Health service brokerage to improve primary care access for populations experiencing vulnerability or disadvantage: a systematic review and realist synthesis

Abstract

Background Individuals experiencing disadvantage or marginalisation often face difficulty accessing primary health care. Overcoming access barriers is important for improving the health of these populations. Brokers can empower and enable people to access resources; however, their role in increasing access to health services has not been well-defined or researched in the literature. This review aims to identify whether a health service broker working with health and social service providers in the community can (a) identify individuals experiencing vulnerability who may benefit from improved access to quality primary care, and (b) link these individuals with an appropriate primary care provider for enduring, appropriate primary care. Methods Six databases were searched for studies published between January 2008 and August 2015 that evaluated a health service broker intervention linking adults experiencing vulnerability to primary care. Relevant websites were also searched. Included studies were analysed using candidacy theory and a realist matrix was developed to identify mechanisms that may have contributed to changes in response to the interventions in different contexts. Results Eleven studies were included in the review. Of the eight studies judged to provide detailed description of the programs, the interventions predominately addressed two domains of candidacy (identification of candidacy and navigation), with limited applicability to the third and fourth dimensions (permeability of services and appearances at health services). Six of the eight studies were judged to have successfully linked their target group to primary care. The majority of the interventions focused on assisting patients to reach services and did not look at ways that providers or health services could alter the way they deliver care to improve access. Conclusions While specific mechanisms behind the interventions could not be identified, it is suggested that individual advocacy may be a key element in the success of these types of interventions. The interventions were found to address some dimensions of candidacy, with health service brokers able to help people to identify their need for care and to access, navigate and interact with services. More consideration should be given to the influence of providers on patient candidacy, rather than placing the onus on patients. Electronic supplementary material The online version of this article (10.1186/s12913-019-4088-z) contains supplementary material, which is available to authorized users.

Engaging with peers to integrate community care: Knowledge synthesis and conceptual map

“…Finally, peers' interventions frequently have an advocacy component or objective. Peers can advocate for the needs of communities, acting as mediators between them and the healthcare system, to render care accessible and adapted 16,34,52 . Research suggests that peers create collective knowledge and a specific narrative identity that calls into question standardized ways of knowing (e.g., scientific, medical) and current clinical practices 2,53 .…”

“…Navigational support can refer to different tasks, such as referrals and linkages to health and community services, appointment booking, follow‐ups with providers, accompaniments or providing practical assistance for housing, food insecurity, financial aid and even hobbies 17 . Such interventions require peers to understand the needs individuals might have, and identify the appropriate resources to which to bridge them 16 . Research suggests that navigational support can facilitate screening of chronic diseases 44 and help to coordinate care across sectors and providers, 11,45 which is critical to address the complex social and healthcare needs of disadvantaged groups 46 …”

Applying the ‘Candidacy’ Model to understand access to key nutrition, food & health services in LMIC contexts: a qualitative study in Odisha, India

“…It recognises that accessing a service is a negotiation between potential users, and gatekeepers and providers, and these interactions are key to whether access is achieved (Dixon-Woods et al, 2006). It has been used effectively to analyse access to other public services, and applied successfully to vulnerable and marginalised groups (Manthorpe et al, 2009;Koehn, 2009;D'Ambruoso et al, 2010;Mackenzie et al, 2013;Thomas et al, 2019), within a variety of settings, including the UK (Dixon-Woods et al, 2005, 2006Garret et al, 2012), Australia (Peiris et al, 2012) Canada (Koehn, 2009) and South Africa (Adeagbo et al, 2019). The model will be applied to NFSA service access in Odisha.…”

Qualitative Case Study: A Pilot Program to Improve the Integration of Care in a Vulnerable Inner-City Community

“…A significant body of literature exists on interventions using CHWs, PNs and LWs in various settings to help vulnerable communities navigate complex health systems, improve service delivery and address the social determinants of health [2,4,5]. There is growing evidence that person-centred interventions provided by these roles, can be effective in improving access to health services (especially cancer screening) [4,6,7,8], promoting a wide range of healthy behaviours [2,4], improving chronic disease management [2,9,10,11,12], reducing preventable health service use [13] and improving the overall health and wellbeing of populations [12], including those from disadvantaged groups [2,6,9,14].…”