ArticlePDF Available

Network and spatial analysis to assess and guide decisions about equitable accessibility to health services: The Public Palliative Care System in Extremadura (Spain).

Authors:

Abstract and Figures

Background: More than 50 million people die every year in the world. A vast majority, however, does not have access to minimum measures to alleviate unnecessary suffering, or even less, to palliative care. Even in places where such care exists, availability of services does not mean, automatically, that they are equally accessible to the population that needs them. Methods: With data from the Autonomous Community of Extremadura in Spain, we generated a mapping model using ArcGIS 10 as a network and spatial analysis tool, which takes into account estimating time to access physical facilities and professionals, and equity indices, to illustrate how potential accessibility could be affected by the presence or removal of administrative, policy-driven restrictions. Results: The approach allowed multiple levels of analysis of administrative restrictions impact on potential accessibility of services. First, it was shown how the minimum average access time to the closest palliative care services in the eight administrative areas of the Autonomous Community was much shorter than the national average. A similar picture was shown in relation to access times to the nearest hospital-based teams. As the measures used did not take into account the population of the municipalities, a third analysis considered potential demand levels, and involved Gini indices and Lorenz Curves, revealing that administrative restrictions may lead to inequity in access to palliative care services. Conclusion: The simultaneous use of maps of accessibility and coverage, illustrating the relative distribution of the resources in a population, while displaying the levels of coverage according to access time to physical facilities and professionals, with and without administrative restrictions, could be of great value to decision makers attempting to promote optimal levels of equity in a large, low-density geographic areas.
Content may be subject to copyright.
Diversity and Equality in Health and Care (2017) 14(4): 184-192
Research Arcle
2017 Insight Medical Publishing Group
Network and Spatial Analysis to Assess and Guide
Decisions about Equitable Accessibility to Health
Services: The Public Palliative Care System in
Extremadura (Spain)
Francisco Javier Jaraíz-Cabanillas1, José Antonio Guérrez-Gallego2, Emilio Herrera-Molina3, Silvia Librada-
Flores3, Jin Su Jeong4, María Nabal-Vicuña5 and Alejandro R Jadad6
1Department of Didaccs of Social Sciences, University of Extremadura, Universidad Avenue, Spain
2Department of Graphical Expression, University of Extremadura, Universidad Avenue, Spain
3NewhealthFoundaon, Menendez Pelayo, Spain
4Escuela Técnica Superior de Ingeniería y Diseño Industrial, Universidad Politécnica de Madrid, Ronda de Valencia, Spain
5Hospital Arnau de Vilanova. Avd Rovira Roure, Spain
6Centre for Global eHealth Innovaon, University Health Network; and Faculty of Medicine and Dalla Lana School of Public
Health, University of Toronto, Canada
ABSTRACT
Background: More than 50 million people die every year
in the world. A vast majority, however, does not have access to
minimum measures to alleviate unnecessary suffering, or even
less, to palliative care. Even in places where such care exists,
availability of services does not mean, automatically, that they
are equally accessible to the population that needs them.
Methods: With data from the Autonomous Community of
Extremadura in Spain, we generated a mapping model using
ArcGIS 10 as a network and spatial analysis tool, which takes
into account estimating time to access physical facilities and
professionals, and equity indices, to illustrate how potential
accessibility could be affected by the presence or removal of
administrative, policy-driven restrictions.
Results: The approach allowed multiple levels of analysis
of administrative restrictions impact on potential accessibility
of services. First, it was shown how the minimum average
access time to the closest palliative care services in the eight
administrative areas of the Autonomous Community was
much shorter than the national average. A similar picture was
shown in relation to access times to the nearest hospital-based
teams. As the measures used did not take into account the
population of the municipalities, a third analysis considered
potential demand levels, and involved Gini indices and Lorenz
Curves, revealing that administrative restrictions may lead to
inequity in access to palliative care services.
Conclusion: The simultaneous use of maps of accessibility
and coverage, illustrating the relative distribution of the
resources in a population, while displaying the levels of
coverage according to access time to physical facilities and
professionals, with and without administrative restrictions,
could be of great value to decision makers attempting to
promote optimal levels of equity in a large, low-density
geographic areas.
Keywords: Equitable accessibility; Network and spatial
analysis; Medical geography; Rural health; Modeling
Background
Only less than 8% of the 100 million people who would get
benets from palliative care worldwide in each year can access
the service [1]. Even though we all wish for a pain-free and
dignied death, this is denied to the majority of humans today as
90% of the world’s morphine is used by 16% of the population.
This is a shameful reection and situation on our species, which
is revealing our entrenched emphasis on curative treatment
while ignoring the inevitability of death.
Throughout the world, policy makers and clinicians faced
with limited resources, favour strategies and actions that
prioritize the diagnosis and treatment of illnesses wherever they
can save lives. Thus, even in many high-income countries, end-
of-life care is left to the charitable and voluntary sector, which
have to underscore its importance and are responsible for the
majority of the funding [2]. As a result, dying is still seen as a
sign of the failure in practically all health systems, leaving as a
remote possibility the realization that dying well is an essential
duty of a caring and civilized society [3].
Even in places where palliative care exists, availability of
services does not mean, automatically, that such services are
equally accessible to the population that needs the services.
One of the key elements that needs to be taken into account
during the study of disparities, particularly at the end of life, is
geography, as accessibility of health services is often inuenced
by the distances that people have to travel, and the time it takes
them to reach them, as well as by the spatial distribution of
Francisco Javier Jaraíz-Cabanillas
185
health care providers and the patients who could benet from
their services [4].
Location-related issues, however, are rarely addressed
by health equity research, as most efforts tend to focus on
describing and analyzing the distribution of social determinants
of health [5]. The methodology we describe here attempts
to ll current niche, by bringing together, simultaneously,
mapping technologies, indices of equity and estimates of time
to access physical facilities and professionals, with and without
administrative restrictions. Such approach could be of great
value to anyone interested in optimizing potential accessibility
of services (the aggregate health resources that are available in
the area, regardless of their use), to ensure that the actual use of
the services available in a given location matches the needs of
the population at end of life equitably [6].
Extremadura (Spain) is a region with clear geographical and
demographic handicaps, as dened by the European Union (EU)
itself. This region is dened by a very low population density (26
in hab/km2), motivated by the dispersion of its inhabitants and
the concentration of most of them in small towns, taking only
one exceeds the 150.000 inhabitants. In addition, demographic
ageing, reduced or zero average annual population growth rate,
the emigration of the young population, the high unemployment
rate, or the large proportion of population occupied in the
Administration, are other factors that make the daily evolution
of the Extremadura region [7].
Only few references have been found in areas of study
with similar characteristics and features (albeit density), such
as some works developed in the coastal counties of Australia
[8,9]. The remaining corresponds to crowded cities and with
a very different demographic and economic dynamics or to
regions with similar characteristics. Hence, the fact that the
methodology used based on the literature review carried out,
to deviate from the existing literature today briey. In rural
and more remote areas, there is a need to provide services for
palliative care due to the long distance and time of access to the
resource population. In the region of Canada, study has shown
the need for resources of CP in nearly 50 regions [10].
Methods
The geographic context for the study was the Autonomous
Community of Extremadura, Spain. This region has had a
palliative care program fully integrated into the public health
care system since 2002, which resulted from a decision by local
health care authorities to guarantee full palliative care coverage
as a basic right. Services are organized in eight “health areas”,
with a palliative care team each, which operates under the
direction of a regional coordinator, and is supplemented by
mobile teams operating from eight acute care hospitals (Figure
1). The provision of palliative care in Extremadura is based on
need alone, and is not conditioned by the patient's geographical
location, his or her condition or disease, or on the ability to pay.
Figure 1: Health ordinaon in the region of Extremadura: Public health areas and palliave care services.
Network and Spaal Analysis to Assess and Guide Decisions about Equitable Accessibility to Health Services: The Public Palliave Care System in Extremadura (Spain) 186
Achieving this goal has been challenging, not only because of
the limited resources available, particularly since the beginning
of the economic crisis, but also because of the negative growth
and low density of a rapidly ageing population (Figure 1) [7].
The software used to generate the model and mapping was
the generic geographic information system, ArcGIS 10, used as
a network and as a spatial analysis tool.
The spatial data were drawn from the geodetic system ED50
(European Datum 1950) and the Universal Transverse Mercator
(UTM) cartographic projection, projected in the 30 spindle for
the study area.
The basic unit of analysis was the municipality, including
relevant data in both the supply and demand side. Each
municipality was represented by the centroid of the urban core;
using coordinates provided the National Geographical Institute
in each case [11]. The total population of each municipality was
estimated based on data from the 2009 Municipal Register [12].
The limits of each of the health services areas were set by
aggregating data included in the inventory of Primary Care
Centers of the Spanish Ministry of Health and Social Policy
[13].
The tolerance used to project the punctual elements on the
network was 2.5 km. The impedance was calculated by dividing
the span length between the same specic speeds, obtaining the
time that takes to pass through a given road portion.
The road network mapping used in this study was based on
data generated by our research group during the evaluation of
the accessibility of centers of economic activity in mainland
Spain in 2008 [14].
The cartography included all the roads of Portugal and
other regions of Spain to allow the generation of an open
communication model.
From the above elements, a transport model was established
by dening the tolerance to project-specic elements on the
network and by assigning impedance to each segment of the
network. From the impedance data, the time separating two
locations within the transport model was estimated, enabling
the creation of a matrix of origin-to-destination times for the
entire region.
The matrix of origin-to-destination times is dened by
the municipalities (as a source) and palliative care services
located in the hospital of reference (as a target). The centroids
of the municipalities have been weighted on the basis of the
claimant population, although only has been conducted in
those with more than 10,000 inhabitants. On the other hand,
in these municipalities it has been considered also the weight
of the population that each one of the census districts dened
by the INE, aiming at much closer to the reality of the density
and ow that present major cities in its different spaces. The
weighting has been held in the municipalities of less than 10,000
inhabitants because it has been considered that the population
entity, the density or movement of these ows would not effect
on the results of the matrix, especially when they are having the
lower socio-economic dynamism of the region.
The estimate of the urban time has been calculated
considering this travel time as variable depending on the
characteristics of the urban core. Since the time analysis carried
out in this research considers all the urban areas of Extremadura
and the peninsular centres of economic activity. In considering
the density of resident population, the running speed and radius
of the urban surface, so much for the urban nucleus that receives
the station of departure as that of arrival, are departing from
the premise from that all the urban areas are considered to be
circular. The population of each municipality is obtained from
the municipal census relative to the year of 2011 and the urban
surface of the National Cartographic Base, 1:200,000 scales.
These travel times are estimated based on the population density
of the areas, through a linear t that allocates a maximum of
80 km/h to the areas of lower density and a minimum of 20
km/h to the more populous ones [14,15].
For estimates of the time to access a particular service
located within the same municipality, the urban displacement
time in that municipality was counted only once. Calculations
of the time required to access a health facility that requires
transportation across municipalities were obtained from
estimates of the time by road between them, as well as the time
urban time within each of them.
Data on each of the palliative care services were obtained
from existing ofcial directories, including:
Name and location of the site, equipment or resource
Resource type: Palliative care unit, clinical support teams
(hospital-based, home-based or mixed), psychosocial
support teams, service coordination, research teams, day
units or rehabilitation facilities
Financing model: Publicly-funded hospitals, private
hospitals in agreement with the National Health Services
or private hospitals without agreement
Stafng: number of physicians, nurses, psychologists,
social workers and other health professionals
Number of beds, whenever relevant
Expected level of population and geographic coverage
assigned by the regional health authority [16].
The accessibility indicators were selected based on a
typological classication proposed for key health services in
Mexico, modied to account, simultaneously, for determinants
of supply (professionals and physical resources) and demand
(population) (Table 1) [16].
The geographical indicator of accessibility (Am), per 100,000
people, was calculated thus:
100 000,
mu u
m
UP
Am Pop
×
=
where Am is the accessibility in Municipality m (mu); Umu is the
users accessing the resources available in Municipality (mu); Pu
is the partition of the resource by users who have access to the
same resource; Popm is the population of m.
Francisco Javier Jaraíz-Cabanillas
187
This approach avoids having to assign a population
exclusively to a single resource and to consider the distance or
access time involved in each case.
The level of user access to a resource (Umu) was estimated as
a function of time. It was assumed that municipalities that are
more than one hour away were not used; that is, the population
accessing it was equal to 0 min. Similarly, it was assumed that
municipalities that were 0 min away from a resource could
serve the entire population. For the rest, direct interpolation in
time function was achieved thus
1
mu
mu m
l
Td
U Pop T

= ×−


where Tdmu is the time required by municipality m to access
resource u; Tl is the time limit (1 h).
As the friction of the distance causes likely following
a complex curvilinear pattern, with less marked falls in very
long and very short distances, it was assumed that a linear loss
could provide a reasonable easy-to-understand approximation,
particularly given the lack of actual data on which to apply a
friction component model.
Finally, the participation of a resource according to the
number of users accessing it (Pu) was assumed to depend
on its size and the total number of users that can access all
the municipalities that were within the time limit as shown
below:
1
u
uy
m mu
R
PU
=
=
where Ru is the number of professionals available in unit
u; Umu is the number of users in Municipality m accessing the
resource u and all the municipalities that are within the time
limit of resource u.
Although, in principle, any resident can attend any health
facility, anywhere in the region, a number of additional
assumptions about accessibility were made. The actual
accessibility level, for instance, depends not only on geographical
factors but also on administrative ones. Thus, two equity models
were established: one estimating coverage with barriers created
by internal management and another without such barriers.
The level of municipality coverage, Mc, was obtained on the
basis of the distance between the municipality of residence of
the potential user and the location of the service as follows:
1
njj
cj
m
Osp Mdp
MPop
=
×
=
where j corresponds to the services available in a municipality;
Ospj is the occupation rate (expressed as a percentage) of a given
service; Mdpj is the population serviced by each municipality;
Popm is the population in each municipality. The level of service
occupation (in percentages) is given by:
s
N
Osp Mdp
=
where Ns is the number of services. So, the population
serviced by a municipality is calculated thus:
160
t
m
A
Mdp Pop 
= ×−


This is only calculated by a service if it takes less than 60
min and is included within the established administrative barrier.
Access time (At) is expressed in minutes. If it is true that most of
the literature advocates locked in 30 min the limit or the uptake
of health services demand barrier, it is no less true that there are
also other authors which extend this up to 60 min, especially
when the study area presents a considerable expansion and a
low population density as it is the case [8,9,17,18].
The indicators can be used to calculate the level of
accessibility with administrative restrictions imposed by
internal management decisions, or without such barriers. In
the restricted model, residents can only be supported by the
service/equipment/resource, organizationally assigned by their
corresponding municipality. In the unrestricted model, mapping
and graphical representations of the potential accessibility for
the population remove internal administrative constraints for
services, ensuring that hospital-based teams would always
be available to patients within 60 min of travel time, while
assuming a linear loss.
The variables can then be displayed in exposed thematic
AmIndicator of accessibility
(mu) Municipality m
Umu
Number of user in Municipality m accessing the resource of u for all the municipalities that are within the time limit of
resource u
PuPartition of resource by users who have access to the same resource
PopmPopulation in each municipality
Tdmu Time required by municipality m to access resource u
TlTime limit (1 h)
RuNumber of professionals available in unit u
McMunicipality coverage
j Services available in a municipality
OspjOccupation rate (expressed as a percentage) of a given service
MdpjPopulation serviced by each municipality
NsNumber of services
AtAccess time expressed in minutes
Table 1: Abbreviaons of the variables/indicators.
Network and Spaal Analysis to Assess and Guide Decisions about Equitable Accessibility to Health Services: The Public Palliave Care System in Extremadura (Spain) 188
cartography with perceptive properties well suited to represent
the type of quantitative information generated by the formulas.
In addition, a manual interval method is used to illustrate the
variables in the legend as a logical and statistically consistent
way.
The distribution of the values on the map follows an
interpolation method based on the inverse of the distance
weighted (IDW), assigning weights to the data in inverse
function of the distance to a particular service point. In relation
to the accessibility of the population to the resources, the
indicator of minimum time access allows to determine how long
it takes to reach the nearest service.
To improve the ease of interpretability of the maps, Lorenz
curves and Gini indices were added [19,18,20]. The former was
obtained by dividing the coverage range into ten equal parts and
representing each decile of coverage along the horizontal axis
with the percentage of the total available to the population on
the ordinate axis. The Gini index was estimated according to the
methods proposed by for grouped data, with zero corresponding
to perfect equality (everyone has access to the same resources)
and 1 corresponding to perfect inequality (only one person has
all the resources and the others have nothing) [20,21].
Results
The rst analysis we conducted focused on potential
accessibility based on the time required to reach a service
from the municipality of origin. Here, the ndings for hospital-
based teams is shown in Figure 2. In this map analyzed, the
color scheme allows the differentiation among time ranges,
in minutes, across municipalities that have the same distance
to a particular resource. In Extremadura (Spain) as a whole,
the minimum average access time of all municipalities to the
closest palliative care services was estimated at 33 min, while
the maximum was 81 min, much better than the national gures
(minimum average time of 41 min and maximum average time
of 130 min). As it could be seen in the same map analyzed, in
the frontier territory there are also areas with very low values
of potential accessibility. These areas have less developed
communication channels or more rugged terrain. As expected,
accessibility decreases the farther municipalities are from a city
with palliative care services available (Figure 2).
The map describes the access times to the nearest hospital-
based teams, averaged over all municipalities in a given health
area, disregarding their population size. In this case, the minimum
average of the eight health areas is 33 min, while the maximum
is 64 min (in the Don Benito–Villanueva area). Once again, these
data compare favourably with the national average times, where
the maximum average times shoot up to 98 min. This measure
of accessibility, which does not account for the population in
the municipalities, could be a fair measure of localization in
equidistance terms, but not in relation to the level of service
demand. Obviously, this approach favours smaller areas, provided
that they are adequately equipped (or supplied) (Figure 3).
Figure 2: Minimal me of access: Populaon to the palliave care hospital service.
Francisco Javier Jaraíz-Cabanillas
189
The various accessibility levels for the population when
internal administrative constraints for services were removed
and the corresponding Gini indices and Lorenz curves. The
average number of accessible resources within 60 min of travel
time was 0.6 with a maximum of 1.4. When compared with
national estimates, the mean value is slightly lower at 0.5, with
a much greater difference in relation to the maximum number,
2.6, for mainland Spain as a whole (Figure 4 and 5).
Administrative constraints were associated with reduced
accessibility in terms of the proportion of the population that
could access the nearest resource within 30 min, or that had to
travel more than 60 min to do so, as compared with the natural,
unrestricted conditions (Figure 5 and Table 2).
To conclude, it seems essential to include a table that compares
the total population residing in each of the areas of health and
the population that accesses the services of palliative care with
or without administrative barriers in the analysis. Only in this
way the politicians and managers linked to the health services
in the Extremadura region can use the valuable information
presented here. The tremendous illustrator of the differences
that exist applying barriers dened by the administration with
regard to access to health services, in this case offered palliative
care in referral hospitals, and if the same shall not apply. The
claimant population of the services with or without barrier in
each of the areas of health can be seen in the table. Likewise, it
can be also shown in the same degree of coverage. There is no
doubt this table would be of greater assistance to policy makers
in the face of their actions in order to promote equity in access
to health services (Table 3).
Figure 3: Average by areas of travel me access: Populaon to the palliave care hospital service.
Comparative access indicator in Extremadura
Without restrictions With restrictions
Average Coverage (resources per 100,000 inhabitants) 0.82 0.82
Gini index 0.27 0.32
Mean time to the nearest resource (min) 21.6 21.6
People needing to travel less than 30 min to reach the nearest resource 76.9% 69.6%
People needing to travel more than 60 min to reach the nearest resource 2.6% 4.9%
Table 2: Comparave access indicator in Extremadura.
Network and Spaal Analysis to Assess and Guide Decisions about Equitable Accessibility to Health Services: The Public Palliave Care System in Extremadura (Spain) 190
Figure 4: Coverage without barrier management of palliave care hospital service.
Figure 5: Distribuon of the populaon according to coverage.
Public health area Population 2009 Demand without
barriers (Population)
Coverage without
barriers
Demand with
barriers
Coverage with
barriers
Badajoz 270,317 296,737 1.098 175,269 0.648
Caceres 198,409 243,548 1.228 123,504 0.622
Coria 47,979 52,110 1.086 34,216 0.713
Don Benito-
Villanueva 142,040 113,951 0.802 81,841 0.576
Llerena-Zafra 106,731 83,220 0.780 64,674 0.606
Merida 166,158 281,818 1.696 112,084 0.675
Navalmoral 54,630 56,049 1.026
de la Mata 41,415 0.758
Plasencia 111,480 148, 067 1.328 77,006 0.691
Total 1,097,744 1,275,499 1.162 710,009 0.647
Table 3: Dierences that exist applying barriers dened by the administraon with regard to access to health services.
Francisco Javier Jaraíz-Cabanillas
191
Conclusion
The methodological approach we have described here
illustrated with real-world data, complements more traditional,
descriptive and static methods that rely on the absolute amount
of resources in a given region to plan and deploy palliative care
services. The simultaneous use of maps of accessibility and
coverage, illustrating the relative distribution of the resources
in the population, while displaying the levels of coverage
according to access time to physical facilities and professionals,
with and without administrative restrictions, could be of great
value to decision makers attempting to promote optimal levels
of equity in a large, low-density geographic area.
It was intriguing to see how administrative constraints may
lead to decreased access to services and equity. If conrmed
by prospective studies, this nding could act as a cautionary
message to well-intentioned policy makers hoping to level the
playing eld for people at the end of life.
The methodology we have presented here could also be of
value to decision-makers interested in equitable provision of
other kinds of services in other regions of the world [10,22].
The user-friendly process could also make it attractive as
a means to simulate future scenarios before the deployment
of services in vast geographic areas. By enabling the “virtual”
manipulation of modiable variables such as the geographic
boundaries of a service area, or the number of health
professionals in a particular facility, this approach could help
ensure that potential accessibility does, in fact, reect the
level of received accessibility, without additional cost, while
reassuring the public about the value added by political and
administrative decisions that intend to promote equitable access
to crucial services.
The proposed methodology is a theoretical model that has
not been validated by health professionals or political managers
from the modication of the guidelines that indicate the
existence of administrative barriers in access to health services.
The proposed theoretical foundation must be validated for
comparison with cases that already have been implemented in
other regions or cities in the world.
However, it remains less certain that this research is
based on a study commissioned by the Ministry of Health in
2009 consultant, expert managers of the health systems of the
different Autonomous Communities and teachers from many
Spanish nationwide universities. On the other hand, while it
developed work, aiming to go by participant to the national
health community, several interviews and surveys were
conducted to know their opinions. In the case of Extremadura,
interviewed the ve heads of the Extremadura Health Services
in issues related to palliative care, which not only opined
about the State of the Service at that particular moment, but
it is also involved in the development and the rst results of
the theoretical methodological proposal was carried out in
the region showing at all times compliance with the process
followed. Obviously, political decision-makers are ultimately
responsible for applying or not all the studies that are carried out
on questions as delicate and difcult to implement as the health-
related. However, having the support of leading practitioners
in the region is already an important step towards possible
encounters and meetings to discuss its implementation.
To conclude, it is necessary to accept the patent limitation
that denes, in a way, the scarcity of sources for regions with
socio-economic characteristics such as exposed here. However,
this research continues to be evident the need of studies as the
here exposed face to alleviating healthcare deciencies of the
population resident in these most depressed areas. The same
National Government, as expressed in the evaluation of the
national strategy for palliative care of the national system of
health, speaks of the need to expand the range of resources
throughout the country and improve its efciency and territorial
cohesion [23,24].
Compeng Interests
The authors declare that they have no competing interests.
Authors’ Contribuons
FJJC drafted the manuscript, made the analysis and
interpretation of data and performed its statistical analysis.
JAGG participated in the design of the study, made substantial
contributions to the acquisition of data, performed the statistical
analysis and helped to draft the manuscript. EHM conceived
the study, participated in its design and coordination and helped
to draft the manuscript. SLF participated in the design of the
study, revised it critically and helped to draft the manuscript.
JSJ and ARJ revised the manuscript for important intellectual
content and provided linguistic support. All the authors read and
approved the nal manuscript.
Acknowledgement
The authors are grateful to Dr. Félix Fernández who
designed the statistical analysis and revised the manuscript
critically for content accuracy. This publication was sponsored
by the Regional Government of Extremadura and the European
Regional Development Found (Ref. GR15121).
References
1. Worldwide Palliative Care Alliance.
2. Hughes-Hallett T, Craft A, Davies C (2011) Creating a
fair and transparent funding system; the nal report of the
palliative care funding review. Department of Health, United
Kingdom.
3. Hughes-Hallett T, Murray SA, Cleary J (2013) Transforming
end-of-life care through innovation. World Innovation
Summit for Health.
4. Wang F, Luo W (2005) Assessing spatial and non-spatial
factors for healthcare access: Towards an integrated approach
to dening health professional shortage areas. Health Place.
11: 131-146.
5. Pons-Vigués M, Diez È, Morrison J (2014) Social and
Network and Spaal Analysis to Assess and Guide Decisions about Equitable Accessibility to Health Services: The Public Palliave Care System in Extremadura (Spain) 192
health policies or interventions to tackle health inequalities
in European cities: A scoping review. BMC Public Health.
14:198.
6. Khan AA (1992) An integrated approach to measuring
potential spatial access to health care services. Socioecon
Plann Sci. 26: 275-287.
7. Herrera E, Rocafort J, De Lima L (2007) Regional palliative
care program in Extremadura: An effective public health
care model in a sparsely populated region. J Pain Symptom
Manage. 33: 591-598.
8. Schuurman N, Fiedler RS, Grzybowski SCW (2006)
Dening rational hospital catchments for non-urban areas
based on travel-time. Int J Health Geogr. 5:43.
9. Pilcher J, Kruske S, Barclay L (2014) A review of rural and
remote health service indexes: Are they relevant for the
development of an Australian rural birth index? BMC Health
Serv Res. 14: 548.
10. Cinnamon J, Schuurman N, Crooks VA (2009) Assessing the
suitability of host communities for secondary palliative care
hubs: A location analysis model. Health Place. 15: 822-830.
11. Centro Nacional de Información Geográca - CNIG
(2010) Información Cartográca de España, 2010 (Spanish
Cartographic Information, 2010). Madrid: Instituto
Geográco Nacional, Ministerio de Fomento.
12. Instituto Nacional de Estadística - INE (2008) Estadística
del Padrón Continuo, 2008 (Municipal Register Statistics,
2008). Madrid: Ministerio de Ciencia e Innovación.
13. Secretaría General de Información Sanitaria e Innovación
(2010) Ordenación Sanitaria del Territorio en las
comunidades autónomas. Sistema de Información de
Atención Primaria (SIAP) (Territorial management health in
the regions. Primary Health Care Information System). Año
2010. Madrid: Ministerio de Sanidad y Política Social.
14. Gutiérrez J, Condeço-Melhorado A, López E (2011)
Evaluating the European added value of TEN-T projects:
a methodological proposal based on spatial spillovers,
accessibility and GIS. J Transp Geogr. 19: 840-850.
15. Gutiérrez-Gallego JA, Naranjo-Gómez JM, Jaraíz-Cabanillas
FJ (2015) A methodology to assess the connectivity caused
by a transportation infrastructure: Application to the high-
speed rail in Extremadura. CSTP. 3: 392-401.
16. Enterprise Solutions for Health (2010) Estudio sobre la
equidad y la accesibilidad en el desarrollo de recursos de
cuidados paliativos en el Sistema Nacional de Salud (Study
on equity and accessibility in the resources development
of palliative care in the National Health System). Madrid:
Ministerio de Sanidad y Consumo.
17. Garrocho C, Campos J (2006) Un indicador de accesibilidad
a unidades de servicios clave para ciudades mexicanas:
Fundamentos, diseño y aplicación (An indicator of
accessibility to key service units in Mexican cities:
Fundaments, design and application). Revista Economía,
Sociedad y Territorio. 22: 349-397.
18. Wan N, Zou B, Sternberg T (2012) A three-step oating
catchment area method for analyzing spatial access to health
services. Int J Geogr Inf Sci. 26: 1073-1089.
19. Donaldson D, Weymark JA (1980) A single-parameter
generalization of the Gini indices of inequality. J Econ
Theory. 22: 67-86.
20. Gupta MR (1984) Functional form for estimating the Lorenz
curve. Econometrica. 52: 1313-1314.
21. Ahmad Kiadaliri A, Naja B, Haghparast-Bidgoli H (2011)
Geographic distribution of need and access to health care in
rural population: An ecological study in Iran. Int J Equity
Health.
22. Ferreira E, Garín MA (1997) Una nota sobre el cálculo del
Indice de Gini (A note on the calculation of the Gini index).
Estadística Española. 39: 207-218.
23. Dixon J, King D, Matosevic T (2015) Equity in the provision
of palliative care in the UK: Review of evidence. Personal
Social Services Research Unit, London School of Economics
and Political Science.
24. MHA (2012) Evaluación de la estrategia de cuidados
paliativos del sistema nacional de salud. Agencia
de evaluación y calidad. Ministerio de Hacienda y
Administraciones Públicas.
Address of Correspondence: Dr. Francisco Javier Jaraíz-
Cabanillas, Department of Territorial Sciences, University of
Extremadura, Universidad Avenue, s/n, 10071, Cáceres, Spain, Tel:
+34 927 257 400, Fax: +34 927 257 401, E-mail: jfjaraiz@unex.es
Submitted: July 03, 2017; Accepted: July 20, 2017; Published: July 27,
2017
... Access to health services is a determining factor for appropriate health care. [1][2][3] Different authors agree that accessibility problems have an impact on vulnerable groups, such as low-income individuals, women, and immigrant groups. 4 The causes of this impaired accessibility include cultural differences, communication and administrative problems, legal status, and even the attitudes of health workers. ...
Article
Full-text available
Objective: To investigate the use of healthcare services and factors associated with accessing them among Chinese immigrants living in Southern Spain. Method: A mixed methodology was used. A cross-sectional survey was first administered to Chinese immigrants (n=133), and they were asked about their visits to the doctor, use of emergency services, and hospitalization. A phenomenological approach was then used with key informants (n=7). In the interviews, additional information, such as barriers and facilitators to improving accessibility, was explored. Results: In the previous year, 51% had visited a doctor and 34% had visited an Emergency Department. The main reasons for hospitalization were pregnancy (37.5%) and surgery (25%). At least 20% of the sample reported having never visited a doctor. Language difficulties and time constraints were identified as important barriers to accessibility. Sex differences were found among the reasons for lack of time, which, in men, were related to work (odds ratio [OR]=7.7) and, in women, were related to childcare (OR=12). The majority of Chinese immigrants preferred to use Traditional Chinese Medicine as their first treatment rather than visiting a doctor. Conclusions: A lower use of health services was found among Chinese immigrants in Spain compared to the native population. When using health services, they choose acute care settings. Communication and waiting times are highlighted as major barriers. Adapting these demands to the healthcare system may help immigrants to trust their healthcare providers, thus increasing their use of health services and improving their treatment.
... Palliative care can be provided across multiple settings. Studies indicate that, while aiming to be holistic, palliative care resources cannot possibly cover all patient and family needs [5]. Furthermore, differences in family structure mean that some patients might require more social and practical support than others. ...
Article
Full-text available
Background: End-of-life needs can be only partly met by formalized health and palliative care resources. This creates the opportunity for the social support network of family and community to play a crucial role in this stage of life. Compassionate communities can be the missing piece to a complete care model at the end of life.
... Palliative care can be provided across multiple settings and at its centre is impeccable assessment. Studies indicate that whilst aiming to be holistic and widespread, palliative care resources cannot possibly cover all patient and family needs [ 5 ]. Furthermore, differences in the family structure (smaller family sizes and employment, etc.) mean that some patients made require more social and practical support than others. ...
Technical Report
Full-text available
Palliative care is often associated with end stage cancer, but it is relevant to anyone with serious illness. It aims at the holistic and active management of pain and other distressing symptoms and the relief of emotional and psychological distress. Yet a significant minority of people across the UK – over 100,000 (roughly a fifth of everyone who dies each year) – do not receive the palliative care they need. And some groups are less likely to receive this care than others. This includes people with conditions other than cancer, people aged 85 or over, people from black, Asian and minority ethnic groups, people who live in the most deprived areas and people without spouses or partners. These findings come from a research study carried out by a team at the LSE’s Personal Social Services Research Unit. It was funded by the Marie Curie charity, which supports people with terminal illnesses and their families, and involved a wide-ranging evidence review and new analyses of data from the National Survey of Bereaved People in England. In the UK, palliative care is delivered by specialist professionals, usually working as part of multi-disciplinary teams. Generalists including GPs, district nurses, hospital doctors, ward nurses, allied health professionals, staff in care homes, social care staff, social workers, chaplains and others are also involved. Twenty per cent of referrals to specialist palliative care are for people with conditions other than cancer. Yet 70 per cent of people who die do so from these conditions. So although the proportion of referrals for non-cancer conditions has risen – from 12 per cent in 2008 – it is still far too far too low. There is plentiful evidence that the palliative care of those with and without cancer are comparable. Some people with cancer may also miss out. For example, those undergoing active cancer treatment and with hematological cancer – cancer of the blood – are less likely to get a specialist referral. What is particularly concerning, however, is that, in the last three months of life, people with non-cancer conditions also have less contact with generalist healthcare providers, including GPs and district nurses. They are also less likely to die at home, even after taking account of factors we know to be strongly associated with dying at home, such as having a spouse or partner. And they are less likely to have their pain well-controlled at home or to receive care that their families consider to be of high quality. Families of people with cardio-vascular disease seemed to be least satisfied with the care their relative received, rating overall care from GPs, care homes and out of hours services in the last three months of life as poor. Identifying pain control in people with dementia is hard even with standardized clinical measures. However, research studies show that even where pain is identified, people with dementia may not receive the palliative care they need. People aged 85 and over account for 39 per cent of deaths, but just 16 per cent of specialist referrals are for this group, even though are no less likely to need specialist palliative care. This figure is up from 11 per cent in 2012, but is, nonetheless, far from equitable. Research studies find that palliative care needs in people over 85 are under-identified by healthcare professionals, possibly because illness and death are expected in old age. People in this age group may also under-report their symptoms. And there can also be confusion about the role of the geriatrician in providing palliative care. People from Black, Asian and minority ethnic (BAME) groups are just as likely as people of white ethnicity to be referred to specialist palliative care services, when one takes into account their age profile. They are also just as likely to die at home rather than in hospital. But they report poorer quality care, they rate the care they receive in care homes as poor and they are more likely to die in hospital than in a care home. People from more deprived areas do not appear to have less access to community-based services. However, they are less satisfied with the care they receive, they are less likely to feel they are treated with dignity by professionals and they more frequently die in hospital. The purpose of our study was to identify whether there was inequity in access to palliative care or in outcomes, rather than to look closely at causes or make detailed proposals for what needs to be done. Nonetheless, we identified important care gaps in all settings. In hospitals these included limited access to face-to-face specialist palliative care services as well as poor communication with patients and families. In the community, there can often be conflicting pressures, confusion about roles and responsibilities and poor coordination. Generalists sometimes lack confidence, knowledge and skills in end of life care. Care homes, which have an increasing role in end of life care, sometimes have insufficient support from external healthcare providers and lack policies, guidance and trained staff. We also reviewed the economic evidence. We found a need for investment to address gaps in services and to meet the growing demand for palliative care from an ageing population, though it was not part of our research to look at this in detail. We did look at the available economic research, primarily evaluations of palliative care services. These showed that once services were in place, better outcomes for patients and families – including better-managed symptoms and dying in their preferred place – were not the only benefits. There were also cost savings from fewer emergency hospital admissions and fewer avoidable hospital deaths. Overall, better palliative care could lead to net savings of more than £40 million per year across the UK.
Article
Full-text available
Gravity-based spatial access models have been widely used to estimate spatial access to healthcare services in an attempt to capture the interaction of various factors. However, these models are inadequate in informing health resource allocation work due to their inappropriate assumption of healthcare demand. For the purpose of effective healthcare resource planning, this article proposes a three-step floating catchment area (3SFCA) method to minimize the healthcare-demand overestimation problem. Specifically, a spatial impedance-based competition scheme is incorporated into the enhanced two-step floating catchment area (E2SFCA) method to account for a reasonable model of healthcare supply and demand. A case study of spatial access to primary care physicians along the Austin–San Antonio corridor area in central Texas showed that the proposed method effectively minimizes the overestimation of healthcare demand and reflects a more balanced geographic pattern of spatial access than E2SFCA. In addition, by using an adjusted spatial access index, the 3SFCA method indicates strong potential for identifying health professional shortage areas. The study concludes that 3SFCA is a promising method to provide health professionals and decision makers with useful healthcare accessibility information.
Article
Full-text available
ABSTRACT: Equity in access to and utilization of health services is a common goal of policy-makers in most countries. The current study aimed to evaluate the distribution of need and access to health care services among Iran's rural population between 2006 and 2009. Census data on population's characteristics in each province were obtained from the Statistical Centre of Iran and National Organization for civil registration. Data about the Rural Health Houses (RHHs) were obtained from the Ministry of Health. The Health Houses-to-rural population ratio (RHP), crude birth rate (CBR) and crude mortality rate (CMR) in rural population were calculated in order to compare their distribution among the provinces. Lorenz curves of RHHs, CMR and CBR were plotted and their decile ratio, Gini Index and Index of Dissimilarity were calculated. Moreover, Spearman rank-order correlation was used to examine the relation between RHHs and CMR and CBR. There were substantial differences in RHHs, CMR and CBR across the provinces. CMR and CBR experienced changes toward more equal distributions between 2006 and 2009, while inverse trend was seen for RHHs. Excluding three provinces with markedly changes in data between 2006 and 2009 as outliers, did not change observed trends. Moreover; there was a significant positive relationship between CMR and RHP in 2009 and a significant negative association between CBR and RHP in 2006 and 2009. When three provinces with outliers were excluded, these significant associations were disappeared. Results showed that there were significant variations in the distribution of RHHs, CMR and CBR across the country. Moreover, the distribution of RHHs did not reflect the needs for health care in terms of CMR and CBR in the study period.
Article
Full-text available
En México, diversas instituciones están trabajando con el gobierno federal y el Programa Hábitat de la Organización de las Naciones Unidas en la construcción de observatorios urbanos que conformen el Observatorio Urbano Nacional (Red OUL). Uno de los propósitos principales de este proyecto es contar con sistemas de indicadores realmente útiles, que apoyen cotidianamente la toma de decisiones de los planificadores urbanos. En este trabajo se propone el diseño de un indicador de accesibilidad a servicios públicos y privados que pueda ser utilizado cotidianamente en tareas de planeación urbana en el contexto nacional, y que enriquezca la construcción de observatorios urbanos en México. Así, este artículo puede contribuir al debate que actualmente se lleva a cabo en México sobre la importancia de la accesibilidad a servicios públicos y privados, como un indicador de desempeño y de calidad metropolitana.
Article
Background: Policy informs the planning and delivery of rural and remote maternity services and influences the perinatal outcomes of the 30 per cent of Australian women and their babies who live outside the major cities. Currently however, there are no planning tools that identify the optimal level of birthing services for rural and remote communities in Australia. To address this, the Australian government has prioritised the development of a rigorous methodology in the Australian National Maternity Services Plan to inform the planning of rural and remote maternity services. Methods: A review of the literature was undertaken to identify planning indexes with component variables as outlined in the Australian National Maternity Services Plan. The indexes were also relevant if they described need associated with a specific type and level of health service in rural and remote areas of high income countries. Only indexes that modelled a range of socioeconomic and or geographical variables, identified access or need for a specific service type in rural and remote communities were included in the review. Results: Four indexes, two Australian and two Canadian met the inclusion criteria. They used combinations of variables including: geographical placement of services; isolation from services and socioeconomic vulnerability to identify access to a type and level of health service in rural and remote areas within 60 minutes. Where geographic isolation reduces access to services for high needs populations, additional measures of disadvantage including indigeneity could strengthen vulnerability scores. Conclusion: Current planning indexes are applicable for the development of an Australian rural birthing index. The variables in each of the indexes were relevant, however use of flexible sized catchments to accurately account for population births and weighting for extreme geographic isolation needs to be considered. Additionally, socioeconomic variables are required that will reflect need for services particularly for isolated high needs populations. These variables could be used with Australian data and appropriate cut-off points to confirm applicability for maternity services. All of the indexes used similar types of variables and are relevant for the development of an Australian Rural Birth Index.
Article
High-speed rail (HSR) affects enormously on the territory and provokes intense socio-economic dynamics because it articulates the territory according to the distribution of the accessibility in the settlements. Thus, the easier it would be the access of the residents from a city to another, the better it would be its opportunities of socio-economic development.These effects motivated by the different degree of accessibility produced in the territory are more acute in the less developed regions. In this regard, this work proposes a methodology applicable not only to any place in general, but in this particular case also to Extremadura because this region is the least developed in Spain.This methodology in which importance resides that it is applicable before the physical implantation of the HSR in the territory allows to achieve the following objectives: delivers a judgment if the distribution of the population which will accede to the HSR is balanced, shows the future hierarchical organization of the territory in more or less favoured zones and determines the degree of connection of the region on a national scale with Spain and an international scale with Portugal.This paper is based on the use of tools for network design and the geographic information systems (GIS) and proposes a new indicator of absolute accessibility parameters application, together with the exploitation of information use of the descriptive statistics.The obtained results show how the isolated areas, without adequate access to high-speed service, are going to continue to exist although it diminishes the lack of equity in the different zones of Extremadura, which is the object of study.
Article
This paper develops a methodology for calculating the European value added value (EVA) generated by transport infrastructure projects. This approach is particularly useful for evaluating projects in the framework of Trans-European Transport Networks (TEN-T), although it may also be used in trans-national projects in other geographical areas. The methodology is based on the appraisal of spatial spillovers generated by trans-national projects by using accessibility indicators (access to markets) and Geographical Information Systems (GIS). Projects are split into sections and spillover effects of each section are then computed. The sections that produce a high proportion of spillovers in relation to internal benefits generate a high EVA. Additionally, indicators are obtained of the effects of each section in terms of spatial concentration on the different countries affected, efficiency (general improvement in accessibility) and territorial cohesion (reduction in accessibility disparities between regions). The validity of this approach is verified by applying it to TEN-T priority project 25. This methodology does not seek to replace existing project appraisal methodologies (particularly the cost-benefit analysis); rather it provides complementary data for decision-making. Sections which are scarcely profitable from the cost-benefit analysis perspective but which have high European value added should receive more European funding than more profitable sections of markedly national interest.Research highlights► A methodology for calculating European value added (EVA) of projects is developed. ► Sections of transport projects producing more spillovers have a greater EVA. ► Sections located near borders tend to have a greater EVA and need more EU funding.
Article
An increased need for palliative care has been acknowledged world-wide. However, recent Canadian end-of-life care frameworks have largely failed to consider the unique challenges of delivery in rural and remote regions. In the Canadian province of British Columbia (BC), urban areas are well-served for specialized palliative care; however, rural and remote regions are not. This study presents a location analysis model designed to determine appropriate locations to allocate palliative care services. Secondary palliative care hubs (PCH) are introduced as an option for delivering these services in rural and remote regions. Results suggest that several BC communities may be appropriate locations for secondary PCHs. This model could be applied to the allocation of palliative care resources in other jurisdictions with similar rural and remote regions.
Article
In recent years there have been several attempts to develop quantitative measures of potential spatial access to health care services which, despite their limitations, offer many positive ideas that can perhaps be integrated into a logically consistent and generally acceptable index. It is in this vein that the current paper presents an integrated approach, drawing partially from past contributions, to measuring potential spatial access to health care services. The final access index is derived as the culmination of a series of individual measures, starting with an initial gravity formulation and progressing through successive stages as new elements, consistent with the definition and conceptualization of potential spatial access, are introduced. Application of the proposed index to the ambulatory medical care system of the Akron, Ohio SMSA, demonstrates the validity of the measure, and its suitability as a potential health care planning tool.