Improving access: modifying Penchansky and Thomas’s Theory of Access

Introducing access to health care

Access to health care is a complex, universal concern and is identified as a basic human right. ¹ Internationally, health care services and policies have been developed and introduced with the aim of improving access to care.^1–3 Access is about enabling a patient in need to receive the right care, from the right provider, at the right time, in the right place, dependent on context.

Until 1981, access was acknowledged as important in health care services, but not well defined and ambiguous in research terms. Utilization theories dominated health care research and a consistently identified but unmeasured variable of utilization in each theory developed was ‘access.’^4–6 In 1981, Penchansky and Thomas ⁶ introduced a theory of access. This was informed by the determinants of use as proposed by Andersen and other utilization theorists.

Access influences consumers and systems in three ways: use of the service, consumer satisfaction and system practice. ⁶ Penchansky and Thomas’s theory provided a useful definition that incorporated dimensions of access. They defined access as the degree of fit between the consumer and the service; the better the fit, the better the access. Access is optimized by accounting for each of the following dimensions: accessibility; availability; acceptability; affordability; and adequacy (or accommodation). The dimensions of access are independent yet interconnected and each is important to assess the achievement of access. Penchansky and Thomas maintained that access is central to health services and that these dimensions cannot be separated from it.^6,7

Applying dimensions of access to health services research

While access is a consideration in health service research and evaluation, it is a particular concern in rural and remote regions due to challenges such as socioeconomic disadvantage, small dispersed communities, vast distances and workforce shortages.

In 1972, Donabedian suggested that ‘the proof of access is use of the service, not simply the presence of a facility,’ but proof of access is more than demonstrating use of a service. ⁴ Use of a health care service by those who have little need of the service compromises resource allocation, and affects appropriate service use and impact, suggesting that proof of access is the use of a service by those who need and would benefit from it. Along with use, the dimensions of access address concerns of barriers to, relevance of and equity in access. This is where applying the dimensions of access helps to inform health care service design, implementation and evaluation to provide evidence of impact.

Penchansky and Thomas’s theory of access has since been used in research, but the dimensions are not always applied as they were conceptualized; they may be omitted, expanded, mislabelled or combined. The dimensions are omitted when only a few are applied, such as only using availability, accessibility and affordability to determine if someone has gained access to a health care service.^1,8 Expansion is splitting the individual dimensions into their components, for instance, taking accessibility and dividing it into its components of geography and timeliness. ⁹ Mislabelled dimensions apply the wrong definition to the term, suggesting, for example, that location is a component of availability; while combined dimensions take two individual dimensions such as availability and adequacy and present them as one. ¹⁰ Improving the accessibility of health care services can optimize the equity of resource allocation and maximize the meeting of community needs for services.

Improving access

Considerations of access were brought to the fore in an evaluation of the Mental Health Emergency Care-Rural Access Program (MHEC-RAP). ¹¹ MHEC-RAP is an emergency telepsychiatry programme providing access to specialist emergency mental health care in rural and remote communities across western New South Wales, Australia. An initial study demonstrated use, providing sufficient evidence of access for Donabedian, but this study led to the reflection, consideration and possibility of another dimension that influences access – namely, awareness (Table 1).

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Table 1.

The dimensions of access.

Dimension of access	Definition	Dimension components and examples
Accessibilitya	Location	An accessible service is within reasonable proximity to the consumer in terms of time and distance.
Availabilitya	Supply and demand	An available service has sufficient services and resources to meet the volume and needs of the consumers and communities served.
Acceptabilitya	Consumer perception	An acceptable service responds to the attitude of the provider and the consumer regarding characteristics of the service and social or cultural concerns. For instance, a patient’s willingness to see a female doctor may determine whether a service is acceptable or not.
Affordabilitya	Financial and incidental costs	Affordable services examine the direct costs for both the service provider and the consumer.
Adequacya (Accommodation)	Organization	An adequate service is well organized to accept clients, and clients are able to use the services. Considerations of adequacy include hours of operation (after-hour services), referral or appointment systems, and facility structures (wheelchair access).
Awarenessb	Communication and information	A service maintains awareness through effective communication and information strategies with relevant users (clinicians, patients, the broader community), including consideration of context and health literacy.

Awareness was a common theme identified from interviews with users and providers of emergency mental health care during the initial study. They spoke about how such a programme was needed and could be useful, but were unaware of the programme and its aims. They did not know that the programme existed, whom it was for, what it did, why and how they would use it, and how to identify and share this information with others who would benefit from the programme. Additional conversations with colleagues and other health providers confirmed the importance of awareness for access, and for making health services useful and effective. Awareness went both ways; a service that was aware of the local context and population need could provide more appropriate and effective care, and patients could better access and use such services if they were simply aware of them in the first place. Penchansky and Thomas did not include awareness as a formal dimension and it is not a component of any of the existing dimensions of their theory.

It seems that awareness has become an assumed dimension of health care access. No health care service can be effective if it does not respond to context or if the intended population does not know it exists. Like the other dimensions of access, awareness facilitates the fit between the patient and the service. One important component under the dimension of awareness is effective communication about the service. This is particularly important in rural and remote communities because of general population mobility as well as the unstable health workforce.^12–15 Mobility creates a group of patients who may be actively seeking care but unaware of the services available to them in a new community. ¹⁶ Long delays can be experienced in filling local vacancies within the health workforce which may leave a gap in service accessibility at that time. High staff turnover means that new staff may not be aware of services available for support and patient referral. Establishing sustainable and well-targeted communication strategies can raise and maintain consumer awareness particularly in areas affected by geographic mobility and workforce instability.

Awareness is more than knowing that a service exists, it is understanding and using that knowledge. It includes identifying that the service is needed, knowing whom the service is for, what it does, when it is available, where and how to use it, why the service would be used, and preserving that knowledge. This preservation of knowledge means that awareness is a perpetual concern. Awareness embraces health literacy as another component of the dimension because it is ‘content and context specific’; health literacy is the outcome of effective communication. ¹⁷ It involves ‘accessing, understanding, and using information to make health decisions,’ and is critical to the empowerment of patients and providers alike.^18,19

Awareness became an element to explore further and was applied in a subsequent evaluation of MHEC-RAP to determine whether the programme improved access. The evaluation again demonstrated use of the programme, but it went on to examine user satisfaction and system practice.^6,20,21 The evaluation confirmed that the five dimensions of access plus awareness were evident in the design and application of the programme model. ²² The five dimensions and awareness were also used to interpret and understand the experience and impact of access to the programme. ²³ MHEC-RAP changed the local provision of care because providers were no longer alone; they felt supported and more confident. Their access had improved and they were sharing information about the programme with other providers and their patients. ²³ From this evaluation, the importance of awareness as a dimension of access was evident. Monitoring, evaluating and improving access to health care is not a simple task. The inclusion of this sixth dimension is necessary to demonstrate that the service is accessible and to determine ways for improving access. The modification of Penchansky and Thomas’s theory of access to incorporate awareness, thereby including components of communication and health literacy, strengthens the conceptual framework for a comprehensive consideration of access.

Access has had a long association with health care and research. Awareness has only recently been given more attention. However, I am not the first to recognize or consider the importance of awareness for access. In 2013, Russell et al. ⁹ included awareness in a framework proposal developed for policy makers to evaluate rural and remote populations’ access to primary health care, and Levesque et al. ¹⁰ suggested that health care services should consider their ‘approachability’ (or awareness) in a proposed patient-centred framework for health care services that same year. For Russell et al., ⁹ awareness is about sharing information and enhancing patient knowledge about health services. The consideration of ‘approachability’ from Levesque et al. ¹⁰ also relates to health literacy; in their framework, services promote themselves so that patients can identify a health need and the appropriate health service to address that need. Their application of awareness addresses users’ knowledge and health literacy .

While the recognition of awareness is increasing within such focused frameworks and individual services, I propose that awareness should become a sixth dimension of the theory of access and applied whenever using the theory to develop, implement, or evaluate health care services and understand issues of access more generally. Such evidence may then direct service development and promotion strategies to improve access to health care.