Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective

Abstract

Background Primary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory. Methods Four general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport. Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants. Results Thirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%). Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility. Conclusions Recruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions. Trial registration ISRCTN18321951 , Registered on 6 March 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3299-2) contains supplementary material, which is available to authorized user...

How nurse practitioners working in rural communities can reduce the barriers to access primary health care services for older adults

“…This inaccessibility to transportation prevented many older adults in rural communities from accessing PHC services. Similarly, Ford et al (2019) found that the transportation costs vs. transportation access were more of a barrier faced by older adults to accessing PHC services. Transportation costs range from the lack of funds to purchase and maintain a vehicle, or service a taxi transportation service (Ford et al, 2019).…”

“…Two articles were published in Australia, two in the United Kingdom, one in South Africa, and one included the countries Canada, the Netherlands, the United States, the United Kingdom, Slovenia, Guam, and To effectively reduce barriers to older adults' access of PHC services in rural communities, nurse practitioners working in rural communities must recognize these barriers. In the literature, sixteen of the eighteen articles discussed barriers to access of PHC services (Batsis et al, 2019;Bresick et al, 2016;Clare, 2019;Dolovich et al, 2019;Ford et al, 2018Ford et al, , 2019Heale et al, 2018;Hewitt et al, 2019;Hungerford et al, 2016;Hunter et al, 2016;Prasad et al, 2014;Ross et al, 2016;Shah et al, 2017Shah et al, , 2019Wakerman et al, 2008;Weil et al, 2018).…”

“…Ten of the eighteen articles in the review of literature highlighted that environmental barriers such as rural and remote locations pose as a barrier for older adults accessing PHC services (Batsis et al, 2019;Ford et al 2018Ford et al , 2019Hewitt et al, 2019;Hungerford et al, 2016;Ross et al, 2016;Shah et al, 2017Shah et al, , 2019Wakerman et al, 2008;Weil et al, 2018). Thus, the location in which older adults reside as a barrier to accessing PHC services is evident in the literature.…”

“…The aging population was an individual barrier that arose multiple times in the literature (Shah et al, 2017;Ford et al, 2019;Weil et al, 2018). Aging has distinct issues and presents unique situations regarding access to PHC (Weil et al, 2018).…”

“…Other individual barriers that arose in the literature which focused on older adults include marginalization due to age, feeling like a nuisance, perceived as excluded from services, and that services are not user-friendly to the elderly (Ford et al, 2018(Ford et al, , 2019Hewitt et al, 2019). Older adults who also found it challenging to access PHC services discussed a sense of frustration that the practice breached "social contract" by not recognizing that they seldom utilized services available (Ford et al, 2018, p. 6).…”