A Framework for Evaluating Safety-Net and other Community-Level Factors on Access for Low-Income Populations

Abstract

The framework presented in this article extends the Andersen behavioral model of health services utilization research to examine the effects of contextual determinants of access. A conceptual framework is suggested for selecting and constructing contextual (or community-level) variables representing the social, economic, structural, and public policy environment that influence low-income people's use of medical care. Contextual variables capture the characteristics of the population that disproportionately relies on the health care safety net, the public policy support for low-income and safety-net populations, and the structure of the health care market and safety-net services within that market. Until recently, the literature in this area has been largely qualitative and descriptive and few multivariate studies comprehensively investigated the contextual determinants of access. The comprehensive and systematic approach suggested by the framework will enable researchers to strengthen the external validity of results by accounting for the influence of a consistent set of contextual factors across locations and populations. A subsequent article in this issue of Inquiry applies the framework to examine access to ambulatory care for low-income adults, both insured and uninsured.

Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities

“…This interest grew out of concerns that policy and delivery system changes that affected the safety net could adversely affect access to care for the most vulnerable subgroups. This study builds on the findings reported from other population-based multivariate studies investigating geographic variation in access (Davidson et al 2004).…”

“…This study adapts a conceptual and analytical framework ( Figure 1) to test the effects of community-and individual-level variables on access (Davidson et al 2004). Individual-level characteristics are attributes of the individual that influence whether a person will seek care.…”

“…Community-level characteristics describe the neighborhood, city, or metropolitan area context in which individuals live and may, or may not, seek care. We have categorized community-level factors as: 1) the safety-net population in need, 2) support for the low-income population, 3) safetynet services, 4) support for the safety net, and 5) the broader health care market (Davidson et al 2004;Norton and Lipson 1998;Meyer et al 1999;IOM 2000).…”

The Case for Synergy Between a Usual Source of Care and Health Insurance Coverage

“…26 We then created four subgroups, including: (1) We used the conceptual model designed by Aday and Andersen to guide the identification of nine additional covariates that might influence access to care, including: age, race, ethnicity, employment, geographic residence, education, household income as a percent of federal poverty level, health status, and marital status. [28][29][30] In two-tailed, chi-square analyses, each covariate was significantly associated with at least one outcome (p<0.10); thus, all covariates were included in logistic regression models.…”

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

“…[12][13][14][15][16] Although individual-level factors (e.g., insurance status, income, and race) have been the predominant focus in empirical research on determinants of access to care, 17,18 the role of neighborhood environment has received increasing attention in recent years. Early sociological conceptualizations of access, [19][20][21][22] along with the social-epidemiologic literature on neighborhood health effects, [23][24][25] have suggested ways in which neighborhoods' structural, built, and social attributes can affect access to health care. Neighborhood stratification by race and socioeconomic status (SES) is associated with differentials in the quality of the physical and the social environment, which can, in turn, affect residents' health care-seeking behavior, via two potential mechanisms.…”