2.4 Social and spatial explanations

GIS-based studies of healthcare access very often focus on distance and the physical difficulty of getting to a particular location. However, healthcare use depends on much more than distance and this exercise explores some of the other influences on healthcare uptake.

GIS is often used to measure potential accessibility – the potential for a given health facility to be reached by the surrounding population. Typically, this involves measuring distances or drive-times to the nearest facility and assuming that those within a given threshold value have adequate access to healthcare. Gulliford et al (2002) refer to this as ‘having access’ to healthcare. Less often, GIS is used to measure revealed accessibility – the actual patterns of health facility use within a given population. Gulliford et al (2002) refer to this as ‘gaining access’ to healthcare.

The size of population ‘gaining access’ to healthcare is typically smaller than those ‘having access’ to healthcare. This is because actual health use depends on much more than geographical distances alone. Gulliford et al (2002) describe four types of barrier to ‘gaining access’:

• physical accessibility: the difficulty of physically reaching a given health facility, which is the type of barrier traditionally measured within a GIS.
• financial accessibility: the difficulty of paying for services or for the related costs of attending a health centre. These related costs may include taking unpaid time off work, paying for childcare, and transport costs. In an insurance-based system (such as the US), financial accessibility is often of paramount importance.
• acceptability and socio-cultural influences: There are a great many socio-cultural aspects to healthcare uptake. One of the most obvious barriers is language. Immigrant communities who do not speak the official language spoken by medical staff may not only be unable to communicate with health professionals during consultations, but may also be unaware of the range of services on offer. There may be more subtle aspects to ‘gaining access’ to healthcare, such as the ability to request a consultation with female medical staff.
• organisational accessibility: Aside from the physical difficulties of travelling to a health centre, there are then potentially further barriers to receiving care once a client has arrived at a health centre. For example, in the developed world, access to appointments with general practitioners is controlled by reception staff and general practitioners will control subsequent access to more specialist care through the medical referral process.

Physical accessibility might be described as a spatial explanation for healthcare access (since it focuses on the geography of populations and healthcare facilities). Financial, organisational and socio-cultural accessibility might together be described as a social explanation for healthcare access. Whilst GIS-based studies of revealed accessibility can identify all four types of barrier to healthcare access, studies of potential accessibility – which form the majority of GIS-based studies (Higgs, 2004) – generally focus on the physical accessibility component of healthcare access at the expense of the other three barrier types.

It is thus important for the GIS analyst to be aware of these other dimensions to healthcare access, which are often more difficult to measure and therefore missing from GIS-based work.
 

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