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[Gender, equality, and health services access: an empirical approximation].

This piece describes the conceptual framework and the objectives that guided a research initiative in the Region of the Americas that was called "Gender, Equity, and Access to Health Services" and that was sponsored in 2001 by the Pan American Health Organization. The piece does not summarize the results of the six projects that were carried under the initiative, whose analyses have not all been completed. Instead, the piece discusses some of the foundations of the initiative and provides a general introduction to the country studies that were done. The six studies were done in Barbados/Jamaica, Brazil, Chile, Colombia, Ecuador, and Peru. The primary objective of the initiative was to stimulate the use of existing quantitative information in the countries, with the goal of starting a process of systematically documenting two things: 1) the unfair, unnecessary, and avoidable inequalities between men and women in their access to health care and 2) the linkages between those inequalities and other socioeconomic factors. The concept of gender equity that guided this examination of health care was not the usual one calling for the equal distribution of resources. Rather, it was the notion that resources should be allocated differentially, according to the particular needs of men and of women, and that persons should pay for health services according to their economic ability rather than their risk level. The starting point for the initiative was the premise that gender inequities in utilizing and paying for health care result from gender differences in the macroeconomic and microeconomic distribution of resources. The piece concludes that achieving equity in health care access will require a better understanding of the gender needs and gender barriers that are linked to social structures and health systems.

Barbados↗
PubMed2006

Brutal neglect: Australian rural women's access to health services.

Access to health services in rural Australia has been particularly problematic because of the vast geographical areas and the sparse population distribution across the inland. The focus on health servicing has been very much on primary health care with most attention being giving to the distribution of doctors in rural Australia. This study takes a closer look at rural health servicing through the eyes of women in rural Australia. Drawing on a survey of 820 women, the study revealed that a focus on primary health care may be resulting in a lack of attention to women's health in areas, such as maternity models of care, domestic violence and mental health. The study also reveals the disquiet of Australian rural women at the poor state of health services.

Adolescent↗
PubMed2004

Overcoming barriers to health service access: influencing the demand side.

Evidence suggests that demand-side barriers may be as important as supply factors in deterring patients from obtaining treatment. Yet relatively little attention is given, either by policy makers or researchers, to ways of minimizing their effect. These barriers are likely to be more important for the poor and other vulnerable groups, where the costs of access, lack of information and cultural barriers impede them from benefiting from public spending. Demand barriers present in low- and middle-income countries and evidence on the effectiveness of interventions to overcome these obstacles are reviewed. Demand barriers are also shown to be important in richer countries, particularly among vulnerable groups. This suggests that while barriers are plentiful, there is a dearth of evidence on ways to reduce them. Where evidence does exist, the data and methodology for evaluating effectiveness and cost-effectiveness is insufficient. An increased focus on obtaining robust evidence on effective interventions could yield high returns. The likely nature of the interventions means that pragmatic policy routes that go beyond the traditional boundaries of the public health sector are required for implementing the findings.

Health Services↗
PubMed2003

Effects of Medicaid managed care programs on health services access and use.

OBJECTIVE: To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees' access to and use of health care services at the national level. DATA SOURCES/STUDY SETTING: 1991-1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs. STUDY DESIGN: Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects. DATA COLLECTION/EXTRACTION METHOD: This study uses pooled individual-level data from up to five years of the NHIS (1991-1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey. PRINCIPAL FINDINGS: We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non-emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access. CONCLUSIONS: Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.

Adult↗
PubMed1999

Health service accessibility and deaths from asthma.

BACKGROUND: Good access to health services may be important for effective asthma management amongst patients, thus preventing unnecessary deaths. In a previous study, we found elevated levels of asthma mortality in English local authority districts with poor access to acute hospitals. Here, the relationship between asthma mortality and access to primary and secondary services within the rural region of East Anglia is examined. METHODS: A geographically based descriptive study, within 536 electoral wards in the region of East Anglia, England. Regression analysis was used to examine the relationship between health service accessibility, and mortality from asthma during the period January 1985 to December 1995. RESULTS: After controlling for confounding factors, there was a significant tendency for asthma mortality to increase with travel time to hospital, with a relative risk of 1.07 for each 10-minute increase in journey time (P = 0.04). There was no consistent trend for mortality to increase with travel time to general practitioner surgeries. CONCLUSIONS: The results of this study support the conclusions of earlier work that inaccessibility of acute hospital services may increase the risk of asthma mortality. The provision of good access to these facilities may be one factor in reducing the burden of avoidable deaths from asthma.

Asthma↗
PubMed2004

[A review of concepts in health services access and utilization].

The purposes of this article are to review the concepts of health services access and utilization and to analyze how these concepts interrelate. Access is a complex concept (often used inaccurately) which changes over time and according to the context. Health services utilization is at the core of health systems functioning. Despite some disagreement, according to this review the prevailing perspective is that access is related to characteristics of services supply. Health care services utilization can be applied as a measure of access, but use of services depends on other factors. Individual and contextual factors influence the use of services. The article shows that the concept of access is becoming more comprehensive and is changing its focus from entry into the health system to outcome of care. Access is valued in relation to its impact on health and depends on the effectiveness of care delivered. As an outcome measure, access becomes multidimensional and difficult to operationalize. Finally, the article discusses how health determinants differ from those of health services utilization, which impacts directly on illness, but only indirectly on health.

Health Services↗
PubMed1997

Medicaid enrollment and health services access by Latino children in inner-city Los Angeles.

OBJECTIVES: To understand the role of parental immigration status on Medicaid enrollment and access to health services for young Latino children. DESIGN: A cross-sectional household survey of the parents of inner-city Latino children. SETTING: South Central and East Los Angeles, Calif, 1992. POPULATION: Children 12 to 36 months old and their parents from 817 Latino families. MAIN OUTCOME VARIABLES: Continuous Medicaid enrollment, continuity of care, deferral of care, and number of visits. METHODS: Univariate analysis, logistic and linear regression by demographic and socioeconomic characteristics, residency status, and language use. RESULTS: Children were primarily born in the United States (96%), but most parents were not citizens (80%). Only 40.0% of eligible children had continuous Medicaid coverage since birth, 18.6% had never been insured, and 20.7% had received episodic Medicaid coverage. Continuous Medicaid coverage was negatively associated with either the caregiver (odds ratio [OR],0.32; 95% confidence interval [CI], 0.19-0.56) or their partner (OR=0.33, 95% CI =0.20-0.55) working. Residency status, language preference, and length of US residency were not associated with continuous Medicaid enrollment. Insurance coverage was associated with more physician visits, greater continuity of care, and fewer deferrals of care. CONCLUSION: While most (84%) young Latino children in inner-city Los Angeles were eligible for Medicaid, a substantial proportion (39.3%) have episodic or no coverage. Insurance status and provider type were more consistently associated with access rather than residency and language preference. In the aftermath of California's Proposition 187 and federal welfare reform, insurance status and access are likely to worsen for these young children unless the wave of antiimmigration sentiments is held in check.

Child↗
PubMed2004

Making public mental-health services accessible to deaf consumers: Illinois Deaf Services 2000.

Illinois Deaf Services 2000 (IDS2000), a public/private partnership, promotes the creation and implementation of strategies to develop and increase access to mental health services for deaf, hard of hearing, late-deafened, and deaf-blind consumers. IDS2000 has resulted in the establishment of service accessibility standards, a technical support and adherence monitoring system, and the beginnings of a statewide telepsychiatry service. These system modifications have resulted in increase by 60% from baseline survey data in the number of deaf, hard of hearing, late-deafened, and deaf-blind consumers identified in community mental-health agencies in Illinois. Depending on the situation of deaf services staff and infrastructure, much of IDS2000 could be replicated in other states in a mostly budget-neutral manner.

Health Services Accessibility↗
PubMed2004

Health service access, use, and insurance coverage among American Indians/Alaska Natives and Whites: what role does the Indian Health Service play?

OBJECTIVES: We compared access and utilization of health services among American Indians/Alaska Natives (AIANs) with that among non-Hispanic Whites. METHODS: We used data from the 1997 and 1999 National Survey of America's Families to estimate odds ratios for several measures of access and utilization and the effects of Indian Health Service (IHS) coverage. RESULTS: AIANs had less insurance coverage and worse access and utilization than Whites. Over half of low-income uninsured AIANs did not have access to the IHS. However, among the low-income population, AIANs with only IHS access fared better than uninsured AIANs and as well as insured Whites for key measures but received less preventive care. CONCLUSIONS: The IHS partially offsets lack of insurance for some uninsured AIANs, but important needs were potentially unmet.

Adolescent↗
PubMed1996

[Health services accessibility in the Murcia region].

OBJECTIVES: To find the geographical accessibility of primary care services and their support facilities. DESIGN: An observational, crossover study. SETTING: Primary health care. PATIENTS OR OTHER PARTICIPANTS: All those collective and single population groupings (354), included in the population register of the Murcia region with 100 or more inhabitants listed or with less inhabitants but with a health care post. MEASUREMENTS AND MAIN RESULTS: The time (crona) taken by the population of the different health districts and areas of the region to reach primary care and support services was determined by direct observation. Crona was defined as the average of three measurements of the time taken to reach these services by people using their normal means of transport and not exceeding the highway code's speed limits. 335 care posts were counted. Only 1,56% of the population, all belonging to Health Area 4, needed more than 30 minutes to reach their local doctor. 18,36% of the population needed more than 30 minutes to reach their referral hospitals. CONCLUSIONS: The number and distribution of facilities in the health care network guarantee adequate access to their services, except in Area 4. Specific studies will have to be designed to check that access problems are connected more to the road network and transport used than to the number and location of care centres.

Cross-Over Studies↗
PubMed1981

Equity, access, and the costs of health services.

Access to health care services for the poor and elderly have improved dramatically over the last 15 years, largely as a result of Medicare, Medicaid, and other Federal initiatives. The poor now consume roughly the same volume of health services as the nonpoor. Yet there are still substantial access barriers for many of the chronically ill, minorities, and residents of inner cities and rural areas. Of broader concern, the improvements in access are now threatened by the response to rising health care costs. Those cost increases are themselves partly--but only partly--attributable to Medicare and Medicaid themselves. True cost containment, as opposed to program cost containment, can restrain cost increases without damaging access, but is politically more difficult to accomplish than measures to reduce access.

Aged↗
PubMed2000

Health services accessibility among Spanish elderly.

The paper aims to identify the variables that best explain the use of health services by people aged 65 and over in Spain. The data comes from the 1993 Spanish National Health Survey (ENSE 93). The conceptual framework is the model proposed by Andersen, who suggests that utilisation is a function of predisposition to use the services, the ability to use them and of need. A bivariate and multivariate analysis (SPSS-X Discriminant Procedure) is conducted to define the predictors that best discriminate users and non-users. The use of each health service is explained by a different set of variables. The need variables play a more important role in predicting the use of non-discretionary services that are more closely related to healing processes (medical consultations, emergencies and hospitalisation). The predisposing and enabling variables are more relevant in explaining the use of dental services, indicating a certain degree of inequity of these discretionary services.

Aged↗
PubMed1995

Health services access and use among older adults in North Carolina: urban vs rural residents.

OBJECTIVES: This study compared health service use and satisfaction with health care among older adults living in urban vs rural counties in North Carolina. METHODS: A stratified random sample of 4162 residents of one urban and four rural counties of North Carolina was surveyed to determine urban/rural variation in inpatient and outpatient health service use, continuity of care and satisfaction with care, and barriers (transportation, cost) to care. RESULTS: Inpatient and outpatient service use did not vary by residence in controlled analyses. Continuity of care was more frequent in rural counties. Transportation was not perceived as a barrier to health care more frequently in rural than in urban counties, but cost was a greater barrier to care among rural elderly people. CONCLUSIONS: In this sample, older persons living in rural counties within reasonable driving distance of urban counties with major medical centers used health services as frequently and were as satisfied with their health care as persons in urban counties. Cost of care, however, was a significant and persistent barrier among rural elderly people, despite Medicare coverage.

Age Factors↗
PubMed2001

Changing access to health services in urban China: implications for equity.

The ongoing reform of public institutions and state-owned enterprises in urban China has had a profound impact on the financing, organization and provision of health services. Access to health care by the urban population has become more inequitable. One of the most pressing concerns is that those who have lost jobs have increasing difficulties accessing health care. Using the data from the national household health surveys conducted in 1993 and 1998, this paper presents empirical results of changing utilization of health care among different income groups. Over 16 000 households and 54 000 individuals in the urban areas were randomly selected to collect information on perceived need of and demand for health care and expenditures on the services. The findings show that the income gap between the highest and lowest income groups increased in real terms from 1993 to 1998. There was a significant decline in the population covered by the government insurance scheme (GIS) and the labour insurance scheme (LIS), while the proportion of the population who had to pay for services out-of-pocket increased from 28% in 1993 to 44% in 1998. There was no statistically significant change in self-reported illness in the 2 weeks prior to survey among the study population over the period. While it was found that more people who reported illness from each income group received medical treatment of some kind, there was a decline in seeking care from a health provider. Among those in the lowest income group who reported illness but did not obtain treatment of any kind, nearly 70% (as compared with 38% in 1993) claimed financial difficulty as the major reason in 1998. The use of in-patient services dropped significantly from 4.5% in 1993 to 3.0% in 1998. The decreased use of in-patient services was more serious in the lowest and lower income groups than in higher and highest income groups. The percentage of patients referred for hospital admission but not being hospitalized had a negative relationship with income level. We can conclude from the data analysis that access of the urban population, particularly the poor, to formal health services has worsened and become more inequitable since the early 1990s. Among possible reasons for this trend are the rapid rise of per capita expenditure on health services and the decline in insurance coverage.

China↗
PubMed1997

Health service accessibility and deaths from asthma in 401 local authority districts in England and Wales, 1988-92.

BACKGROUND: The possible contribution of health service accessibility to asthma mortality has not previously been studied in the UK. METHODS: Using regression analysis, the relationship between geographical isolation from large acute hospital services and mortality from asthma for 401 local authority districts in England and Wales was examined for the period 1988-92. RESULTS: Asthma mortality was found to be strongly associated with the proportion of district households where the head was of social class 4 or 5 (adjusted relative risk 1.61, 95% confidence interval (CI) 1.12 to 2.33), and the proportion of households without access to a car (adjusted relative risk 1.59, 95% CI 0.97 to 2.62). After controlling for these factors, there was a tendency for mortality to rise with increasing distance from hospital, with a relative risk of 1.01 for an increase in distance of one kilometre (95% CI 1.00 to 1.02). CONCLUSIONS: The findings suggest that problems of accessibility of care may mean that the control of asthma amongst sufferers living in districts most remote from major health service units might be less than optimal, and this could result in a number of potentially avoidable deaths.

Adolescent↗
PubMed2006

Telemental health technology in deaf and general mental-health services: access and use.

Long-distance travel to provide mental health services for deaf people has implications for efficiency, safety, and equality of service. However, uptake of Telemental Health (TMH) has been slow in both deaf and general mental health services. A quantitative study was used to investigate access to TMH and whether staff confidence, experience, or demographics affect TMH use. It was concluded that staff in neither deaf mental health services nor general mental health services had adequate knowledge of or access to TMH. Staff expressed concerns over TMH's appropriateness in their work. Previous use of videoconferencing was assosciated significantly with confidence, but previous use of videophones was not. Neither staff in deaf services nor deaf staff were more experienced with or more confident about videoconferencing, whereas, within deaf services, deaf staff were significantly more confident about videophone use. Training implications are discussed.

Adolescent↗