Access to primary care for socio-economically disadvantaged older people in rural areas: A realist review

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Objective: The aim of this review is to identify and understand the contexts that effect access to high quality primary care for socio-economically disadvantaged older people in rural areas.
Design: A realist review
Data sources: MEDLINE and EMBASE electronic databases and grey literature (from inception to Dec 2014).
Eligibility criteria for selecting studies: Broad inclusion criteria were used to allow articles which were not specific, but might be relevant to the population of interest to be considered. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded for concepts relating to context, mechanism or outcome.
Analysis: An overarching patient pathway was generated and used as the basis to explore contexts, causal mechanisms and outcomes.
Results: 162 articles were included. Most were from the USA or UK, cross sectional in design and presented subgroup data by age, rurality or deprivation. From these studies a patient pathway was generated which included seven steps (problem identified, decision to seek help, actively seek help, obtain appointment, get to appointment, primary care interaction and outcome). Important contexts were stoicism, education status, expectations of ageing, financial resources, understanding the health care system, access to suitable transport, capacity in primary care, the booking system and experience of health care. Prominent causal mechanisms were health literacy, perceived convenience, patient empowerment and responsiveness of the practice.
Conclusions: Socio-economically disadvantaged older people in rural areas face personal, community and health care barriers that limit their access to primary care. Initiatives should be targeted at local contextual factors to help individuals recognise problems, feel welcome, navigate the health care system, book appointments easily, access appropriate transport and have sufficient time with professional staff to improve their experience of health care; all of which will require dedicated primary care resources.
Original languageEnglish
Article numbere010652
JournalBMJ Open
Issue number5
Publication statusPublished - 17 May 2016


  • Organisation of health services
  • Health Services Administration & Management
  • Quality in health care
  • Primary Care

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