health Survey (2014-2015), which aimed to represent 98.8% of the population of Quebec aged 15 years and older through stratified sampling and data weighting (response rate of 61%). Univariate and multivariable analyses were used to compare contraceptive practices between immigrant and Canadian-born women. Two dependent variables were considered: (1) women who used contraception vs. no contraceptive method of any kind, and (2) among women who used contraception, those who used methods that required them to access health care (birth control pill, IUD, or tubal ligation) vs. women who used other methods (condom, coitus interruptus, other).

RESULTS

The logistic regression results revealed a strong association between immigration status and contraceptive practices, at two levels: (1) immigrant women had lower odds to use contraception than Canadian-born women; and (2) of the women who use contraception, immigrants had lower odds than those born in Canada to use feminine medical contraception. These findings held true for immigrant women regardless of the number of years they have spent in Canada. Women who lived in low-income households or who had not had a medical consultation for more than one year also had lower odds to use feminine medical contraception.

CONCLUSION

Barriers in access to contraceptive care interfere with women's reproductive health and autonomy. The lower odds for immigrant women to use contraception, and particularly the most effective methods, suggest that their contraceptive care needs are at least partially unmet or inadequately addressed. This is concerning given that other studies show no differences in fertility intention between immigrant and Canadian-born women, and high rates of abortion for immigrant women.

Ensuring Access to Neurologic Care: Challenges and Opportunities

Neurologic disorders are prevalent in the United States, with an estimated 60% of Americans experiencing at least one neurologic condition. This volume of neurologic disease requires commensurate care. In this article, we review access to neurologic care and examine challenges and opportunities across several dimensions of access. Long wait times for neurologists and evidence that neurologists see only a fraction of certain neurologic conditions suggest issues with the availability of care; better triage of neurologists' expertise and employment of neurology advanced practice providers may improve the supply of neurologic care. Accessibility of neurologic care is hindered by regional inequities and urban/rural disparities, which may be attenuated through the use of telemedicine. High out-of-pocket costs and excessive pharmaceutical prices inhibit the affordability of neurologic care; these obstacles may be addressed with more appropriate test utilization and more effective drug price negotiation. Lastly, innovative care models facilitated by recent technological advances have the potential to profoundly expand access to neurologic care.

Navigating healthcare during the pandemic: Experiences of racialized immigrants and racialized non-immigrants in Ontario's Peel Region

While public health policies implemented during COVID-19, such as prioritizing essential health services and "no visitor" strategies, were important to treat COVID-19 patients and curb disease outbreaks, their potential negative effects on the health of the general population is a growing concern. Research highlights that these policy changes contributed to a near-universal decline in access to all healthcare services and triggered increased morbidity and mortality rates. However, little is known about how health policy changes differentially shaped healthcare access within and between population groups and regions. Few studies qualitatively examine the indirect effects of policy changes on healthcare access among groups disproportionately impacted by COVID-19. This article examines how COVID-19 health policy changes impacted racialized immigrant and racialized non-immigrants' ability to connect with a provider, navigate telehealth and in-person healthcare, and access specialized healthcare in the Peel Region of Ontario, Canada. Using a Client Centered Framework, findings from in-depth interviews (n = 79) reveal that policy changes generated new (in)abilities for individuals to perceive, seek, reach, pay and engage in healthcare services. Health policy changes created new barriers to reach healthcare, compounding health challenges. While telehealth opened more effective avenues to access healthcare among some people, it created new disparities for individuals with limited English language skills and/or for those experiencing technological inequities. Although individuals recognized their need for specialized healthcare, the prioritization of essential services, gaps in health insurance coverage, and new COVID-19 economic inequities created barriers to specialized healthcare. We close with a discussion of the impacts for policy and practice.

The Intersection of Sarcopenia and Musculoskeletal Pain: Addressing Interconnected Challenges in Aging Care

The global aging population faces a growing prevalence of sarcopenia and musculoskeletal (MSK) pain, two interrelated conditions that diminish physical function, quality of life, and independence in older adults. Sarcopenia, characterized by the loss of muscle strength, mass, and function, often coexists with MSK pain, with emerging evidence suggesting that each condition may contribute to the progression of the other. This perspective explores the bidirectional relationship between sarcopenia and MSK pain, highlighting shared mechanisms, including inactivity, cellular aging, chronic inflammation, gender-related hormonal changes, and psychosocial factors such as depression and social isolation, which underlie the mutual exacerbation between conditions. Through a multidisciplinary framework, the article emphasizes integrating care across specialties to address these interconnected conditions. Practical approaches, including comprehensive screening protocols, tailored resistance exercise, and nutritional support, are discussed alongside innovative hybrid care models combining in-person and telemedicine systems to enhance accessibility and continuity of care. A call to action is presented for clinicians, policymakers, and researchers to adopt collaborative strategies, prioritize investment in integrated healthcare, and bridge critical knowledge gaps. By reframing care delivery and advancing multidisciplinary efforts, this perspective aims to effectively address the complex challenges posed by the intersection of sarcopenia and MSK pain in older adults.

Culture Is Key: Engaging Culturally and Linguistically Diverse Populations in Breast Cancer Screening in High Income Contexts: A Scoping Review

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in Australia and is the second highest cause of cancer mortality in Australian women. Screening in the form of mammography can significantly reduce mortality; however, research suggests that women from culturally and linguistically diverse (CALD) backgrounds are less likely to participate in mammography screening. While there is an established body of literature describing the lower engagement of CALD populations in screening and the associated challenges they face, less is known about evidence-based interventions to improve engagement.

METHODS

A systematic scoping review was conducted to gain insights into best practice interventions to improve engagement of CALD populations in breast cancer screening. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. PUBMED, EMBASE and CINHAL databases were searched for studies published between January 2012 and October 2023.

RESULTS

The search yielded 3249 studies; after removing duplicates, 2011 titles and abstracts were screened, and 121 papers underwent full text review. Forty-one were included in the review. Key intervention types were identified, with combination or multi-component studies being most effective at increasing mammography in CALD populations. Cultural appropriateness and tailoring are the most important considerations to be integrated into screening programs.

CONCLUSION

CALD populations have lower engagement and experience many challenges in accessing screening services. This review found that the integration of cultural appropriateness and tailoring is critical in the successful delivery of breast screening services to CALD populations. Individual strategies are insufficient to engage this population in screening; multicomponent strategies are the most effective.

Syrian refugee women's experiences of barriers to mental health services for postpartum depression

OBJECTIVE

To describe Syrian refugee women's experiences of the barriers to access mental health services for postpartum depression (PPD).

DESIGN

A descriptive qualitative study was conducted.

METHODS

Fifteen purposefully selected Syrian refugee women who scored ≥10 on the Edinburgh Postnatal Depression Scale participated in the semi-structured telephone interviews. Transcripts were coded verbatim and analysed thematically according to the dimensions of Levesque's model of patient-centred access to healthcare. Data were collected between August 2022 and February 2023.

RESULTS

Five themes with 14 subthemes were identified: (1) approachability covered lack of knowledge and misconceptions related to PPD and its treatment, lack of awareness of available psychosocial services and perceived need of mental health treatment; (2) acceptability comprised being a refugee, stigma of mental illness, cultural preferences of healthcare provider and language barrier; (3) availability and accommodation encompassed transportation barrier and location of the centre, no support for childcare and lack of time; (4) affordability included financial difficulties and health insurance coverage; (5) appropriateness comprised no screening for PPD and intermittent services with limited focus on mental health.

CONCLUSIONS

The findings of this study reveal that Syrian refugee women experienced multi-faceted complex barriers to access mental health services for PPD. It is important for health professionals, including nurses, and policymakers to address the cultural mental health needs of this population and establish strategies to protect their legal and health rights.

IMPACT

Our study has important practice and policy implications for establishing strategies designed specifically for refugee mothers to mitigate their perceived barriers to PPD treatment and ultimately improve their mental health.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research was used.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. Participants were Syrian refugee women with PPD symptoms and contributed only to the interviews and member checking.

Sociodemographic Variables Associated with Self-reported Access to Mental Healthcare Among Brazilian Immigrant Women in the U.S

Brazilians are a rapidly growing immigrant population in the United States (U.S.), yet little is known about their mental health and access to mental healthcare. Our goal was to access associations between the pursuit of- and access to-mental healthcare with mental health status and socio-demographic characteristics among Brazilian immigrant women. We conducted an online survey of Brazilian women aged 18 or older who reported being born in Brazil and currently residing in the U.S. We recruited respondents via Brazilian cultural media, community organizations serving Brazilian immigrants, and social media. We assessed respondents' perceived access to mental healthcare, self-reported mental health (CES-D-10), and socio-demographic characteristics and conducted multivariable logistic regression. Our analysis included 351 participants. Half (52%) had CES-D-10 scores indicating high levels of depressive symptomatology. A third (33%) reported seeking care for their mental health in the past 12 months, 87% of whom reported obtaining care. Results of multivariable logistic regression determined that respondents who sought mental healthcare were more likely to have higher CES-D-10 scores (OR = 1.09, 95% CI 1.03-1.15), very low incomes (<$10,000 per year; OR = 0.34, 95% CI 0.12-0.96), and were marginally more likely to have a primary care provider (OR = 2.11, 95% CI 1.00, 4.46). We found that despite a high level of depressive symptomology, only one-third reported accessing care. While difficulty accessing care for mental issues is a widespread issue, our findings suggest that efforts are needed to ameliorate mental health issues for Brazilian women to reduce systemic, interpersonal, and individual barriers to seeking care among the 13% who sought healthcare but were unable to receive it.

Perceptions of health and healthcare needs in low-resource settings: qualitative insights from Bengaluru's urban slum and rural areas

Background

Despite the multitude of healthcare services available in India, health inequalities persist. People in low-resource settings are both disadvantaged and have the greatest need for healthcare. To address these disparities and achieve universal health coverage, healthcare services need to be tailored to the specific needs of this population.

Objective

This study aimed to understand health and healthcare perceptions of people in slums and villages in and around Bengaluru, a city in the southern part of India. It was conducted in partnership with Bangalore Baptist Hospital, a charity hospital dedicated to supporting underserved populations in this region.

Methods

The study employed qualitative methods. Twenty-eight open-ended interviews and eight focus groups were conducted with residents of selected slums and villages in and around Bengaluru. The interviews were transcribed verbatim, translated to English and analyzed applying thematic analysis.

Results and conclusion

The study finds that participants defined health as the absence of illness, the ability to work, and the result of a good lifestyle. With regards to healthcare expectations, the analysis shows the themes of the "good doctor," recovering quickly, cost affordability, cleanliness, and emergency services and diagnostic facilities. In addition, stigma related to healthcare, was identified, especially among residents of villages. Participants highlight the importance of good relationships with healthcare providers and accessible healthcare facilities to improve healthcare uptake in Bengaluru's slums and rural areas. This study also shows that achieving universal health coverage requires addressing not only direct costs but also other associated expenses like travel and lost wages, considering healthcare costs as a comprehensive expense tied to patients' living conditions. These results contribute to the growing body of literature on health and healthcare perceptions in low-resource settings, offering insights that may inform future research and context-specific strategies for improving healthcare access and delivery.

Healthcare Avoidance and Delay Among Trans Adults: Associations With Mental and Behavioral Health Outcomes

INTRODUCTION

Healthcare avoidance and delay is prevalent among transgender (trans) populations. This study sought to identify patterns of healthcare avoidance and delay and examine their associations with 5 behavioral health outcomes among trans adults: depression, anxiety, tobacco and alcohol use, and intimate partner violence.

METHODS

This study used survey data collected in 2023 from 789 trans adults in Washington state. Healthcare avoidance and delay was operationalized using latent class analysis with 4 indicators. Adjusted multinomial models predicted class membership by 10 demographic and socioeconomic characteristics, and adjusted logistic regression models predicted each outcome by class.

RESULTS

The sample was predominantly White (60.3%), trans women (82.7%), and financially stable (59.6%). Participants were assigned to one of 3 classes: Low Healthcare Avoidance and Delay (58.9%), Stigma Healthcare Avoidance and Delay class (33.6%), and Combined Healthcare Avoidance and Delay class (i.e., both cost and stigma, 7.5%). Combined members were younger, more likely to be trans men or nonbinary, and occupied lower socioeconomic positions than other classes. Stigma members were more likely to live in rural or suburban areas than the Low class. Stigma and Combined members were associated with increased odds of depressive symptoms, anxious symptoms, and intimate partner violence.

CONCLUSIONS

Although the demographic profiles of the Combined Healthcare Avoidance and Delay and Stigma Healthcare Avoidance and Delay classes were distinct, the behavioral health of these groups was comparable. Preventing healthcare avoidance and delay among trans adults and mitigating its potential health consequences requires greater attention to health services affordability and acceptability.

User journey method: a case study for improving digital intervention use measurement

BACKGROUND

Many digital mental health interventions meet low levels of use. However, current use measurement methods do not necessarily help identify which intervention elements are associated with dropout, despite this information potentially facilitating iterative intervention development. Here, we suggest improving the comprehensiveness of intervention use measurement with the user journey method, which evaluates every intervention element to identify intervention-specific use barriers.

METHODS

We applied user journey method in a clinical trial that investigated the efficacy of a novel game-based intervention, Meliora, for adult Major Depressive Disorder. We modelled the intervention for its four technological (Recruitment, Website, Questionnaires, Intervention Software) and two interpersonal elements (Assessment, Support). We then applied the user journey method to measure how many users proceeded from one element to the next combining social media analytics, website use data, signup data, clinical subject coordinator interview data, symptom questionnaire data, and behavioral intervention use data. These measurements were complemented with the qualitative analysis of the study discovery sources and email support contacts.

RESULTS

Recruitment: The intervention recruitment reached at least 145,000 Finns, with social media, word-of-mouth, and news and web sources being the most effective recruitment channels. Website: The study website received 16,243 visitors, which led to 1,007 sign-ups.

ASSESSMENT

895 participants were assessed and 735 were accepted. Intervention Software: 498 participants were assigned to the active intervention or comparator, of whom 457 used them at least once: on average, for 17.3 h (SD = 20.4 h) on 19.7 days (SD = 20.7 d) over a period of 38.9 days (SD = 31.2 d). The 28 intervention levels were associated with an average dropout rate of 2.6%, with two sections exhibiting an increase against this baseline. 150 participants met the minimum adherence goal of 24 h use. Questionnaires: 116 participants completed the post-intervention questionnaire.

SUPPORT

313 signed-up participants contacted the researchers via email.

CONCLUSION

The user journey method allowed for the comprehensive evaluation of the six intervention elements, and enabled identifying use barriers expediting iterative intervention development and implementation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05426265. Registered 28 June 2022, https://clinicaltrials.gov/ct2/show/NCT05426265 .

Dimensions of cisheteronormativity that influence healthcare utilization practices in LGBTQ+ populations: A systematic review

INTRODUCTION

Cisheteronormativity in healthcare settings may further exacerbate existing health disparities between LGBTQ+ and non-LGBTQ+ populations. The aim of the current review is to identify dimensions of cisheteronormativity that manifest in healthcare settings to influence healthcare utilization by LGBTQ+ individuals.

METHOD

8148 articles were screened, with 53 remaining for inclusion.

RESULTS

Thematic synthesis identified five themes linked to negative healthcare use: 1) Lack of Provider LGBTQ+ Knowledge, 2) Endorsements of Cisheteronormativity, 3) Assumptions of LGBTQ+ experiences and assumptions of non-LGBTQ+ identity, 4) Negation, and 5) Abuse of Power.

CONCLUSION

Findings emphasize the need for provider education regarding LGBTQ+ identities and the dismantling of cisheteronormative structures in healthcare.

Influencing Factors for the Acceptability of Accessing HIV Pre-exposure Prophylaxis via Community Pharmacies in Wales

INTRODUCTION

HIV prevention methods, such as pre-exposure prophylaxis (PrEP), have been a significant contributing factor to a global decline in HIV transmission. PrEP has been available through the NHS in Wales since 2017. However, access is exclusively via sexual health clinics, and those accessing PrEP do not reflect those being diagnosed with HIV. Widening access beyond sexual health clinics may be one approach to encourage more equitable uptake, and there is growing interest in offering PrEP services in community pharmacies. We, therefore, aimed to explore the acceptability of PrEP services being delivered through community pharmacies among prospective service users.

METHODS

We conducted a qualitative interview study of people living in Wales who either (i) currently access, (ii) previously accessed or are (iii) considering accessing PrEP via a sexual health clinic. Participants were recruited via community networks, and interviews were conducted virtually. Our topic guide was informed by Levesque's conceptual framework of access to healthcare, and we used reflexive thematic analysis.

RESULTS

We interviewed 24 participants and included data from 20 in the analysis. Four themes were generated: experiences of accessing PrEP via sexual health clinics, the prospect of PrEP access via community pharmacies, other community settings in which PrEP may be accessed and concerns around integrated healthcare and healthcare data.

CONCLUSION

PrEP access via community pharmacy is likely to be an acceptable option for people. There are uncertainties surrounding what a PrEP service would look like in a community pharmacy setting, and this would need clarifying to prospective users to increase the salience of access.

PATIENT AND PUBLIC CONTRIBUTION

A team-based approach was taken for developing the topic guide and agreeing on the codes for this study. This included people with lived experience of accessing PrEP in Wales.

The Landscape of Health Technology for Equity Deserving Groups in Rural Communities: A Systematic Review

BACKGROUND

Equity-deserving groups face well-known health disparities that are exacerbated by rural residence. Health technologies have shown promise in reducing disparities among these groups, but there has been no comprehensive evidence synthesis of outcomes.

PURPOSE

The purpose of this systematic review was to examine the patient, healthcare, and economic outcomes of health technology applications with rural living equity-deserving groups.

RESEARCH DESIGN

The databases searched included Medline and Embase. Articles were assessed for bias using the McGill mixed methods appraisal tool.

ANALYSIS

Data were synthesized narratively using a convergent integrated approach for qualitative and quantitative findings.

RESULTS

This evidence synthesis includes papers (n = 21) that reported on health technologies targeting rural equity-deserving groups. Overall, patient outcomes - knowledge, self-efficacy, weight loss, and clinical indicators - improved. Healthcare access improved with greater convenience, flexibility, time and travel savings, though travel was still occasionally necessary. All studies reported satisfaction with health technologies. Technology challenges reported related to connectivity and infrastructure issues influencing appointment quality and modality options. While some studies reported additional costs, overall, studies indicated cost savings for patients.

CONCLUSIONS

There is a paucity of research on health technologies targeting rural equity-deserving groups, and the available research has primarily focused on women. While current evidence was primarily of high quality, research is needed inclusive of equity-deserving groups and interventions co-designed with users that integrate culturally sensitive approaches. Review registered with Prospero ID = CRD42021285994.

Telemedicine-delivered treatment for substance use disorder: A scoping review

IntroductionThe COVID pandemic prompted a significant increase in the utilization of telemedicine (TM) for substance use disorder (SUD) treatment. As we transition towards a "new normal" policy, it is crucial to comprehensively understand the evidence of TM in SUD treatment. This scoping review aims to summarize existing evidence regarding TM's acceptability, quality, effectiveness, access/utilization, and cost in the context of SUD treatment in order to identify knowledge gaps and inform policy decisions regarding TM for SUDs.MethodWe searched studies published in 2012-2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis.ResultsA total of 856 relevant articles were screened, with a final total of 42 articles included in the review. TM in SUD treatment was perceived to be generally beneficial and acceptable. TM was as effective as in-person SUD care in terms of substance use reduction and treatment retention; however, most studies lacked rigorous designs and follow-up durations were brief (≤3 months). Telephone-based TM platforms (vs video) were positively associated with older age, lower education, and no prior overdose. Providers generally consider TM to be affordable for patients, but no relevant studies were available from patient perspectives.ConclusionsTM in SUD treatment is generally perceived to be beneficial and acceptable and as effective as in-person care, although more rigorously designed studies on effectiveness are still lacking. Access and utilization of TM may vary by platform. TM service quality and costs are the least studied and warrant further investigations.

Utilizing natural language processing for precision prevention of mental health disorders among youth: A systematic review

BACKGROUND

The global mental health crisis has created barriers to youth mental healthcare, leaving many disorders unaddressed. Precision prevention, which identifies individual risks, offers the potential for tailored interventions. While natural language processing (NLP) has shown promise in the early detection of mental health disorders, no review has examined its role in youth mental health detection. We hypothesize that NLP can improve early detection and personalized care in mental healthcare among youth.

METHODOLOGY

After screening 1197 articles from 5 databases, 12 papers were included covering six categories: (1) mental health disorders, (2) data sources, (3) NLP objective for mental health detection, (4) annotation and validation techniques, (5) linguistic markers, and (6) performance and evaluation. Study quality was assessed using Hawker's checklist for disparate study designs.

RESULTS

Most studies focused on suicide risk (42 %), depression (25 %), and stress (17 %). Social media (42 %) and interviews (33 %) were the most common data sources, with linguistic inquiry and word count and support vector machines frequently used for analysis. While most studies were exploratory, one implemented a real-time tool for detecting mental health risks. Validation methods, including precision and recall metrics, showed strong predictive performance.

CONCLUSIONS

This review highlights the potential of NLP in youth mental health detection, addressing challenges such as bias, data quality, and ethical concerns. Future research should refine NLP models using diverse, multimodal datasets, addressing data imbalance, and improving real-time detection. Exploring transformer-based models and ensuring ethical, inclusive data handling will be key to advancing NLP-driven interventions.

Access to healthcare for people with disabilities in Zambia: a qualitative study

People with disabilities globally experience poorer health outcomes than people without disabilities. The United Nations Convention on the Rights of Persons with Disabilities emphasises that people with disabilities must have equal access to healthcare, yet evidence demonstrates barriers to access across contexts. Research on this topic is limited in Zambia, and this study therefore aimed to generate evidence on access to healthcare for people with disabilities in Zambia. In this qualitative study, we conducted in-depth interviews with 48 participants, including 16 adults with disabilities, 16 caregivers of a child with disabilities, 12 primary healthcare professionals, and four key informants from government and civil society. Participants were recruited from three districts in Lusaka Province (Lusaka, Chongwe and Kafue), the most populated province in Zambia. Participants were purposively sampled to maximise variation by sex, age, impairment type, district and locality (rural, urban, peri-urban). Data collection was completed in August 2022. Key themes were mapped against the Levesque Framework of healthcare access. Participants reported limited information on available services, stigma from community members and healthcare professionals, limited knowledge on disability and a lack of training for healthcare professionals, and challenges with inaccessible health facilities and transport. Some people with disabilities benefited from government schemes, such as the National Health Insurance Scheme, but implementation faced challenges and not all people with disabilities accessed these services. Government action is needed to improve disability-inclusive healthcare in Zambia, alleviating barriers to reduce health disparities. Recommended actions include training for healthcare professionals and improved facility accessibility.

A systematic review of barriers and facilitators for ethnically diverse communities in accessing adult and paediatric hearing services

OBJECTIVE

To conduct a systematic review of identified barriers and facilitators for ethnically diverse adults and children in accessing hearing health services.

DESIGN

Searches were performed in electronic databases MEDLINE, EMBASE, CINAHL, Pychinfo, LLBA, and Scopus. The Strengthening of Reporting of Observational Studies in Epidemiology and Standards for Reporting Qualitative Research were used to assess quality of articles. Barriers and facilitators for ethnically diverse adults and children to access hearing services were summarised descriptively using Levesque et al.'s conceptual framework of access to healthcare.

STUDY SAMPLE

25 articles met the inclusion criteria.

RESULTS

Barriers and facilitators were identified for every domain of Levesque's framework for ethnically diverse adults, children, and their families. Personal barriers included health literacy, health beliefs, and stigma. Environmental barriers included language, limited cultural and interpreter training for clinicians, time constraints in appointments, direct and indirect costs. Facilitators included availability of translated and/or simplified information, cultural responsiveness training, outreach programs, and community health workers to engage with ethnically diverse communities.

CONCLUSION

With increasingly multicultural societies globally, there is an increased need to provide culturally responsive care and accessible hearing health services. Understanding current barriers and facilitators to accessibility would facilitate global sustainable development goals around reduced inequality, health, and wellbeing.

Engaging community groups to enhance healthcare access for persons with disabilities in rural Uganda: A qualitative exploration

Community participation is a promising strategy for addressing local health needs through identification of context-specific challenges and developing sustainable solutions. However, its feasibility for persons with disabilities, who are often marginalized and excluded from participation, remains uncertain. Our study examines barriers and facilitators to community group participation in improving healthcare access for persons with disabilities in Uganda. Semi-structured interviews with 27 purposively selected persons with disabilities in Luuka district, Eastern Uganda were undertaken between September and November 2022. Questions were asked about participation in existing groups and interest in joining community groups for persons with disabilities to improve healthcare access. All interviews were recorded and transcribed and analysed with a thematic approach. Our study uncovered a notable lack of active engagement among persons with disabilities in existing community groups. Participants expressed a strong desire to belong to disability-focused groups, primarily driven by the desire for unified advocacy. Facilitators for group formation included the opportunity for collaborative problem-solving, unified advocacy, and the chance to share lived experiences. Conversely, barriers to participation encompassed issues such as low self-esteem, financial constraints preventing monetary contributions, and the lack of reasonable accommodations, such as inaccessible meeting venues. Recommendations for group formation included community-wide sensitisation, stakeholder engagement, integration of health-livelihood initiatives, linkage to services, and managing group dynamics to ensure inclusiveness, a manageable group size, and realistic monetary contributions. Persons with disabilities are eager to participate in community groups and recognize the importance of strengthening community-based healthcare initiatives. Addressing barriers to group formation can unlock the potential of these groups to support persons with disabilities effectively. These findings offer valuable insights for developing community-based interventions to enhance healthcare access for persons with disabilities. Further research is essential to fully grasp the key mechanisms and dynamics within these groups to ensure their long-term sustainability.

Pushing for Equity, Pulling at Heartstrings: Perinatal Care Access for Uninsured Migrants

Despite widely accepted clinical care guidelines, uninsured pregnant migrants in Canada face health inequalities and there are ethical implications of denying them publicly-funded care. Uninsured migrants face multiple barriers (financial, systemic, and cultural) to their perinatal care access, which can negatively impact their health and psychosocial outcomes, as well as those of their families. Drawing on interviews with 10 uninsured migrant women in Montreal, Canada, we explore the factors that enabled their access to perinatal care. Our findings underline the importance of health professionals' ability to exercise discretion to volunteer their time, reduce their fees, or "go the extra mile" to ensure care. On the part of the pregnant migrants themselves, individual factors such as resourcefulness, patient proficiency, and social location may enable their care access. This individualization of the access to care is both ethically and politically problematic, and we discuss the role of social workers in addressing the needs of this population.