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Negotiating candidacy: Ethnic minority seniors' access to care

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Negotiating candidacy: Ethnic minority seniors' access to care

Abstract

The ‘Barriers to Access to Care for Ethnic Minority Seniors’ (BACEMS) study in Vancouver, British Columbia, found that immigrant families torn between changing values and the economic realities that accompany immigration cannot always provide optimal care for their elders. Ethnic minority seniors further identified language barriers, immigration status, and limited awareness of the roles of the health authority and of specific service providers as barriers to health care. The configuration and delivery of health services, and health-care providers' limited knowledge of the seniors' needs and confounded these problems. To explore the barriers to access, the BACEMS study relied primarily on focus group data collected from ethnic minority seniors and their families and from health and multicultural service providers. The applicability of the recently developed model of ‘candidacy’, which emphasises the dynamic, multi-dimensional and contingent character of health-care access to ethnic minority seniors, was assessed. The candidacy framework increased sensitivity to ethnic minority seniors' issues and enabled organisation of the data into manageable conceptual units, which facilitated translation into recommendations for action, and revealed gaps that pose questions for future research. It has the potential to make Canadian research on the topic more co-ordinated. Also available at http://pubmedcentralcanada.ca/articlerender.cgi?accid=PMC3693980 (open access)
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... Dixon Woods et al. [18] have defined candidacy as the following: ". . . the ways in which people's eligibility for medical attention and intervention is jointly negotiated between individuals and health services" [18 p.7]. Candidacy has seven dimensions that, according to Dixon-Woods et al. capture the characteristics at play during this joint negotiation [18,22]. These dimensions are 1) identification, which refers to users recognizing symptoms and health needs; 2) navigation by healthcare users, which requires an awareness of the services available; 3) permeability of services, which encompasses accessibility of the services (may include competence to apply); 4) appearances at the health services (implying credibility, or ways of formulating the healthcare need in a credible way); 5) adjudications, which are judgments made by professionals from their interpretation of their clients' needs; 6) offers and resistance to reference by the patients as well as their reactions to offers of medication; and 7) operating conditions, which are locally specific influences on interactions between practitioners and patients. ...
... They also found that their patient group had experienced many barriers to accessing and negotiating medical health services, and the greatest problem during negotiation was language. Koehn [22] used the candidacy framework in a study of ethnic minority seniors' access to healthcare in Canada. Koehn argues that the first six dimensions in the theory deal with negotiation, but the seventh dimension represents the environmental context in which the negotiation occurs; thus, this dimension lies beyond negotiation [22]. ...
... Koehn [22] used the candidacy framework in a study of ethnic minority seniors' access to healthcare in Canada. Koehn argues that the first six dimensions in the theory deal with negotiation, but the seventh dimension represents the environmental context in which the negotiation occurs; thus, this dimension lies beyond negotiation [22]. ...
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This article describes and analyzes conceptions of equal access to healthcare by health workers and Sub Saharan African women living in Norway. The main objective of the study was to find out if there is equal access to healthcare as understood by both the provider and receiver side of healthcare. The two sides have different positions from where to observe and judge the services given, which can give a broader understanding of the healthcare system. Do Sub Saharan African women find healthcare services unjust and discriminating? Do health workers share conceptions of access held by these women? This study used a qualitative fieldwork research design. One hundred interviews were done with health workers and 55 interviews were done with Somali, Gambian and Eritrean women who all had experienced female genital mutilation/cutting (FGM/C). The study found a mismatch in the conceptions of access to healthcare between health workers and the women. Health workers did not believe there was equal access to healthcare and were critical of how the system functioned, whereas the women trusted the system and believed there was equal access. However, both sides had corresponding views on the following challenges facing the healthcare system: little time available to identify symptoms, difficulties in navigating the system, difficulties in getting referrals, and some negative adjudication by some health workers. Bourdieu’s concepts of field, habitus and hysteresis, and candidacy theory were used to analyze the collected data. It was concluded that health workers and the women based their experiences of healthcare on differing cultural frames and expectations. The women seemed to base their assessments of healthcare on previous experiences from their home country, while health workers based their understanding from experiences within the system.
... A large literature on candidacy has now developed, mostly affirming its value in systematically accounting for access to healthcare and how vulnerabilities may arise in relation to it (Koehn, 2009;Mackenzie, Conway, Hastings, Munro and O'Donnell, 2013), while also deepening and refining understanding of the original construct. One important addition, for example, is the concept of recursivity, which describes the interdependency between people's experiences of health services and their future actions in relation to help-seeking (Hunter et al., 2013). ...
... Once a need for help had been identified by service users (or in some cases, their carers), they had to gain a point of entry to services. The original formulation of candidacy and subsequent analyses have shown that significant work may be needed to find a way to and through the healthcare system (Dixon-Woods et al., 2006;Koehn, 2009). Successful navigation may depend on resources, commitment, perseverance, and competence in negotiating complex and often disjointed and frustrating systems that may be unevenly and unfairly distributed. ...
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Candidacy, a construct describing how people's eligibility for care is negotiated between themselves and services, has received limited attention in the context of mental health care. In addition, candidacy research has only rarely studied the views of carers and health professionals. In this article, we use concepts relating to candidacy to enable a theoretically informed examination of experiences of access to secondary mental health services during the first wave of the COVID-19 pandemic in England. We report a qualitative study of the views and experiences of service users, carers, and healthcare professionals. Analysis of 65 in-depth interviews was based on the constant comparative method. We found that wide-ranging service changes designed to address the imperatives of the pandemic were highly consequential for people's candidacy. Macro-level changes, including increased emphasis on crisis and risk management and adapted risk assessment systems, produced effects that went far beyond restrictions in the availability of services: they profoundly re-structured service users' identification of their own candidacy, including perceptions of what counted as a problem worthy of attention and whether they as individuals needed, deserved, and were entitled to care. Services became less permeable, such that finding a point of entry to those services that remained open, required more work of service users and carers. Healthcare professionals were routinely confronted by complex decisions and ethical dilemmas about provision of care, and their implicit judgements about access may have important implications for equity. Many of the challenges of access exposed by the pandemic related to pre-existing resource deficits and institutional weaknesses in care for people living with mental health difficulties. Overall, these findings affirm the value of the construct of candidacy for explaining access to mental healthcare, but also enable deepened understanding of the specific features of candidacy, offering enduring learning and implications for policy and practice.
... Permeability of services reflects ease of access to care by those seeking it. Services such as hospital emergency departments are highly porous, while access to specialist services necessitates a referral and at least some agreement between referrer and provider about expectations of care [59]. Our data suggests that some NHS services in the UK are impervious to people with fibromyalgia, constituted by pressure to address core individual speciality work, local access polices, and a long-standing focus in NHS services on either physical or mental health. ...
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Background The UK’s “Getting It Right First Time” programme recommends that management of people with fibromyalgia should centre on primary care. However, it remains unclear as to how best to organise health systems to deliver services to optimise patient outcomes. Aim To profile UK healthcare services for people with fibromyalgia: provision of National Health Services (NHS) and use of non-NHS services by people with fibromyalgia. Methods Two online open surveys (A and B) incorporating questions about diagnosis, treatment and management of fibromyalgia and gaps in healthcare services were conducted between 11th September 2019 and 3rd February 2020. These were targeted to NHS healthcare professionals consulting with people with fibromyalgia (Survey A) and people ≥16 years diagnosed with fibromyalgia using non-NHS services to manage their condition (Survey B). Descriptive statistics were used to report quantitative data. Thematic analysis was undertaken for qualitative data. Results Survey A received 1701 responses from NHS healthcare professionals across the UK. Survey B received 549 responses from people with fibromyalgia. The results show that NHS services for people with fibromyalgia are highly disparate, with few professionals reporting care pathways in their localities. Diagnosing fibromyalgia is variable among NHS healthcare professionals and education and pharmacotherapy are mainstays of NHS treatment and management. The greatest perceived unmet need in healthcare for people with fibromyalgia is a lack of available services. From the pooled qualitative data, three themes were developed: ‘a troublesome label’, ‘a heavy burden’ and ‘a low priority’. Through the concept of candidacy, these themes provide insight into limited access to healthcare for people with fibromyalgia in the UK. Conclusion This study highlights problems across the NHS in service provision and access for people with fibromyalgia, including several issues less commonly discussed; potential bias towards people with self-diagnosed fibromyalgia, challenges facing general practitioners seeking involvement of secondary care services for people with fibromyalgia, and a lack of mental health and multidisciplinary holistic services to support those affected. The need for new models of primary and community care that offer timely diagnosis, interventions to support self-management with access to specialist services if needed, is paramount.
... Adjusting to a new country can be very stressful and have health impacts [32] and consequently, immigrants with more social support [28] and less cultural incompatibility [11] had better utilization. The qualitative literature also points to the importance of culturally appropriate care [26], beliefs by immigrants that the health care system is not adaptable to their beliefs [33], experiences of racial discrimination by health care providers [29], and beliefs by immigrants that providers of a similar cultural background may be able to provide care more appropriate to their needs [34]. These findings suggest that there is a role for interventions both within the health care system and within the larger public policy arena, to promote immigrant patients' sense of belonging to the local community and utilization of health care, and to ensure that culturally appropriate care is available. ...
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Background Immigrants to Canada face unique barriers to health care, which leads to inequities in health care utilization. Lower utilization of health care by immigrants to Canada is associated with the deteriorating health of individual immigrants as well as increased costs to the health care system. The existing literature suggests that time since immigration is an important predictor for utilization of health care for Canadian immigrants; however, few studies have included this variable in their analysis. This study aims to examine the relationships between having a regular health care provider and time since immigration, and number of medical consultations in the past year and time since immigration. Methods A secondary cross-sectional data analysis using Andersen and Newman’s Framework of Health Service Utilization and data from the 2015–2016 Canadian Community Health Survey (CCHS) was conducted to examine health care utilization among immigrants in Canada. We used multiple logistic regression to examine the relationship between time since immigration and having a regular physician and negative binomial regression to compare the number of consultations of recent (less than 10 years since immigration) and established (10 or more years since immigration) immigrants. Results Eighty four percent of immigrant respondents to CCHS 2015–2016 had a regular health care provider. After controlling for other independent variables, established immigrants were 1.75 (95% confidence interval: 1.45–2.10) times more likely to have a regular health care provider compared to recent immigrants. Immigrants had a mean of 3.37 (standard deviation 4.53) medical consultations in the preceding year. There was no difference in the mean number of medical consultations by recent and established immigrants. Conclusions After controlling for other independent variables, this study found that time since immigration had a significant effect on having a regular provider but not on number of consultations. Differences in health care utilization for recent and for established immigrants observed in this study may be partially explained by Canada’s evolving immigration policy and the economic and social integration of immigrants over time.
... The Candidacy model [14] which has been widely applied to understand uptake of healthcare services at a broad level [15,16] is perceived as a useful theoretical framework to enhance conceptual understanding of findings from this review. Postulated by Dixon-woods et al. [14], the Candidacy model articulates how intersections between structural, cultural, organisational and professional factors influence people's access and utilisation of healthcare services, especially among vulnerable and disadvantaged groups. ...
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Purpose To synthesise findings from published studies on barriers and facilitators to Black men accessing and utilising post-treatment psychosocial support after prostate cancer (CaP) treatment. Methods Searches of Medline, Embase, PsycInfo, Cochrane Database of Systematic Reviews and Central, CINAHL plus and Scopus were undertaken from inception to May 2021. English language studies involving Black men aged ≥18 and reporting experiences of, or suggestions for, psychosocial support after CaP treatment were included. Low or moderate quality studies were excluded. Searches identified 4,453 articles and following deduplication, 2,325 were screened for eligibility. Two independent reviewers carried out screening, quality appraisal and data extraction. Data were analysed using thematic synthesis. Results Ten qualitative studies involving 139 Black men were included. Data analysis identified four analytical constructs: experience of psychosocial support for dealing with treatment side effects (including impact on self-esteem and fear of recurrence); barriers to use of psychosocial support (such as perceptions of masculinity and stigma around sexual dysfunction); facilitators to use of psychosocial support (including the influence of others and self-motivation); and practical solutions for designing and delivering post-treatment psychosocial support (the need for trusted healthcare and cultural channels). Conclusions Few intervention studies have focused on behaviours among Black CaP survivors, with existing research predominantly involving Caucasian men. There is a need for a collaborative approach to CaP care that recognises not only medical expertise but also the autonomy of Black men as experts of their illness experience, and the influence of cultural and social networks.
... Drawing on the findings from this study, several suggestions can be made for what policy makers and care providers could do to address local inequalities in access to and use of aged care. Studies on inequalities in access to care faced by older migrants often call for more services that better meet older migrants' cultural and linguistic preferences (Koehn, 2009;Ahaddour et al., 2016). This study confirms that what is here termed 'minority-specific' services do facilitate access. ...
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The literature on older migrants often focuses on identifying the characteristics of ethnic groups that constitute ‘barriers’ for members of these populations to access care. This paper offers an alternative conceptualisation of access to care, by combining relational approaches to place and the notion of super-diversity. From this perspective, ‘access to care’ is perceived as an outcome of an individual's embeddedness in relationships of care in urban places. The objective of the study is to identify relationships of care that facilitate access to aged care for older first-generation migrants. Thirty-two semi-structured interviews were conducted with older migrants who were residents of Nijmegen or The Hague, The Netherlands. All interviewees had accessed home care, home aid and/or day care. Both relationships with minority-specific services and informal relationships of care, particularly those within local minority communities, were found to facilitate access to aged care. Past experiences with health and social care were also found to influence current relationships with formal care providers. This study, therefore, suggests that policy makers and care organisations should build long-term positive relationships with new and incoming migrant groups. In addition, it argues that policy makers and care providers should identify locally relevant shared migration-related (rather than ethnic) identities around which communities can be mobilised and targeted with appropriate services.
... The tendency for some researchers and practitioners to attribute lack of access to needed resources-such as health care-to cultural differences is therefore questionable. Problematically, it shifts the burden of responsibility for inequitable access to marginalised individuals and serves to create distinctions between 'us' and 'them', a phenomenon known as Othering (Koehn 2009;Torres 2019). In Canada and other Western countries, this form of inadvertent discrimination often originates in or is supported by policies and institutional structures intended to be equitable but designed in accordance with Eurocentric, middle-class values (Brotman 2003). ...
Article
Older Punjabi Sikh women are central to their families and communities, but their own needs are often overlooked. Probing the intersections of gender, ethnicity and age and interlocking experiences of sexism, racism and ageism within and beyond their own communities can deepen our understanding of why this happens and what we can do about it. Vertical hierarchies of women that develop in response to male domination, the gendered nature of women’s work and leisure activities, migration patterns that result in generational role reversals, unmet childcare needs, and sponsorship policies that engender dependency and promote isolation of older adults all play a role. These disparate threads are integrated through application of the intersectional life course lens, which recognises the importance of structural influences and oppressions on life course transitions over time and space.
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