Spatial Accessibility of Primary Care in England: A Cross-Sectional Study Using a Floating Catchment Area Method

Gravity models for potential spatial healthcare access measurement: a systematic methodological review

BACKGROUND

Quantifying spatial access to care-the interplay of accessibility and availability-is vital for healthcare planning and understanding implications of services (mal-)distribution. A plethora of methods aims to measure potential spatial access to healthcare services. The current study conducts a systematic review to identify and assess gravity model-type methods for spatial healthcare access measurement and to summarize the use of these measures in empirical research.

METHODS

A two-step approach was used to identify (1) methodological studies that presented a novel gravity model for measuring spatial access to healthcare and (2) empirical studies that applied one of these methods in a healthcare context. The review was conducted according to the PRISMA guidelines. EMBASE, CINAHL, Web of Science, and Scopus were searched in the first step. Forward citation search was used in the second step.

RESULTS

We identified 43 studies presenting a methodological development and 346 empirical application cases of those methods in 309 studies. Two major conceptual developments emerged: The Two-Step Floating Catchment Area (2SFCA) method and the Kernel Density (KD) method. Virtually all other methodological developments evolved from the 2SFCA method, forming the 2SFCA method family. Novel methodologies within the 2SFCA family introduced developments regarding distance decay within the catchment area, variable catchment area sizes, outcome unit, provider competition, local and global distance decay, subgroup-specific access, multiple transportation modes, and time-dependent access. Methodological developments aimed to either approximate reality, fit a specific context, or correct methodology. Empirical studies almost exclusively applied methods from the 2SFCA family while other gravity model types were applied rarely. Distance decay within catchment areas was frequently implemented in application studies, however, the initial 2SFCA method remains common in empirical research. Most empirical studies used the spatial access measure for descriptive purposes. Increasingly, gravity model measures also served as potential explanatory factor for health outcomes.

CONCLUSIONS

Gravity models for measuring potential spatial healthcare access are almost exclusively dominated by the family of 2SFCA methods-both for methodological developments and applications in empirical research. While methodological developments incorporate increasing methodological complexity, research practice largely applies gravity models with straightforward intuition and moderate data and computational requirements.

Geographic opportunities for assisted reproduction: a study of regional variations in access to fertility treatment in England

It is estimated that one in seven couples in the UK experience infertility, though just over half of those affected by it seek professional help. Previous studies pointed to potential socioeconomic barriers in accessing assisted reproduction; however, less is known about geographic accessibility to fertility treatment and the way it is associated with measures of deprivation. In this study, we used publicly available data on fertility clinics, combined with official statistics for 315 local authorities in England, to create a standardized measure of geographic accessibility to fertility services. In addition, using a negative binomial regression model, we estimated the link between socioeconomic measures at the local authority level and availability of fertility services. We found that geographic accessibility to assisted reproduction is significantly higher in the most advantaged local authorities in terms of average household income and level of deprivation. This may lead to reduced opportunities for realizing fertility aspirations among those suffering from infertility in more deprived areas. Taking into account both socioeconomic and geographic barriers to accessing fertility treatment can contribute to a better understanding of help-seeking patterns for infertility, likelihood of achieving a live birth and inform policy to equalise opportunities in access to infertility treatment.

Spatial Accessibility of Primary Care in the Dual Public-Private Health System in Rural Areas, Malaysia

Disparities in access to health services in rural areas represent a global health issue. Various external factors contribute to these disparities and each root requires specific remedial action to alleviate the issue. This study elucidates an approach to assessing the spatial accessibility of primary care, considering Malaysia's dual public-private system specifically in rural areas, and identifies its associated ecological factors. Spatial accessibility was calculated using the Enhance 2-Step Floating Catchment Area (E2SFCA) method, modified as per local context. Data were secondary sourced from Population and Housing Census data and administrative datasets pertaining to health facilities and road network. The spatial pattern of the E2SFCA scores were depicted using Hot spot Analysis. Hierarchical multiple linear regression and geographical weight regression were performed to identify factors that affect E2SFCA scores. Hot spot areas revolved near the urban agglomeration, largely contributed by the private sector. Distance to urban areas, road density, population density dependency ratios and ethnic composition were among the associated factors. Accurate conceptualization and comprehensive assessment of accessibility are crucial for evidence-based decision making by the policymakers and health authorities in identifying areas that need attention for a more specific and localized planning and development.

Assessing Spatial Accessibility of Community Hospitals for the Elderly in Beijing, China

Accessibility of health services signifies the quality and equitability of universal health provision. The hierarchical medical system recently implemented in China offers the policy instruments to improve medical services to the elderly in an aging society. As the critical primary care gateway, accessibility to community hospitals has significant impacts on people's health. However, current research has paid little attention to spatial accessibility within walking distance of community hospitals, especially for the elderly. This study selected four districts with different urbanization levels in the rapidly developing Beijing metropolis. The spatial interaction model was applied to measure the accessibility of community hospitals for the elderly at the community level. An attractiveness index was computed based on key hospital traits. The results showed that: (1) community hospitals could cover 82.66% of elderly residents, and 77.63% of the communities were within walking distance. The served elderly proportion was relatively high in central urban areas and low in the suburbs. (2) The attractiveness indices of hospitals varied notably between districts, with higher values in more urbanized areas. (3) The spatial accessibility for the elderly of hospitals differed significantly between the four districts, with a descending gradient from central to suburban and rural areas, as indicated by the Gini coefficients and Lorenz curves. (4) The accessibility index was strongly related to the served elderly population and the hospital-residence distance. The findings provide policy directions to the government, including providing more primary-care resources to suburban and rural areas, building new community hospitals in identified provision gaps, upgrading some clinics to hospitals in rural areas, and planning hospitals according to the projected trend of the elderly population in terms of quantity and distribution. The considerable provision disparity between core urban, suburban and rural areas can be addressed by refined spatial health planning informed by research.

Research on the Equity and Optimal Allocation of Basic Medical Services in Guangzhou in the Context of COVID-19

Optimizing the allocation of basic medical services and ensuring their equity are necessary to improve the ability to respond to public health emergencies and promote health equity in the context of COVID-19. This study aims to analyze the equity of Guangzhou's basic medical service and identify areas where health resources are relatively scarce. The spatial distribution and patterns of basic medical services were analyzed using kernel density analysis and standard deviation ellipse. The equity was analyzed using the Gini coefficient and Lorenz curve in terms of population and geographical area, respectively. Considering the medical demand and supply sides, the Gaussian two-step floating catchment area method was used to analyze the accessibility to different levels of medical institutions. The kernel density analysis and standard deviation ellipse showed that the spatial distribution of medical and health resources in Guangzhou is unevenly distributed, and high-level hospitals and medical resources are mainly concentrated in the centrum. From the perspective of population, Guangzhou's medical equity is generally reasonable. The accessibility of medical institutions differs with different levels, and the tertiary medical institutions have the best accessibility, while the unclassified, primary, and secondary medical institutions generally have lower accessibility. The accessibility of districts in Guangzhou varies greatly. Areas in the center are most accessible to basic medical services, while accessibility in outskirt areas has gradually decreased. Conclusion: The quantity of per capita medical and health resources in Guangzhou, as evidenced by basic medical services, is sufficient, but the spatial distribution is unequal. The developed city center enjoys more adequate healthcare resources than the distant suburbs. Primary healthcare should be built, especially in distant suburbs, to strengthen basic medical service equity in Guangzhou.

Investigating the impact of bank branch closures on access to financial services in the early stages of the COVID-19 pandemic

There is a longstanding policy interest in understanding the impacts of changes in access to public and private services in rural areas. To date much of the empirical analysis concerning changing patterns of accessibility has been predicated on assumptions regarding the mode of transport used to access such facilities. The availability of new and open sources of data, and the increasing sophistication of spatial analytical tools, has enabled alternative transportation modes to be included when investigating the impact of service changes. In this study a nationwide analysis of changes in public transport provision and bank closures has enabled the identification of those parts of Wales that were disproportionally impacted by the loss of financial services during the early years of the COVID-19 pandemic. Drawing on local scenarios which show the combined impact of such changes, the findings demonstrate how temporal variations in accessibility can be used to examine potential patterns of exclusion that arise from the loss of key services. We conclude by suggesting that any assessment of changes in accessibility needs a holistic approach that considers changes in the transport infrastructure alongside other facets of service provision to understand the full impact of such closures on rural communities.

An External Patient Healthcare Index (EPHI) for Simulating Spatial Tendencies in Healthcare Seeking Behavior

Background

Healthcare resources are always more limited compared with demand, but better matching supply with demand can improve overall resource efficiency. In countries like China where patients are free to choose healthcare facilities, over-utilization and under-utilization of healthcare resources co-exist because of unreasonable healthcare seeking behavior. However, scholarship regarding the spatial distribution of utilization for healthcare resources, resulting from unreasonable spatial tendencies in healthcare seeking, is rare.

Methods

In this article, we propose a new External Patient Healthcare Index (EPHI) to simulate the spatial distribution of utilization for healthcare resources, based on the Two-Step Floating Catchment Area (2SFCA) method, which is widely used to assess potential spatial accessibility. Instead of using individual-level healthcare utilization data which is difficult to obtain, the EPHI uses institution-level aggregated data, including numbers of inpatient/outpatient visits. By comparing the estimated utilization (based on local healthcare institution services provision) with the expected utilization (based on local population morbidity), guest patients (e.g., patients flowing in for treatment) and bypass patients (patients flowing out) can be identified. To test the applicability of this index, a case study was carried out on China's Hainan Island. The spatial tendencies of patients for inpatient and outpatient services were simulated, then incorporated with spatial access to healthcare resources to evaluate overall resource allocation efficiency, thus guiding future resource allocations and investment for policy makers and healthcare providers.

Results

The EPHI revealed that bypass activities widely exist on Hainan Island in both inpatient and outpatient care, with patients tending to travel from less developed regions with fewer healthcare resources to more highly developed regions with more healthcare resources to receive healthcare. Comparison with spatial accessibility demonstrated how bypass activities on Hainan produced an under-utilization of doctors in less developed regions and over-utilization of doctors in more developed coastal regions.

Conclusions

This case study on Hainan Island demonstrates that this new index can very clearly identify both the sources and sinks of patient spatial tendencies. Combining these results with spatial accessibility of healthcare resources, how efficiently the available supply matches the utilization can be revealed, indicating wide-ranging applicability for local governments and policymakers.

Knowledge, attitudes and practices of parents towards antibiotic use in rural communities in Peru: a cross-sectional multicentre study

Background

The inappropriate use of antibiotics significantly contributes to the development of antibiotic resistance. There is limited information about the use of antibiotics among parents from rural areas in Peru. This study aimed to describe the knowledge, attitudes and practices towards antibiotics among parents of children < 5 years of age from rural communities in Peru; to explore the association between knowledge and attitudes towards antibiotics and to explore determinants of low knowledge and self-medicating his/her child with antibiotics.

Methods

Cross-sectional study in six rural primary health centres in Peru using a self-administered survey. Crude and adjusted Prevalence Ratios (PR), and 95% Confidence Intervals (95% CI) were calculated to explore determinants of low knowledge and of having self-medicated his/her child with antibiotics. Linear regression was used to explore the association between knowledge and attitudes.

Results

A total of 231 parents were included. The largest gap in knowledge was among 183 parents (79%) who did not know that antibiotics cannot cure viral infections. The largest gap in attitudes was among 185 participants (80%) that did not disagree with “If I want my child to receive antibiotics, I would not be satisfied if the doctor refuses to prescribe them”. More than half of parents (n = 120, 52%) reported having self-medicated his/her child with antibiotics. A positive correlation was found between knowledge and attitudes (Coefficient 0.53, 95% CI 0.38–0.68) after adjusting for the age and the education of the parent. Parents who were < 20 years old were more likely to have low knowledge about antibiotics (crude PR 2.39, 95% CI 1.32–4.34) compared to those aged > 40 years.

Parents who had self-medicated his/her child with antibiotics (n = 120, 52%) were more likely to have purchased antibiotics without prescription (aPR 2.70, 95% CI 1.74–4.19) and to have received antibiotics after the recommendation of a pharmacist (aPR 1.79, 95% CI 1.13–2.82).

Conclusions

Knowledge about antibiotics among parents from rural settings in Peru is limited and highlights the need for educational interventions. Public health policies to limit the acquisition of antibiotics without prescription should be implemented.

Assessing Spatial Accessibility to Primary Health Care Services in Beijing, China

Primary health care has been emphasized as a pillar of China’s current round of health reforms throughout the previous decade. The purpose of this study is to analyze the accessibility of primary health care services in Beijing and to identify locations with a relative scarcity of health personnel. Seven ecological conservation districts, which are relatively underdeveloped, were selected in the study. The Gini coefficient and Lorenz curve, as well as the shortest trip time and modified two-step floating catchment area (M2SFCA) approach, are used to quantify inequalities in primary health care resources and spatial accessibility. The Gini coefficient of primary medical services was calculated as high as 0.705, showing a significant disparity in primary care services. A total of 81.22% of communities reached the nearest primary care institution within 15 min. The average accessibility of primary healthcare services, as measured by the number of health professionals per 1000 population, was 2.34 in the 1715 communities of seven ecological conservation districts. Three hundred and ninety-one communities (22.80%) were identified with relatively low accessibility. More primary health professionals should be allocated to Miyun, Mentougou, and Changping Districts. Overall, the primary healthcare resources were distributed unevenly in most districts. According to our study, expanding primary healthcare institutions, increasing the number of competent health professionals, and enhancing road networks will all be effective ways to increase spatial accessibility and reduce primary healthcare service disparity in Beijing.

Whether Urbanization Has Intensified the Spread of Infectious Diseases-Renewed Question by the COVID-19 Pandemic

The outbreak of the COVID-19 epidemic has triggered adiscussion of the relationship between urbanization and the spread of infectious diseases. Namely, whether urbanization will exacerbate the spread of infectious diseases. Based on 31 provincial data from 2002 to 2018 in China, the impact of urbanization on the spread of infectious diseases from the dimensions of "population" and "land" is analyzed in this paper by using the GMM (generalized method of moments) model. The empirical study shows that the population increase brought by urbanization does not aggravate the spread of infectious diseases. On the contrary, urban education, employment and entrepreneurship, housing, medical and health care, and other basic public services brought by population urbanization can help reduce the risk of the spread of infectious diseases. The increasing density of buildings caused by land urbanization increases the risk of the spread of infectious diseases. Moreover, the impact of urbanization on the spread of infectious diseases has regional heterogeneity. Therefore, the prevention and control of disease play a crucial role.

Geographic and Temporal Access to Basic Banking Services Offered through Post Offices in Wales

Access to 'universal banking services' through the post office network has been a goal of the UK governments over the last twenty years. Various policies and mechanisms have been put in place in an attempt to maintain national geographical coverage with access points while increasing the financial viability of the network. One such mechanism is represented by the six official criteria for access to post offices, expressed as a percentage of the UK population living within one mile, three miles, and six miles of a post office. The method for calculating compliance with these access criteria is not published. Nor will any granular results be published, but only an annual statement that the criteria are being met. This article examines geographical and temporal access to post offices in order to understand the territorial coverage of the network and the impact this has on the provision of basic banking services. The area under investigation is Wales, for which we are reviewing the Government's official access criteria. Through the Post Office Ltd website, we are collecting up-to-date information on the locations and opening hours of post offices in Wales. In addition, a detailed population grid is combined with calculated areas of equidistant geographical access, called isochrones, to determine the number of people who have access to the post office network. The isochrones are based on the Welsh road network and are calculated for different travel modes and thresholds using a powerful routing engine. Our results show that the official access criteria are largely unmet in Wales. In addition, and in contrast to previous studies, we show a rural-urban divide not in terms of spatial access, but in the combination of spatial and temporal access. The results are of both practical and theoretical value and will hopefully inform policy makers.

Quality of life in the urban environment and primary health services for the elderly during the Covid-19 pandemic: An application to the city of Milan (Italy)

The outbreak of the Coronavirus during the first months of 2020 completely reshaped urban lives because of the need to limit the spread of the disease and ensure essential services to the most vulnerable city users, such as elderly people. The urban population in European is ageing at unprecedented rate; at the same time, ageing is associated with increased vulnerability and dependence on medical care services. Age-friendly approaches are consequently necessary in urban planning strategies to ensure equal accessibility to essential services, not least in view of coronavirus pandemic. This article aims at defining a methodology for measuring urban accessibility to healthcare services as indicative of quality of life for the elderly within the city of Milan - affected by Covid - both in ordinary working scenarios and during the pandemic. The outputs show that entire neighbourhoods' elderly populations suffer from very poor accessibility to primary health services, especially in the city suburbs, and their condition deteriorates even more because of limited services and activities. The methodology would be effective to suggest policy recommendations to distribution of public services in urban areas and to reduce the potential effects of the Covid-19 pandemic on old people's health and quality of life.

An integrated analysis of spatial access to the three-tier healthcare delivery system in China: a case study of Hainan Island

BACKGROUND

Access to healthcare is critical for the implementation of Universal Health Coverage. With the development of healthcare insurance systems around the world, spatial impedance to healthcare institutions has attracted increasing attention. However, most spatial access methodologies have been developed in Western countries, whose healthcare systems are different from those in Low- and Middle-Income Countries (LMICs).

METHODS

Hainan Island was taken as an example to explore the utilization of modern spatial access techniques under China's specialized Three-Tier Health Care Delivery System. Healthcare institutions were first classified according to the three tiers. Then shortest travel time was calculated for each institution's tier, overlapped to identify eight types of multilevel healthcare access zones. Spatial access to doctors based on the Enhanced Two-Step Floating Catchment Area Method was also calculated.

RESULTS

On Hainan Island, about 90% of the population lived within a 60-min service range for Tier 3 (hospital) healthcare institutions, 80% lived within 30 min of Tier 2 (health centers), and 75% lived within 15 min of Tier 1 (clinics). Based on local policy, 76.36% of the population living in 48.52% of the area were able to receive timely services at all tiers of healthcare institutions. The weighted average access to doctors was 2.31 per thousand residents, but the regional disparity was large, with 64.66% being contributed by Tier 3 healthcare institutions.

CONCLUSION

Spatial access to healthcare institutions on Hainan Island was generally good according to travel time and general abundance of doctors, but inequity between regions and imbalance between different healthcare institution tiers exist. Primary healthcare institutions, especially in Tier 2, should be strengthened.

Emergency Oral Contraceptive Consultations in Pharmacies in a Rural Setting: An Epidemiological Analysis

BACKGROUND

Emergency contraception has been available in pharmacies across England since 2001.There is a paucity of evidence describing those women accessing the service, particularly in rural locations, where pharmacies are integral to improving healthcare accessibility.

METHODS

Routinely collected data from all pharmacy consultations for emergency contraception in Shropshire, England, were obtained and anonymized for the study period April 1, 2016 to January 31, 2019. Consultations were described by time, age of consultee, rationale for consultation, method dispensed (levonorgestrel or ulipristal acetate), referral for copper intrauterine device fitting, chlamydia screening where appropriate and reason for choosing pharmacy setting. Repeat attenders were also described separately.

RESULTS

3499 consultations occurred during the study period; 39% were aged between 16-20 years, and 52% attended following unprotected sexual intercourse. Levonorgestrel was initially most prescribed, however ulipristal acetate overtook it in 2018. Onward referral for copper intrauterine device and age-appropriate chlamydia screening took place in 3% and 4% of the eligible populations respectively. Women overwhelmingly chose the pharmacy setting owing to its convenience. Repeat attenders tended to be younger than single attenders, but otherwise similar.

CONCLUSION

Pharmacy-based emergency contraception is an important and well-utilized service in this rural location and continued funding and possible service expansion should be considered.

Prediction of hospital visits for the general inpatient care using floating catchment area methods: a reconceptualization of spatial accessibility

Background

The adequate allocation of inpatient care resources requires assumptions about the need for health care and how this need will be met. However, in current practice, these assumptions are often based on outdated methods (e.g. Hill-Burton Formula). This study evaluated floating catchment area (FCA) methods, which have been applied as measures of spatial accessibility, focusing on their ability to predict the need for health care in the inpatient sector in Germany.

Methods

We tested three FCA methods (enhanced (E2SFCA), modified (M2SFCA) and integrated (iFCA)) for their accuracy in predicting hospital visits regarding six medical diagnoses (atrial flutter/fibrillation, heart failure, femoral fracture, gonarthrosis, stroke, and epilepsy) on national level in Germany. We further used the closest provider approach for benchmark purposes. The predicted visits were compared with the actual visits for all six diagnoses using a correlation analysis and a maximum error from the actual visits of ± 5%, ± 10% and ± 15%.

Results

The analysis of 229 million distances between hospitals and population locations revealed a high and significant correlation of predicted with actual visits for all three FCA methods across all six diagnoses up to ρ = 0.79 (p < 0.001). Overall, all FCA methods showed a substantially higher correlation with actual hospital visits compared to the closest provider approach (up to ρ = 0.51; p < 0.001). Allowing a 5% error of the absolute values, the analysis revealed up to 13.4% correctly predicted hospital visits using the FCA methods (15% error: up to 32.5% correctly predicted hospital). Finally, the potential of the FCA methods could be revealed by using the actual hospital visits as the measure of hospital attractiveness, which returned very strong correlations with the actual hospital visits up to ρ = 0.99 (p < 0.001).

Conclusion

We were able to demonstrate the impact of FCA measures regarding the prediction of hospital visits in non-emergency settings, and their superiority over commonly used methods (i.e. closest provider). However, hospital beds were inadequate as the measure of hospital attractiveness resulting in low accuracy of predicted hospital visits. More reliable measures must be integrated within the proposed methods. Still, this study strengthens the possibilities of FCA methods in health care planning beyond their original application in measuring spatial accessibility.

Role of Area-Level Access to Primary Care on the Geographic Variation of Cardiometabolic Risk Factor Distribution: A Multilevel Analysis of the Adult Residents in the Illawarra-Shoalhaven Region of NSW, Australia

BACKGROUND

Access to primary care is important for the identification, control and management of cardiometabolic risk factors (CMRFs). This study investigated whether differences in geographic access to primary care explained area-level variation in CMRFs.

METHODS

Multilevel logistic regression models were used to derive the association between area-level access to primary care and seven discrete CMRFs after adjusting for individual and area-level co-variates. Two-step floating catchment area method was used to calculate the geographic access to primary care for the small areas within the study region.

RESULTS

Geographic access to primary care was inversely associated with low high density lipoprotein (OR 0.94, CI 0.91-0.96) and obesity (OR 0.91, CI 0.88-0.93), after adjusting for age, sex and area-level disadvantage. The intra-cluster correlation coefficient (ICCs) of all the fully adjusted models ranged between 0.4-1.8%, indicating low general contextual effects of the areas on CMRF distribution. The area-level variation in CMRFs explained by primary care access was ≤10.5%.

CONCLUSION

The findings of the study support proportionate universal interventions for the prevention and control of CMRFs, rather than any area specific interventions based on their primary care access, as the contextual influence of areas on all the analysed CMRFs were found to be minimal. The findings also call for future research that includes other aspects of primary care access, such as road-network access, financial affordability and individual-level acceptance of the services in order to gain an overall picture of the area-level contributing role of primary care on CMRFs in the study region.

Assessment of Spatial Accessibility to Residential Care Facilities in 2020 in Guangzhou by Small-Scale Residential Community Data

Population aging has increasingly challenged socio-economic development worldwide, highlighting the significance of relevant research such as accessibility to residential care facilities (RCFs). However, a number of previous studies are carried out only on street (town)-to-district scales, which could cause errors of the accessibility to RCFs for a family. In order to improve the resolution to individual families, we measure and compare the accessibilities to RCFs based on 3494 residential communities and 169 streets of Guangzhou in 2020 through the two-step floating catchment area (2SFCA) method. It was found that the distributions of the elderly and the service-dense blobs of the RCFs show patterns of a three-level spatial distribution, with a characteristic clustering at the center with peripheral dispersion. The resultant accessibility to RCFs in Guangzhou, ranging from 2.5 to 3.45, is generally consistent with the studies focusing on street scales. However, the maximum difference in the accessibility of two residential communities on the same street ranges from less than 0.02 to 0.94 in Guangzhou, indicating large variations. Although the relative errors of the accessibility results based on bi-scale data are relatively low, the cumulative errors can be high, e.g., over 25% in many streets of large cities. Consequently, hundreds of elderly persons per street can be adversely affected by those errors, with six streets over 1000. Therefore, this study focusing on the smaller-scale residential community data may provide more accurate reference to individual households. For the spatial allocation and optimal layout of Guangzhou and similar cities with population aging, we suggest maximizing RCFs in metropolises by taking full advantage of existing residential care facilities with necessary restructuring, improvements, and expansions on service capability. While for less connected cities, we encourage building new RCFs in situ.

Predicting general practitioner utilisation at a small area level across Western Australia

Equitable delivery of GP services is a key goal in universal healthcare systems. In Australia, information to evaluate equitable delivery is limited, especially at finer geographic scales, leaving an information void that needs to be filled to inform, prioritise and target interventions. To fill this void, GP utilisation was estimated by combining responses on GP utilisation from a national survey differentiated by demographic and area-based socioeconomic and remoteness characteristics with similar characteristics represented geographically at a fine scale. These estimates were then compared to actual GP utilisation to evaluate their predictive reliability. Comparable estimates were found in the greater metropolitan area, with 76% of areas having estimated GP utilisation within ±10% of actual utilisation. Larger discrepancies were found as areas became remoter, with 84% of areas reporting estimated utilisation that was higher than actual utilisation. Comparing the geographic differences between estimated and actual utilisation allowed us to examine the reliability of our methodology. Given the identified limitations, a proxy for GP utilisation at a small area level can be created, a dataset that is not currently published at this geography. This approach has the potential to be applied Australia-wide, providing another valuable tool to evaluate the equitable delivery of primary health care nationally.

Coastal proximity and mental health among urban adults in England: The moderating effect of household income

After adjusting for covariates, self-reported general health in England is higher among populations living closer to the coast, and the association is strongest amongst more deprived groups. We explored whether similar findings were present for mental health using cross-sectional data for urban adults in the Health Survey for England (2008-2012, N ≥25,963). For urban adults, living ≤1 km from the coast, in comparison to >50 km, was associated with better mental health as measured by the GHQ12. Stratification by household income revealed this was only amongst the lowest-earning households, and extended to ≤5 km. Our findings support the contention that, for urban adults, coastal settings may help to reduce health inequalities in England.

Using Geographic Information Systems to investigate variations in accessibility to 'extended hours' primary healthcare provision

There are ongoing policy concerns surrounding the difficulty in obtaining timely appointments to primary healthcare services and the potential impact on, for example, attendance at accident and emergency services and potential health outcomes. Using the case study of potential access to primary healthcare services in Wales, Geographic Information System (GIS)-based tools that permit a consideration of population-to-provider ratios over space are used to examine variations in geographical accessibility to general practitioner (GP) surgeries offering appointment times outside of 'core' operating hours. Correlation analysis is used to explore the association of accessibility scores with potential demand for such services using UK Population Census data. Unlike the situation in England, there is a tendency for accessibility to those surgeries offering 'extended' hours of appointment times to be better for more deprived census areas in Wales. However, accessibility to surgeries offering appointments in the evening was associated with lower levels of working age population classed as 'economically active'; that is, those who could be targeted beneficiaries of policies geared towards 'extended' appointment hours provision. Such models have the potential to identify spatial mismatches of different facets of primary healthcare, such as 'extended' hours provision available at GP surgeries, and are worthy of further investigation, especially in relation to policies targeted at particular demographic groups.

Primary care in Germany: access and utilisation-a cross-sectional study with data from the German Socio-Economic Panel (SOEP)

OBJECTIVES

(1) To describe the accessibility of general practitioners (GPs) by the German population; (2) to determine factors on individual and area level, such as settlement structure and area deprivation, which are associated with the walking distance to a GP; and (3) to identify factors that may cause differences in the utilisation of any doctors.

DESIGN

Cross-sectional study using individual survey data from the representative German Socio-Economic Panel (SOEP) linked with area deprivation data from the German Index of Multiple Deprivation for 2010 (GIMD 2010) and official data for settlement structure (urban/rural areas) at district level. Logistic regression models were estimated to determine the relationship of individual and area factors with the distance to a GP. Negative binomial regressions were used to analyse the association with utilisation.

SETTING

Germany.

POPULATION

n=20 601 respondents from the SOEP survey data 2009.

PRIMARY OUTCOME MEASURE

Walking distance to a GP.

SECONDARY OUTCOME MEASURE

Doctor visits.

RESULTS

Nearly 70% of the sample lives within a 20 min walk to a GP. People living in the most deprived areas have a 1.4-fold (95% CI 1.3 to 1.6) increased probability of a greater walking distance compared with the least deprived quintile, even after controlling for settlement structure and individual factors. In rural districts, people have a 3.1-fold (95% CI 2.8 to 3.4) higher probability of a greater walking distance compared with those in cities. Both area deprivation and rurality have a negative relationship with the utilisation of physicians, whereas the distance to a GP is not associated with the utilisation of physicians.

CONCLUSION

Walking distance to a GP depends on individual and area factors. In Germany, area deprivation is negatively correlated with the accessibility of GPs while controlling for settlement structure and individual factors. Both area factors are negatively associated with the utilisation of doctors. This knowledge could be used for future GP requirement plans.