PubMed · 9832777
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Z Matthews. The outsiders.. https://pubmed.ncbi.nlm.nih.gov/9832777/
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BACKGROUND: Rural populations experience persistent inequities in access to palliative care. Existing evidence often describes individual barriers separately, with less attention to how access breaks down across the care pathway or how different service configurations shape access. OBJECTIVES: To synthesise evidence on access to palliative care in rural settings and examine how access barriers, service models, and implementation conditions interact across the care pathway. METHODS: A mixed-methods systematic review using a convergent integrated approach searched nine databases (PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO, CNKI, WanFang, SinoMed) from inception to 15 March 2026, supplemented by hand-searching. Eligible studies were primary qualitative, quantitative, and mixed-methods studies on access to palliative care for adults in rural or non-urban settings. Two reviewers independently screened studies, extracted data, and assessed quality using the Mixed Methods Appraisal Tool. Findings were mapped to the Levesque access framework, analysed using the updated Consolidated Framework for Implementation Research, and integrated through mixed-methods synthesis, with additional coding of service models. RESULTS: Thirty-four studies were included, of which 26 were conducted in high-income countries and eight in low- and middle-income countries. Service configurations included specialist or hospice-oriented care, generalist or primary-care-oriented care, mixed specialist-generalist models, home-based and caregiver-centred care, nurse-coordinated services, telehealth-supported care, and community or implementation-oriented approaches. Access broke down cumulatively across four interdependent stages: recognition, entry, reach, and use and continuity, with affordability constraining every stage. Recognition was limited by low awareness, poor service visibility, and delayed identification of need. Entry was shaped by stigma, trust, family expectations, and unclear referral processes. Reach was constrained by distance, transport, workforce shortages, limited specialist capacity, and weak infrastructure. Use and continuity were affected by fragmented coordination, weak transitions, unstable follow-up, and reliance on family caregivers. Access problems varied across service configurations. Evidence on service innovations was methodologically less certain, and the overall evidence base remained concentrated in high-income countries. CONCLUSIONS: Access to palliative care in rural settings is best understood as a pathway and service-configuration problem rather than simply a deficit in service availability. Improving access requires earlier recognition, clearer referral routes, stronger specialist-generalist and nursing links, better support for family caregivers, and greater attention to affordability, continuity, and rural settings with limited resources. REGISTRATION: International Prospective Register of Systematic Reviews: CRD420261340783.
An increasing number of studies are documenting the existence of inequities, and attention is now turning to exploring pathways through which they are generated and might be attacked. This appears to be an opportune time to consider what has been learned and what future directions might be taken by researchers to fill gaps in knowledge and make research more useful for policy interventions. This commentary briefly reviews some of the main contributions of past research that have possible relevance to pathways, considers what those pathways might include, and concludes with implications for future research. It makes the case for a conceptualization of influences on equity that explicitly includes distribution of health as an outcome as well as characteristics of the society as influences.
The aim of the study was to examine whether improved quality of primary physician services, measured by patient satisfaction, leads to fewer admissions to somatic hospitals. We studied differences in hospital admissions at the municipality level in Norway. In addition to the standard explanatory variables for use of hospitals--gender, age, socio-economic status and travelling distance to the nearest hospital--we also included a measure of patient satisfaction with primary physician services in the municipality. Data on patient satisfaction was obtained from an extensive questionnaire survey of 63,798 respondents. We found a statistically significant negative relationship between patient satisfaction and the number of hospital admissions. This conclusion was robust with regard to the empirical specification, and the effect was large.