Exploring access to care among older people in the last phase of life using the behavioural model of health services use: a qualitative study from the perspective of the next of kin of older persons who had died in a nursing home

Equity in healthcare access and service coverage for older people: a scoping review of the conceptual literature

There is currently no global review of the conceptual literature on the equity of healthcare coverage (including access) for older people. It is important to understand the factors affecting access to health and social care for this group, so that policy and service actions can be taken to reduce potential inequities. A scoping review of published and grey literature was conducted with the aim of summarising how health and social care service access and coverage for older people has been conceptualised. PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, SciELO, LILACS, BIREME and Global Index Medicus were searched. Selection of sources and data charting were conducted independently by two reviewers. The database searches retrieved 10 517 citations; 32 relevant articles were identified for inclusion from a global evidence base. Data were summarised and a meta-framework and model produced listing concepts specific to equitable health and social care service coverage relating to older people. The meta-framework identified the following relevant factors: acceptability, affordability, appropriateness, availability and resources, awareness, capacity for decision-making, need, personal social and cultural circumstances, physical accessibility. This scoping review is relevant to the development and specification of policy for older people. It conceptualises those factors, such as acceptability and affordability, that affect an older person's ability and capacity to access integrated, person-centred health and social care services in a meaningful way. These factors should be taken into account when seeking to determine whether equity in service use or access is being achieved for older people.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization

BACKGROUND

Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship.

METHODS

This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored.

RESULTS

GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists.

CONCLUSIONS

Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Application of Andersen's behavioural model of health services use: a scoping review with a focus on qualitative health services research

INTRODUCTION

Qualitative methods have become integral in health services research, and Andersen's behavioural model of health services use (BMHSU) is one of the most commonly employed models of health service utilisation. The model focuses on three core factors to explain healthcare utilisation: predisposing, enabling and need factors. A recent overview of the application of the BMHSU is lacking, particularly regarding its application in qualitative research. Therefore, we provide (1) a descriptive overview of the application of the BMHSU in health services research in general and (2) a qualitative synthesis on the (un)suitability of the model in qualitative health services research.

METHODS

We searched five databases from March to April 2019, and in April 2020. For inclusion, each study had to focus on individuals ≥18 years of age and to cite the BMHSU, a modified version of the model, or the three core factors that constitute the model, regardless of study design, or publication type. We used MS Excel to perform descriptive statistics, and applied MAXQDA 2020 as part of a qualitative content analysis.

RESULTS

From a total of 6319 results, we identified 1879 publications dealing with the BMSHU. The main methodological approach was quantitative (89%). More than half of the studies are based on the BMHSU from 1995. 77 studies employed a qualitative design, the BMHSU was applied to justify the theoretical background (62%), structure the data collection (40%) and perform data coding (78%). Various publications highlight the usefulness of the BMHSU for qualitative data, while others criticise the model for several reasons (eg, its lack of cultural or psychosocial factors).

CONCLUSIONS

The application of different and older models of healthcare utilisation hinders comparative health services research. Future research should consider quantitative or qualitative study designs and account for the most current and comprehensive model of the BMHSU.

Rural and urban differences in patient experience in China: a coarsened exact matching study from the perspective of residents

BACKGROUND

Patient experience is a key measure widely used to evaluate quality of healthcare, yet there is little discussion about it in China using national survey data. This study aimed to explore rural and urban differences in patient experience in China.

METHODS

Data regarding this study were drawn from Chinese General Social Survey (CGSS) 2015, with a sample size of 9604. Patient experience was measured by the evaluation on healthcare services. Coarsened exact matching (CEM) method was used to balance covariates between the rural and urban respondents. Three thousand three hundred seventy-two participants finally comprised the matched cohort, including 1592 rural residents and 1780 urban residents. Rural and urban differences in patient experience were tested by ordinary least-squares regression and ordered logistic regression.

RESULTS

The mean (SD) score of patient experience for rural and urban residents was 72.35(17.32) and 69.45(17.00), respectively. Urban residents reported worse patient experience than rural counterparts (Crude analysis: Coef. = - 2.897, 95%CI: - 4.434, - 1.361; OR = 0.706, 95%CI: 0.595, 0.838; Multivariate analysis: Coef. = - 3.040, 95%CI: - 4.473, - 1.607; OR = 0.675, 95%CI: 0.569, 0.801). Older (Coef. = 2.029, 95%CI: 0.338, 3.719) and healthier (Coef. = 2.287, 95%CI: 0.729, 3.845; OR = 1.217, 95%CI: 1.008, 1.469) rural residents living in western area (Coef. = 2.098, 95%CI: 0.464, 3.732; OR = 1.276, 95%CI: 1.044, 1.560) with higher social status (Coef. = 1.158, 95%CI: 0.756, 1.561; OR = 1.145, 95%CI: 1.090, 1.204), evaluation on adequacy (Coef. = 7.018, 95%CI: 5.045, 8.992; OR = 2.163, 95%CI: 1.719, 2.721), distribution (Coef. = 4.464, 95%CI: 2.471, 6.456; OR = 1.658, 95%CI: 1.312, 2.096) and accessibility (Coef. = 2.995, 95%CI: 0.963, 5.026; OR = 1.525, 95%CI: 1.217, 1.911) of healthcare resources had better patient experience. In addition, urban peers with lower education (OR = 0.763, 95%CI: 0.625, 0.931) and higher family economic status (Coef. = 2.990, 95%CI: 0.959, 5.021; OR = 1.371, 95%CI: 1.090,1.723) reported better patient experience.

CONCLUSIONS

Differences in patient experience for rural and urban residents were observed in this study. It is necessary to not only encourage residents to form a habit of seeking healthcare services in local primary healthcare institutions first and then go to large hospitals in urban areas when necessary, but also endeavor to reduce the disparity of healthcare resources between rural and urban areas by improving quality and capacity of rural healthcare institutions and primary healthcare system of China.

Occupational Physicians' Perspectives on Determinants of Employee Participation in a Randomized Controlled Musculoskeletal Health Promotion Measure: A Qualitative Study

Occupational physicians (OPs) are key figures for advising employees and employers about prevention and health at the workplace. However, knowledge of their views on participation in health promotion measures is sparse. This qualitative study aims to explore occupational physicians' experiences with employee participation in a randomized controlled workplace measure for musculoskeletal disorders (MSDs) in Germany. We conducted eight semi-structured telephone interviews with occupational physicians. Interviews were transcribed verbatim and analyzed using a combination of conventional and directed content analysis. Findings were mapped based on Andersen's behavioral model of health services use, resulting in four categories and 10 subcategories. (a) Contextual factors of the measure comprised impacts of the healthcare system and company environment, (b) individual factors of measure participation comprised demographic, social, belief, and MSD need characteristics, (c) health behavior during the measure included OPs' communication, employees' personal practices and measure participation, and (d) outcomes of participation included health status, satisfaction, and dissatisfaction with the measure. Findings imply occupational physicians' and employees' views should be investigated on a broader scale. Researchers should use present statements for the development of intervention studies, while political and managerial authorities can improve organizational conditions of prevention based on these findings.

Being the next of kin of an older person living in a nursing home: an interview study about quality of life

Background

The length of stay in nursing homes before death in Sweden has significantly decreased, and nearly one-third of people die within 6 weeks of entering a nursing home. Support for the next of kin is one of the cornerstones of palliative care, but the principles are not always adhered to as recommended when caring for the elderly, which can affect the quality of life of their next of kin. The aim of this study was to explore the experiences of quality of life among the next of kin of older persons who live in nursing homes before an educational intervention of palliative care.

Methods

This is an explorative qualitative interview study with 40 next of kin using qualitative content analysis performed at baseline before the implementation of the principles of palliative care in nursing homes.

Results

The next of kin’s experiences of quality of life were expressed in three themes: Orientation to the new life situation, Challenges in their relationship and the Significance of the quality of care in the nursing home. The next of kin experienced a sense of relief, although the older person was constantly on their minds, and they could feel lonely. The difference in the couple’slife situations was experienced as burdensome by the next of kin. The challenges in the relationship were described as stressful, related to a guilty conscience and the older person’s vulnerability. The nursing home could be a context facilitating good relations. The perceptions of quality of care in terms of person-centredness affected the quality of life of the next of kin.

Conclusions

The findings show that four factors are decisive for the quality of life of next of kin: the relationships within the family, the degree of relief that nursing home care entails as compared to home care, the older person’s health status and whether the care is person-centred. Increased knowledge and education regarding palliative care in nursing homes are needed to better meet the needs of next of kin. Implementation of palliative care should take into account the need for support for next of kin.

Trial registration

NCT02708498, 15 March 2016.

Changes in Perceived Accessibility to Healthcare from the Elderly between 2005 and 2014 in China: An Oaxaca-Blinder Decomposition Analysis

Elderly people are characterized with high needs for healthcare, accompanied by high barriers in access to healthcare. This study aimed to identify temporal changes in access to healthcare and determinants of such changes from the elderly in China, over the period between 2005 and 2014. Two waves (2005 and 2014) of data were extracted from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), measuring changes in perceived accessibility to healthcare when needed by the elderly (≥65 years). The effects of the explanatory variables (need, predisposing and enabling factors) on the changes were divided into two components using the Oaxaca-Blinder decomposition method: (1) the endowment portion as a result of distribution differences of the explanatory variables and (2) the coefficient portion as a result of differential responses of the dependent variable to the explanatory variables. Perceived accessibility to healthcare from the elderly increased from 89.6% in 2005 to 96.7% in 2014. The coefficient portion (82%) contributed more to the change than the endowment portion (63%) after adjustments for a negative interaction effect (-45%) between the two. Lower perceived accessibility was associated with older age, lower income, lower affordability of daily expenses and lower insurance coverage. But the coefficient effects suggested that their impacts on perceived accessibility to healthcare declined over time. By contrast, the impacts of gender and out-of-pocket payment ratio for medical care on perceived accessibility to healthcare increased over time. Perceived accessibility to healthcare from the elderly improved between 2005 and 2014. Gender gaps are closing. But the increased effect of out-of-pocket medical payments on perceived accessibility to healthcare deserves further investigation and policy interventions.

Inter-organisational collaboration in palliative care trajectories for nursing home residents: A nation-wide mixed methods study among key persons

Introduction

Multiple care organisations, such as home care services, nursing homes and hospitals, are responsible for providing an appropriate response to the palliative care needs of older people admitted into long-term care facilities. Integrated palliative care aims to provide seamless and continuous care. A possible organisational strategy to help realise integrated palliative care for this population is to create a network in which these organisations collaborate. The aim is to analyse the collaboration processes of the various organisations involved in providing palliative care to nursing home residents.

Method

A sequential mixed-methods study, including a survey sent to 502 participants to evaluate the collaboration between home and residential care, and between hospital and residential care, and additionally three focus group interviews involving a purposive selection among the survey participants. Participants are key persons from the nursing homes, hospitals and home care organisations that are part of the 15 Flemish palliative care networks dispersed throughout the region of Flanders, Belgium.

Results

Survey data were gathered from 308 key persons (response rate: 61%), and 16 people participated in three focus group interviews. Interpersonal dimensions of collaboration are rated higher than structural dimensions. This effect is statistically significant. Qualitative analyses identified guidelines, education, and information-transfer as structural challenges. Additionally, for further development, members should become acquainted and the network should prioritise the establishment of a communication infrastructure, shared leadership support and formalisation.

Discussion

The insights of key persons suggest the need for further structuration and can serve as a guideline for interventions directed at improving inter-organisational collaboration in palliative care trajectories for nursing home residents.

The establishment of a shared care plan as it is experienced by elderly people and their next of kin: A qualitative study

One strategy to achieve coordination of care for older people with complex care needs is the establishment of shared care plans. The aim of this study was to explore the process of establishing a shared care plan from the perspective of elderly people and their next of kin. Data were collected via 12 semi-structured interviews with 12 older persons targeted in joint care planning and 11 next of kin, either alone or together. The analysis was conducted using content analysis. The results reflect the process of establishing a shared care plan in the three categories; Preparation, Content and Results with belonging sub-categories. Preparation showed that the possibility to influence the preparation of the joint care plan meeting was sometimes limited and the purpose was not always clear. The Content category showed that the meeting was sometimes experienced as an unstructured, general conversation or focused on practical matters. And Results of the process were shown to be successful in terms of having positive effects or fulfilling needs, but also sometimes as being pointless. Thus, the results show that the process of establishing a shared care plan is somewhat unclear to the older person and their next of kin and that they are rarely involved in the decisions regarding when and if a shared care plan is needed. If joint care planning is expected to serve as a tool to accomplish a more person-centred care, then the person must be regarded as an equal partner all throughout the decision-making and planning process.

Theoretical Perspectives of Hospitalized Older Patients and Their Health-Related Problems and Quality of Care: Systematic Literature Review

Introduction:

The proportion of aged people is growing worldwide. Older persons are affected by a number of physical, psychological and social factors that influence their health and quality of life. These factors are usually multiple and are often masked by sensory and cognitive impairments.

Purpose:

The purpose of this study was to examine the available literature emphasizing older persons’ care, care-related problems, and older persons’ quality of healthcare. Also, the paper aimed at exploring the future direction of research needs.

Results:

Good quality older patients’ care involves safety, professional interventions, recognition and management of physical and emotional wellbeing. Care of older patients requires addressing the aging process itself, the expected decrease in functionality, and diminished cognitive ability. Little statistical data were found to address the quality of hospitalized elderly patients in particular as well as study on healthcare facilities and nursing homes. Literature does not provide much guidance to the effectiveness of care strategies.

Conclusion:

The results assert that elderly health care is a priority. However, health care systems are not specific about elderly patients’ needs, leading to low quality of elderly care. There is a need to use an integrated model of care to improve the quality of life and quality of care provided to hospitalized older patients.

On studying ageism in long-term care: a systematic review of the literature

BACKGROUND

Ageism in long-term care is pervasive, but it is not easy to define, to identify and to fight it in practice. These difficulties could be overcome if we develop research capable to conceptualize, detect, measure, and understand the multidimensionality and complexity of ageism. Nevertheless, to achieve this, it is fundamental to know how ageism in long-term care has been previously studied.

METHODS

This paper systematically reviews studies on ageism in long-term care services published before October 2015 and indexed in Web of Science, PubMed, and Social Care Online electronic databases. Electronic searches were complemented with visual scanning of reference lists and hand searching of leading journals in the field of gerontology. Four specific review questions were addressed: Which analytical angles (aetiology, prevalence, manifestations, consequences, and interventions) have been explored? Which theories and concepts have been used? Which methods have been employed? Which variants of ageism have been covered?

RESULTS

Studies have focused mainly on the manifestations, etiology, and prevalence of ageism, neglecting its consequences and the interventions to tackle it; a significant number of studies used scales of ageism which, despite being appropriate considering the aims of the research, present important limitations; most studies have focused on residential services, neglecting non-residential services; some of the variants of ageism have been well covered, while implicit and self-ageism have been under-explored.

CONCLUSIONS

Research on ageism in long-term care services is scarce but important. Much has been done but much remains to be done. An agenda for future research is presented.