FAIRSTEPS: Integrative Review of the Barriers and Enablers to Primary Care Equity

Problem

Primary care inequities are unjust and avoidable. High quality healthcare can improve outcomes by up to 20%. Locally targeted interventions, developed by primary care services to reflect the needs of their setting, were argued to be integral to tackling health equity in the 2010 Marmot report. The FAIRSTEPS study was conducted to produce an evidence-informed framework to guide this process. This element of the review aimed to inform the FAIRSTEPS framework development with a comprehensive understanding of the wide-ranging barriers and enablers to primary care equity.

Approach

An integrative review of primary care interventions in published and grey literature was undertaken. Sources were limited to those in English since 2010 from countries with developed primary care services whose services sought to achieve universal availability (Canada, North Western Europe, Scandinavia or Australasia). Searches were performed via Medline, Embase and CINAHL for published literature. Grey literature was sourced via relevant websites, experts in the field and hand searching. During evidence selection, a substantial number of publications were identified which described no intervention but provided rich information on what influenced the provision of equitable services. A supplementary review was therefore undertaken to identify themes from this data.

Findings

There were 4 overarching themes: 1] Healthcare ‘actors’ (health practitioner, practice & network and health system) 2] Patient & community ‘actors’ 3] Influencing elements (personal, local and societal) 4] Targeted Innovations. 1] Health practitioners’ conceptualisation of inequity is impactful to patient outcomes and could be enhanced through early exposure in training to deprived settings. Practices & networks adapting services to be authentically patient-focused and increasing staff diversity improves equity, however workforce pressures often prevent local innovation and further deepen inequity. 2] Patients knowledge and education (health, digital, reading literacy), health beliefs, fear and expectations are important and influence their self-advocacy. Instability of circumstances and increased rates of trauma are linked to vulnerability characteristics and worsen access. Communities can provide support, motivation and bridge cultural gaps but also embody stigma. 3] Influencing elements incorporate normalisation of poor health, trust, language, structural discrimination and political will. 4] Targeted innovations take a system-based approach; collecting data and responding strategically.

Consequences

This review provides a comprehensive overview of barriers and enablers to primary care equity. The analysis is rooted in a practical approach, allowing frontline practitioners and commissioners to position themselves in their conceptual landscape alongside the patient, community and wider health system. This work offers an explanation as to how these ‘actors’ and their influences construct the barriers and enablers to equally distributed primary care. This should allow easy identification of the local barriers amenable to change (and those which are outside their influence) and ‘actors’ or influencing elements which could be effectively targeted to improve equity.