ACCESS TO PRIMARY HEALTH CARE:
DOES NEIGHBOURHOOD OF RESIDENCE MATTER?
By
Laura Bissonnette
A thesis submitted in conformity with the requirements
for the degree of Master of Arts
Graduate Department of Geography
University of Toronto
© Copyright by Laura Bissonnette (2009)
Abstract
Access to primary health care: Does neighbourhood of residence matter?
For the degree of Master of Arts, 2009
Graduate Department of Geography
University of Toronto
Access to primary health care is an important determinant of health. Within current research there has been limited examination of neighbourhood level variations in access to care, despite knowledge that local contexts shape health. The objective of this research is to examine neighbourhood-level access to primary health care in the city of Mississauga, Ontario. Street address locations of primary care physicians were obtained from the College of Physicians and Surgeons of Ontario (CPSO) website and analyzed using geographic information systems (GIS). A 'Three Step Floating Catchment Area' (3SFCA) method was derived and used to measure multiple dimensions of access for the population as a whole, for specific linguistic groups and for recent immigrants. This research identifies significant neighbourhood-level variations in access to care for each dimension of access and population subgroup studied.
The research findings contribute to a more nuanced understanding of neighbourhood-level variability in access to health care.
Table of Contents
Chapter 1: Introduction………………………………………………......1
1.1 Research Context and Research Question ……………………….1
1.2 Outline………………………………………………………………....8
Chapter 2: Literature Review…………………………………………...10
2.1 Introduction…………………………………………………………...10
2.2 Neighbourhood Level Analysis of Health Data…………………...10
2.2.1 Conceptual Definitions of Neighbourhoods……………………..11
2.2.2 Operational Definitions of Neighbourhoods………………….....12
2.2.3 Neighbourhoods and Health……………………………………...16
2.3 Access to Health Care…………………………………………....….21
2.3.1 Components of ‘Access’…………………………………….....….22
2.3.2 Conceptualization of Potential Access……...................…........25
2.3.3 Measuring Potential Access………………………………….......26
2.4 Conclusion…………………………………………………………....48
Chapter 3: Data & Methods……………………………………………..53
3.1 Introduction…………………………………………………………...53
3.2 Research Context……………………………………………………54
3.3 Data Collection……………………………………………………....56
3.4 Data Analysis………………………………………………………...59
3.4.1 Stage 1: Raw Distribution of Primary Care………………….….60
3.4.2 Stage 2: Potential Spatial Access to Care……………………...60
3.4.3 Stage 3: Cumulative Index of Accessibility………………….….65
3.4.4 Stage 4: Aspatial Dimensions of Access to Care...………...…67
Chapter 4: Results…………………………………………………….70
4.1 Introduction…………………………………………...……………..70
4.2 Description of Mississauga’s Primary Care………..…………….70
4.3 Spatial Accessibility to Primary Care………………..…………....72
4.3.1 Driving Access (3Km) to Primary Care……………..………..…73
4.3.2 Walking Access (800m) to Primary Care……………..………...77
4.4 Cumulative Index of Potential Accessibility……………...............80
4.5 Aspatial Dimensions of Access to Care..............………..…….....83
4.5.1 Language-Specific Access to Primary Care……………..…..…83
4.5.2 Access to Primary Care for Recent Immigrants…………..…....90
Chapter 5: Discussion……………………………………………….......92
5.1 Summary of Key Findings…………………….………………….....92
5.1.1 Spatial Access to Primary Care………………………………......92
5.1.2 Aspatial Dimensions of Access to Care...................……….......94
5.2 Research Contributions………………………………………..........96
5.2.1 Neighbourhood-Level Access to Health Care………….…….....96
5.2.2 Development of the 3SFCA Method…………………………......98
5.2.3 Aspatial Dimensions of Access to Care .............………….......101
5.3 Research Limitations………………………………………..…...…103
5.4 Recommendations for Future Research……………………..…..105
5.5 Policy Recommendations……………………………………….....107
5.5.1 Municipal Policy Intervention...................................................107
5.5.2 Other Sources of Primary Care: Development of LHINs.........110
5.5.3 Constraints of Urban Form in Policy Intervention....................111
5.6 Conclusions………………………………………….……………...113
References……………………………………………………………....114
Appendices………………………………………………………….......127
Appendix A: Neighbourhood Demographics…………………….......127
Appendix B: Raw Physician Data……………………………….….....130
Appendix C: Access Ratios…………………………………………....131
Figure 3. Distribution of primary care physicians (PCPs) in Mississauga.
Figure 4. Distribution of Physicians Accepting New Patients and Walk-in Clinics
in Mississauga.
Figure 5. Physicians-Per-1,000 Population Using 3Km Catchments.
Figure 6. Physicians Accepting New Patients-Per-1,000 Population Using 3Km
Catchments.
Figure 7. Access to Walk-in Clinics-Per-1,000 Population Using 3Km
Catchments.
Figure 8. Physicians-per-1,000 Population Using 800 m Catchments.
Figure 9. Physicians Accepting New Patients-Per-1,000 Population Using 800 m
Catchments.
Figure 10. Walk in Clinics -per-1,000 Population Using 800 m Catchments.
Figure 11. Spatial Index of Accessibility.
Figure 12. Index of Accessibility Map.
Chapter 5: Discussion
5.1 Summary of Key Findings
The objectives of this research were three-fold. The first objective was to evaluate current methodology used to measure potential access and devise an appropriate methodology to be used in this specific Canadian setting. The second objective was to identify neighbourhood-level disparities in potential access to primary health care in Mississauga, Ontario. The third objective was to explore alternative spatial and aspatial dimensions of potential access to health care to develop a more nuanced understanding of potential access in this research setting. The following discussion will highlight the key findings with respect to the original research objectives.
5.1.1 Spatial Access to Primary Care
Preliminary investigation into access to Mississauga’s primary care physicians reveals strong patterns of spatial clustering. The raw distribution shows that the city’s 677 PCPs are located primarily in central and south Mississauga, with few in the northern-most neighbourhoods. As previously stated, the degree of clustering is so high that only four neighbourhoods (Central Erin Mills, Cooksville, Applewood & Meadowvale) possess nearly one-half (46%) of all physicians. The distribution of walk-in clinics and of physicians that are accepting patients follows a similar pattern of spatial clustering, with the majority of each located in central and south Mississauga.
Spatial clustering of primary care becomes stronger when considering health care supply relative to population demand using 3Km and 800m access ratios. At 3 Km, the highest access neighbourhoods for the measure PCPs-per1,000 were primarily located along the south-west and south-east borders of the city. Neighbourhoods in the highest access quartile for the second measure, PCPs accepting-per-1,000, were primarily in the eastern-most tip of the city. The third measure showed the same spatial distribution as that of the first, with high access neighbourhoods situated mainly along the south-west and south-east borders of the city, and many of the same high access neighbourhoods identified.
The spatial access ratios at 800m showed very similar distribution of high access ratios as occurred at 3Km, although the degree of clustering was slightly less. In several cases, neighbourhoods that were of high accessibility based on driving distance were of low accessibility by walking distance. One such example is Malton. This neighbourhood displays a disparity in access to care that favours individuals with access to a vehicle.
Based on the examination of access to primary health care, there is a clear demonstration that significant neighbourhood-level differences in potential spatial access to care do exist. While several neighbourhoods are consistently of high access by all measures (e.g. Cooksville, Fairview & Applewood), others are low access by all measures (e.g. Northeast 1, Southdown). This indicates in more general terms that neighbourhood-level variation in access to care does exist. The index of accessibility supports these findings, given that neighbourhood level access scores range from extreme ends of the scale of -12 and +12. However, a more varied picture of access emerges when considering alternative dimensions and alternative distances. Several neighbourhoods switch between high and low access depending on the measure of access and distance examined. Dixie, Lakeview, Churchill Meadows and Meadowvale Business are several that stand out in this respect.
5.1.2 Aspatial Dimensions of Access to Care
Because of the diversity of Mississauga’s population it was pertinent to determine how access to primary care may differ amongst the population based on aspatial/social characteristics such as language of mother tongue and immigrant status. While there are many languages spoken in the city, this research has focused on some of the largest by population – Arabic, Tagalog, Polish, Punjabi and Urdu. Also examined were access levels for individuals speaking French so that access based on official versus non-official second languages can be compared.
This exploration of particular population subgroups reveals significant geographic disparities in access for language-related population sub-groups. For each mother tongue, access to physicians with language-specific capabilities varies significantly between neighbourhoods. Access to health care for each language explored displays some degree of spatial clustering. Individuals not residing in or near those clusters of high access neighbourhoods may face significant difficulties in accessing language-specific health care. To further compound this problem, several neighbourhoods obtained low access scores for all languages studied. These neighbourhoods may be severely lacking in care that is sensitive to the particular language needs of the population residing within them. Further investigation is required to determine whether there is a demand for such care in these neighbourhoods, and how these needs could best be addressed.
For some languages, low accessibility tends to correspond with high population numbers of individuals. This was particularly demonstrated at a distance of 800m, and most particularly for access to Tagalog speaking physicians. This indicates that there may be large numbers of individuals in these neighbourhoods that face language barriers in access to care. An additional finding was that access ratios varied significantly between language groups. Accessibility was very high for the French and Arabic languages, moderate for Punjabi and Urdu, and very low for Polish and Tagalog. This reveals that language appropriate care may be more obtainable for some population groups than it is for others. Specifically, access to health care for Tagalog and Urdu may be very problematic. While the traditional policy focus in Canada is to equalize accessibility between the two official languages, French and English, these findings indicate a need to focus on facilitating accessibility for non-official linguistic groups.
The examination of access to care for recent immigrants reveals strong disparities. Neighbourhoods with the best access by vehicle are clustered in the east end of the city, while those with the best access for pedestrians are generally located throughout the central and south end of the city. However, the populations of recent immigrants are more heavily concentrated throughout the northern end of the city and some central neighbourhoods, and as such, the distribution of access does not correspond with the highest levels of potential population demand.
5.2 Research Contributions
This examination of access to primary care serves as an example of research that bridges research and literature in several fields including health geography and neighbourhoods and health in particular, quantitative literature on potential spatial access to health care and literature on primary health care in Canada. In doing do, this research has made a number of contributions that fill gaps in these existing bodies of literature. The methodological and theoretical contributions of these endeavors are explored in the following section.
5.2.1 Neighbourhood-Level Access to Health Care
The study of neighbourhood-level access to health care is a relatively small and recent field of enquiry. Within this field, research findings have continually utilized statistical units as proxy for neighbourhoods. Such studies typically demonstrate that access to health care is higher in urban centres and lower in urban peripheries. Problematic with these findings is that they are highly dependent on choices made with regards to research methodology and neighbourhood boundaries.
This research contributes to the existing body of literature on neighbourhood level access to care by identifying the existence of local level variation in access to primary care within this particular urban setting. This is accomplished through the use of meaningful neighbourhoods that are recognized by Mississauga residents and used in city planning. Through this analysis it was demonstrated that access to care showed a much more differential spatial pattern than is typically identified. Furthermore, this pattern of accessibility is highly dependent on the scale of analysis (e.g. 3Km vs. 800m). This demonstrates that the investigation of intra-urban variability in access to care is a highly relevant venue of inquiry. In addition, there may be cause to re-evaluate previously studied urban areas using newer methodologies such as the 3SFCA developed here so that previously undiscovered disparities in access to care may be identified.
This research additionally contributes to the current dialogue on neighbourhoods and access to health care by demonstrating how one methodology can be adapted to examine multiple dimensions of access. While it is recognized in the literature that potential access contains numerous spatial (Penchansky & Thomas, 1981) and aspatial (Khan, 1992) components, the majority of the literature focuses on narrow definitions of potential access. This may be due to the fact that there has yet to be a precedent established for how such dimensions of access can be measured using readily available data. The measurement of access to physicians accepting patients, to walk-in clinics and access for particular population subgroups in this analysis demonstrates how a more nuanced understanding of access to care can be obtained using available data. In performing this analysis, a highly variable picture emerged whereby the spatial pattern of accessibility differed significantly based on the dimension of access studied. This demonstrates a need to continually investigate alternative dimensions of potential access.
5.2.2 Development of the 3SFCA Method
Within the area of health geography focusing on access to health services there has been heightened interest of late to develop methods to adequately describe local-level variations in access to care (e.g. see Luo & Wang, 2003; Luo, 2004; Langford & Higgs, 2006; Luo & Qi in press; McGrail & Humphreys in press). However, most methods are developed for use in international contexts based on statistical units of analysis (e.g. census tracts). Such methods are not necessarily appropriat in contexts where more locally and politically meaningful units of analysis are available, nor do they work on units of variable size such as the neighbourhoods of Mississauga. Building upon previous research, this study has advanced existing methodologies and techniques used to measure access to health care, and better understand local level variations in access.
The Three Step Floating Catchment Area method is a significant methodological contribution that will help further future explorations into neighbourhood-level variations in access to health care. While the existing 2SFCA method has been viewed as an innovative and improved way to measure access to health care, it was found here that it may not be appropriate for this research. The 2SFCA method works well when study areas are roughly uniform in size, and are not excessively large in comparison to the size of the catchment used. While it is not the position of this research to state whether or not these criteria were satisfied in previous research settings employing the 2SFCA method, they were not satisfied in Mississauga. In contrast, the inclusion of a third step into this method to create the 3SFCA method allowed catchments to be created around the small and roughly equally sized dissemination areas and further aggregated to the locally relevant neighbourhoods. This improvement suits the method adequately for Canadian research where dissemination areas are available nationwide as units of data analysis. Additionally, the third step of this method demonstrates how access ratios can be calculated using statistical units and readily available data and further adapted to provide measures of accessibility for locally relevant neighbourhoods.
In addition to furthering existing methodology, the development of the three-step floating catchment area method for this research also demonstrates the importance of evaluating the appropriateness of existing methodology within the context of which it is to be used. There are a large number of techniques available for the examination of access to health care, but not every technique will be appropriate in every setting. It became apparent early on in this project that while the existing 2SFCA technique was a sophisticated tool to measure access to care, it would be problematic if used in this setting. Thus, the development of the three-step technique was necessary. It is therefore acknowledged that the three-step method developed here may not work in all geographic settings, and there is a continual need to thoroughly consider the rigor and appropriateness of methods in the particular context they are to be used.
Given the recent development of FCA based methods in the literature, there has been a limited exploration of how such methods can be used to explore access to care by multiple modes of transportation. While alternative buffer distances have been used in the literature, and such distances have been quoted as representing “adequate” travel distances to care, the mode of travel has yet to have been specified. This is a considerable gap in the literature, given that not all individuals travel by car, and a distance that is adequate for one individual by one mean of transportation may not be adequate by another who travels by different means. This research helps fill this gap in knowledge by demonstrating how the size of the buffer used in the 3SFCA can be altered to represent driving distance versus walking distance. It further demonstrates differential results between the two scales examined. One limitation of this research is that it was unable to consider travel distances by bus, as a detailed digital GIS file of the Mississauga public Transit network was not available. It is recommended that future research adapt FCA based methods for the analysis of access by public transportation by using transit network files, when available, as the network on which to create catchments.
An additional contribution of this research stemming from the use of the 3SFCA method and available physician data is the demonstration of how additional dimensions of access to care can be investigated. Within the literature, quantitative studies on access to care tend to focus on the spatial dimensions of access. Furthermore, such investigations typically focus on only one spatial dimension of access (i.e. access to all PCPs by the general population). It is rare for research to examine additional dimensions of access, such as access to walk-in facilities or physicians accepting patients. This research fills a gap in the literature by developing and using a methodology that is able to address alternative dimensions of access to care, thus providing a more comprehensive and holistic picture of potential access.
This research is exploratory in demonstrating how multiple measures of accessibility can be combined into cumulative indices of accessibility. There may be several benefits in creating such an index. One underlying objective of this project is to identify neighbourhoods of interest for future research. Perhaps the most logical concluding step to this research is to identify neighbourhoods which are repeatedly demonstrating poor access and those that repeatedly demonstrate high access. One could do this by visually inspecting maps showing separate measures of access, but this would be more greatly prone to error (Odoi et al, 2005). The use of an index demonstrates a more conclusive method to accomplish this goa method to accomplish this goal.
5.2.3 Aspatial Dimensions of Access to Care
Within the body of literature focusing on potential access to care, there has been little attention paid to how potential access may differ based on aspatial/social characteristics of the population, including language and 101 immigrant status. Such inquiries are much more common in studies of realized access where the use of care is the focus. Recently, several inquiries into access to care for linguistic groups and immigrants have been made within Canada (Asanin & Wilson, 2008; Wang, 2007). There is clearly a need for additional research into this line of inquiry. This research contributes to the very small body of literature on this subject by examining access to care for specific linguistic groups within Mississauga as well as for recent immigrants. Such contributions help to further the dialogue of neighbourhood-level health research by shedding light on the relationships between spatial and social dimensions of access to care.
It may have been expected that the spatial pattern of access would differ between the general population and specific linguistic minority groups. However, for the most part, this was not found. Primarily, neighbourhoods of low access for the general population were also of low accessibility for linguistic minorities. What is important to note is that the levels of access differed significantly between the six linguistic groups examined. This is demonstrated by accessibility ratios that are relatively high for the French speaking population but quite low for other linguistic groups including Tagalog and Polish. While the equalization of access between the official Canadian languages of English and French remains a federal policy focus (Health-Canada, 2009), this research demonstrates a need to address disparities in language-specific access to health care for non official languages.
5.3 Research Limitations
Before concluding the discussion of this research, it is pertinent to acknowledge that the methods chosen here do have several limitations and assumptions inherent in their design. These limitations include the choice of buffer distances of 3Km and 800m, problems with using small DA units of analysis, and potential edge effects that may occur in this municipal setting. Each of these limitations will be explored further below.
The use of a buffering technique to count provider-to-population ratios has several limitations. Firstly, this technique inevitably makes the assumption that individuals falling within a facility catchment have equal access, and those outside of it do not have access at all. This is an oversimplification, where in reality there is generally a gradation of access based on distance, and not an absolute cut-off. Additionally, the use of buffers requires choosing a radius that represents an ‘acceptable’ distance. While a distance of 800m is commonly used in the literature to represent an acceptable walking distance to services (Sallis et al, 2004; Lovett et al, 2002), it must be recognized that this distance is not walkable by all. Individuals with mobility problems, elderly persons, and those who are ill (and hence needing health care) may have difficulties traveling this distance. A distance of 3 Km as a driving distance may also pose problems. The time taken to traverse this distance may differ significantly depending on the location in the city, the presence of traffic congestion, road types, construction, and time of day. Such differences are impossible to take into account with the available data. This illustrates why the continual production and enhancement of digital data is essential to the accuracy of such access studies.
An additional limitation to this study is in using dissemination areas as the unit to obtain population data from. This was done because smaller units tend to show greater between-region variability in access to care (Apparicio et al, 2008). However, the population numbers of DA’s, as with other census units, are rounded to preserve confidentiality. Because there are more DA’s than census tracts, the overall amount of rounding that occurs is greater, resulting in a greater degree of inaccuracy. Additionally, when the population being studied is particularly small, there is a chance the population total may be reduced significantly or eliminated altogether through rounding. This is particularly problematic when studying minority populations with small numbers. The minority languages studied here comprise the city’s largest (non-English) linguistic groups, and rounding error should be of minimal influence. However, this problem should be kept in mind if the three-step method were to be used for very small population subgroups.
One final limitation of this study relates to potential edge effects that may have occurred when conducting the analysis. This study considered population and physician data for the city of Mississauga alone, and did not consider data for neighbouring municipalities. However, because Mississauga is bordered on three sides by other municipalities, this could be problematic. In reality, it is highly plausible that individuals in the peripheral neighbourhoods of the city may choose to seek care in other municipalities rather in their neighbourhood of residence. Additionally, it is plausible that individuals living outside of the city may choose to access care within neighbourhoods of Mississauga. This may have the effect of underestimating health care (and access ratios) for those living in the peripheral neighbourhoods of the city on the three sides bordered by other municipalities. Such problems would be less likely to occur in the analysis of cities that are more isolated and surrounded by sparsely populated rural areas.
5.4 Recommendations for Future Research
This research has provided valuable information on potential access to primary care. This information may be used in future research to further the dialogue of neighbourhood-level access to care, as well as to further methodology used to examine potential access. First and foremost, this research demonstrates the importance of focusing on intra-urban variations in access to care. While the majority of existing research has found little neighbourhood-level variation in access to health care, these findings may result from an over-reliance on the use of statistical units as proxy for neighbourhoods. Research should continue to examine local level variations in access to care using neighbourhood boundaries that are recognized by residents, used in city planning, and are more likely to correspond to the scale that health related processes occur at.
Secondly, as a neighbourhood-level study, this research demonstrates the importance of examining more nuanced dimensions of potential access. Furthermore, it has demonstrated that such dimensions of access can be examined using a readily available data set without the need to expend time and money obtaining additional data. Future research should build upon this example and begin to investigate the dimensions of access examined here in other Canadian and possibly in international settings. Additionally, dimensions of access that further explore the availability of physicians such as by full time equivalencies (FTEs) and the potential need of the population as adjusted for age, gender, ethnicity and other demographic characteristics would further this research. Thirdly, this research has demonstrated disparities in access to care for the city of Mississauga, Ontario. There is a large opportunity for future studies that focus on this city, as well as other cities within Canada. While the literature on access to care is dominated by US and other international studies, there is a need for Canadian research so that health care provision and policy can be amended accordingly. Lastly, it is recognized that while potential access is a fundamental component of access to care, it is only one factor that may lead to realized use of health services. Additional individual characteristics including age, gender, ethnicity, socioeconomic status, beliefs about health and the actual need for care will also determine whether and where an individual seeks care (Gatrell, 2001: 155; Aday & Anderson, 1974). There is a need for ongoing research demonstrating how potential access is related to realized access, and how it is moderated by individual characteristics to influence decision making and overall health outcomes.
5.5 Policy Recommendations
This study reveals a number of significant findings that could be used in public policy to alleviate inequities in access to health care. While health care in Canada is funded by provincial governments, it is increasingly becoming a concern of municipalities. As previously mentioned, the state of health care in Canada is in transition. Federal funding cuts to provinces and decreases in the numbers of practicing family doctors in recent decades has resulted in a restructuring in the way health care is being delivered, particularly with respect to primary health care (Iglehart, 2000). The focus and responsibility of primary health care delivery is increasing on the local (i.e. sub-municipal) level. Municipalities are becoming responsible for funding a greater number of services that were previously a provincial concern (Elliott et al, 2000). As a result, municipalities are becomingly increasingly responsible for the quality of primary care delivery. This following section will address some of the ways in which municipalities can address and alleviate inequitable health care distribution.
5.5.1 Municipal Policy Intervention
In general, policy interventions that may improve access to health services can be discussed as those that bring people to services, those that move services closer to people and those that reduce barriers other than distance (Haynes, 2003: 26). An example of the former would include the improvement of existing transportation systems. For example, additional public transportation routs to areas with abundant health care services could be added in neighbourhoods with the poorest geographical access to health care, particularly in the north end of the city. Such a strategy was undertaken in the UK, where government subsidies for conventional bus services were increased in 1997 and following years, in attempts to increase access for individuals without vehicles (Haynes, 2003: 26). Additionally, new means of transportation could be created which would focus on shuttling those in need to a point of health care. The establishment of a community car scheme (Haynes, 2003: 27) in the poorest access neighbourhoods could help those without transport, as well as those with disabilities and the elderly who may have difficulty with public transportation. This may be of particular use in the north end of Mississauga, an area which was of low accessibility by all measures examined.
The primary strategy that could be used to bring health care closer to the neighbourhoods in need would be a municipal effort to bring about shift in the current distribution to one that is more equitable. Such efforts may be in the form of positive (e.g. tax) incentives for physicians to locate in the northern neighbourhoods where geographical access is poor, and for physicians with second language capabilities to locate in neighbourhoods where access to those languages is low and the population in need is the highest. These strategies, as mentioned, would have to work around existing zoning and land use constraints. Municipal strategies could also be regulatory in nature. Restrictions on the areas where new physicians may practice (such as maximizing the number of physicians who are able to practice in a medical complex) or where existing physicians may move to can be placed so that additional primary care does not locate in areas that are already of high access, and instead are funneled into neighbourhoods that are low access. These redistributive efforts would take time, but over the course of years, a gradual increase in the equitability of provision should occur.
Strategies aimed at reducing social differences in access to health care could be focused on eliminating language barriers in access to care. This research identified that access to physicians based on language abilities is potentially a larger problem for minority languages than it is for the Frenchspeaking population. Thus, there is a need for policy to shift focus from creating equal access between the two official Canadian languages and begin to focus on the non-official minority languages. Ways to mediate this without redistributing physicians could involve the inclusion of interpreter services in family practice settings (Brach and Frasierector, 2000). While such translation services may be available in hospitals, particularly in the emergency ward, they are rarely present in other primary care settings (Wang et al, 2008; Barr & Wanatt, 2005). The ability to receive quality care at the neighbourhood level from a GP may reduce the need for individuals to overuse emergency care (Asanin & Wilson, 2008). Perhaps the most appropriate way to target such services is to identify neighbourhoods where the language-specific access ratios are lowest and the population speaking that language is the highest. This would then be an appropriate location for the provision of translator services. Additionally, the inclusion of information in non-official languages at family practices and health care centres would enhance the quality of care for individuals speaking those languages and increase the likelihood that their health care needs are met. Such languages could be chosen based on those spoken most frequently within a neighbourhood.
5.5.2 Other Sources of Primary Care: Development of LHINs
As mentioned in Chapter 3, there are a number of settings in which primary health care can be administered. One such setting is the Local Health Integration Network (LHIN). LHINs are a recent addition to local level primary health care delivery, and have been operating in Canada since April 1 of 2006 (OLHIN, 2009). LHINs offer a much broader and comprehensive range of primary care than do family practices by integrating and coordinating services such as community health services, addiction and mental health counseling and long-term care (Elson, 2006). These primary services are no longer the responsibility of the provincial Ministry of Health, demonstrating an increasingly municipal and local focus on primary care in Canada. However, individual GP/FP practices remain under provincial control under this new system (Elson, 2006).
Given the multiple levels of regulatory control over primary care in Canada, there is a need to conceptualize how different modes of primary care delivery can work together to optimally provide services at the local level (Elson, 2006). LHINs, similar to Walk-in health care services, were created during a time when public dissatisfaction with the quality and waiting times for GP/FP provision was increasing. The intention with these added services was to fill a gap in the 110 provision of primary care at the local level that family practices were failing to address. However, these alternative modes of delivery for primary care are not intended to take the place of having a dedicated family doctor. Individuals who use community based primary care such as walk-in services still tend to prefer to consult with family doctors, and appreciate the added quality of service provision that occurs when a physician knows a patient and understands their specific medical history (Brown et al, 2002). Such benefits of GP/FP provision in family practice are not trivial. As such, the municipal policy focus on primary care should not ignore the ways in which family care provision can be optimized municipally in favour of new modes of delivery such as LHINs. Instead, municipal policy focus should begin to focus on how primary health care can be optimized considering the multiple delivery systems that are now operating at the local level, including family practices, walk-in clinics, and LHINs. Such a task has yet to be adequately addressed (Levitt, McMullan & Freeman-Collins, 2005), and will be of increasing importance in future years as the emphasis on LHINs and municipal control over neighbourhood level health care increases.
5.5.3 Constraints of Urban Form in Policy Intervention
At this point it is pertinent to include a comment regarding constraints that may exist when attempting to implement municipal-level policy to alleviate health provision shortages. It was determined by this research that the provision of health care significantly varied across Mississauga by all conceptualizations (e.g. spatial, aspatial and by scale) examined here. There may be multiple causes of this varied picture of accessibility, but all relate to the distribution of physicians relative to the distribution of the population. There are two main determinants of physician distribution recognized in the literature. First, the location where a physician may practice is heavily constrained by the existing urban form of the city, and particularly by the existing zoning and land use allowances. This zoning may play a large role in the reasoning why several of Mississauga’s neighbourhoods (e.g. Gateway, Northeast 2, Sheridan Park, Southdown) were consistently of low accessibility by all measures examined. For example, if these neighbourhoods are primarily industrial or green-space, they will not contain sites where health care practices may be situated, nor will they contain adequate residential settlements requiring such care. More investigation is required to determine if this is the case. In such a scenario, municipal policy will have little effect at redistributing health care into such areas. Additionally, there may not be a need to do so. However, a second key factor affecting the distribution of physicians is the actual choice of the physicians themselves in where to locate their practice. Research indicates that physicians tend to choose to locate practices near their place of residence. Additionally, physicians prefer to locate in areas where support can be received, such as in a practice with other physicians or near a hospital (Szafran, Crutcher & Chaytors, 2001). This element of choice allows for policy intervention to mediate inequities in health care distribution, and additional research is required to determine the optimal way to do so.
5.6 Conclusions
This analysis has revealed significant intra-urban variability in potential access to primary health care, considering multiple measures of access, population groups, and at multiple distances. These findings were made possible through the development of a GIS methodology that is appropriate for this research setting, and through careful consideration of the appropriate neighbourhood units to use. There is a need for ongoing examination of neighbourhood-level access to primary care using appropriate methodology and neighbourhood units. In particular, examination of access to primary care in additional Canadian cities will help to further the understanding how access to care differs in the context of increasing concerns over the state of primary health care in Canada.
5.1.1 Spatial Access to Primary Care
Preliminary investigation into access to Mississauga’s primary care physicians reveals strong patterns of spatial clustering. The raw distribution shows that the city’s 677 PCPs are located primarily in central and south Mississauga, with few in the northern-most neighbourhoods. As previously stated, the degree of clustering is so high that only four neighbourhoods (Central Erin Mills, Cooksville, Applewood & Meadowvale) possess nearly one-half (46%) of all physicians. The distribution of walk-in clinics and of physicians that are accepting patients follows a similar pattern of spatial clustering, with the majority of each located in central and south Mississauga.
Spatial clustering of primary care becomes stronger when considering health care supply relative to population demand using 3Km and 800m access ratios. At 3 Km, the highest access neighbourhoods for the measure PCPs-per1,000 were primarily located along the south-west and south-east borders of the city. Neighbourhoods in the highest access quartile for the second measure, PCPs accepting-per-1,000, were primarily in the eastern-most tip of the city. The third measure showed the same spatial distribution as that of the first, with high access neighbourhoods situated mainly along the south-west and south-east borders of the city, and many of the same high access neighbourhoods identified.
The spatial access ratios at 800m showed very similar distribution of high access ratios as occurred at 3Km, although the degree of clustering was slightly less. In several cases, neighbourhoods that were of high accessibility based on driving distance were of low accessibility by walking distance. One such example is Malton. This neighbourhood displays a disparity in access to care that favours individuals with access to a vehicle.
Based on the examination of access to primary health care, there is a clear demonstration that significant neighbourhood-level differences in potential spatial access to care do exist. While several neighbourhoods are consistently of high access by all measures (e.g. Cooksville, Fairview & Applewood), others are low access by all measures (e.g. Northeast 1, Southdown). This indicates in more general terms that neighbourhood-level variation in access to care does exist. The index of accessibility supports these findings, given that neighbourhood level access scores range from extreme ends of the scale of -12 and +12. However, a more varied picture of access emerges when considering alternative dimensions and alternative distances. Several neighbourhoods switch between high and low access depending on the measure of access and distance examined. Dixie, Lakeview, Churchill Meadows and Meadowvale Business are several that stand out in this respect.
5.1.2 Aspatial Dimensions of Access to Care
Because of the diversity of Mississauga’s population it was pertinent to determine how access to primary care may differ amongst the population based on aspatial/social characteristics such as language of mother tongue and immigrant status. While there are many languages spoken in the city, this research has focused on some of the largest by population – Arabic, Tagalog, Polish, Punjabi and Urdu. Also examined were access levels for individuals speaking French so that access based on official versus non-official second languages can be compared.
This exploration of particular population subgroups reveals significant geographic disparities in access for language-related population sub-groups. For each mother tongue, access to physicians with language-specific capabilities varies significantly between neighbourhoods. Access to health care for each language explored displays some degree of spatial clustering. Individuals not residing in or near those clusters of high access neighbourhoods may face significant difficulties in accessing language-specific health care. To further compound this problem, several neighbourhoods obtained low access scores for all languages studied. These neighbourhoods may be severely lacking in care that is sensitive to the particular language needs of the population residing within them. Further investigation is required to determine whether there is a demand for such care in these neighbourhoods, and how these needs could best be addressed.
For some languages, low accessibility tends to correspond with high population numbers of individuals. This was particularly demonstrated at a distance of 800m, and most particularly for access to Tagalog speaking physicians. This indicates that there may be large numbers of individuals in these neighbourhoods that face language barriers in access to care. An additional finding was that access ratios varied significantly between language groups. Accessibility was very high for the French and Arabic languages, moderate for Punjabi and Urdu, and very low for Polish and Tagalog. This reveals that language appropriate care may be more obtainable for some population groups than it is for others. Specifically, access to health care for Tagalog and Urdu may be very problematic. While the traditional policy focus in Canada is to equalize accessibility between the two official languages, French and English, these findings indicate a need to focus on facilitating accessibility for non-official linguistic groups.
The examination of access to care for recent immigrants reveals strong disparities. Neighbourhoods with the best access by vehicle are clustered in the east end of the city, while those with the best access for pedestrians are generally located throughout the central and south end of the city. However, the populations of recent immigrants are more heavily concentrated throughout the northern end of the city and some central neighbourhoods, and as such, the distribution of access does not correspond with the highest levels of potential population demand.
5.2 Research Contributions
This examination of access to primary care serves as an example of research that bridges research and literature in several fields including health geography and neighbourhoods and health in particular, quantitative literature on potential spatial access to health care and literature on primary health care in Canada. In doing do, this research has made a number of contributions that fill gaps in these existing bodies of literature. The methodological and theoretical contributions of these endeavors are explored in the following section.
5.2.1 Neighbourhood-Level Access to Health Care
The study of neighbourhood-level access to health care is a relatively small and recent field of enquiry. Within this field, research findings have continually utilized statistical units as proxy for neighbourhoods. Such studies typically demonstrate that access to health care is higher in urban centres and lower in urban peripheries. Problematic with these findings is that they are highly dependent on choices made with regards to research methodology and neighbourhood boundaries.
This research contributes to the existing body of literature on neighbourhood level access to care by identifying the existence of local level variation in access to primary care within this particular urban setting. This is accomplished through the use of meaningful neighbourhoods that are recognized by Mississauga residents and used in city planning. Through this analysis it was demonstrated that access to care showed a much more differential spatial pattern than is typically identified. Furthermore, this pattern of accessibility is highly dependent on the scale of analysis (e.g. 3Km vs. 800m). This demonstrates that the investigation of intra-urban variability in access to care is a highly relevant venue of inquiry. In addition, there may be cause to re-evaluate previously studied urban areas using newer methodologies such as the 3SFCA developed here so that previously undiscovered disparities in access to care may be identified.
This research additionally contributes to the current dialogue on neighbourhoods and access to health care by demonstrating how one methodology can be adapted to examine multiple dimensions of access. While it is recognized in the literature that potential access contains numerous spatial (Penchansky & Thomas, 1981) and aspatial (Khan, 1992) components, the majority of the literature focuses on narrow definitions of potential access. This may be due to the fact that there has yet to be a precedent established for how such dimensions of access can be measured using readily available data. The measurement of access to physicians accepting patients, to walk-in clinics and access for particular population subgroups in this analysis demonstrates how a more nuanced understanding of access to care can be obtained using available data. In performing this analysis, a highly variable picture emerged whereby the spatial pattern of accessibility differed significantly based on the dimension of access studied. This demonstrates a need to continually investigate alternative dimensions of potential access.
5.2.2 Development of the 3SFCA Method
Within the area of health geography focusing on access to health services there has been heightened interest of late to develop methods to adequately describe local-level variations in access to care (e.g. see Luo & Wang, 2003; Luo, 2004; Langford & Higgs, 2006; Luo & Qi in press; McGrail & Humphreys in press). However, most methods are developed for use in international contexts based on statistical units of analysis (e.g. census tracts). Such methods are not necessarily appropriat in contexts where more locally and politically meaningful units of analysis are available, nor do they work on units of variable size such as the neighbourhoods of Mississauga. Building upon previous research, this study has advanced existing methodologies and techniques used to measure access to health care, and better understand local level variations in access.
The Three Step Floating Catchment Area method is a significant methodological contribution that will help further future explorations into neighbourhood-level variations in access to health care. While the existing 2SFCA method has been viewed as an innovative and improved way to measure access to health care, it was found here that it may not be appropriate for this research. The 2SFCA method works well when study areas are roughly uniform in size, and are not excessively large in comparison to the size of the catchment used. While it is not the position of this research to state whether or not these criteria were satisfied in previous research settings employing the 2SFCA method, they were not satisfied in Mississauga. In contrast, the inclusion of a third step into this method to create the 3SFCA method allowed catchments to be created around the small and roughly equally sized dissemination areas and further aggregated to the locally relevant neighbourhoods. This improvement suits the method adequately for Canadian research where dissemination areas are available nationwide as units of data analysis. Additionally, the third step of this method demonstrates how access ratios can be calculated using statistical units and readily available data and further adapted to provide measures of accessibility for locally relevant neighbourhoods.
In addition to furthering existing methodology, the development of the three-step floating catchment area method for this research also demonstrates the importance of evaluating the appropriateness of existing methodology within the context of which it is to be used. There are a large number of techniques available for the examination of access to health care, but not every technique will be appropriate in every setting. It became apparent early on in this project that while the existing 2SFCA technique was a sophisticated tool to measure access to care, it would be problematic if used in this setting. Thus, the development of the three-step technique was necessary. It is therefore acknowledged that the three-step method developed here may not work in all geographic settings, and there is a continual need to thoroughly consider the rigor and appropriateness of methods in the particular context they are to be used.
Given the recent development of FCA based methods in the literature, there has been a limited exploration of how such methods can be used to explore access to care by multiple modes of transportation. While alternative buffer distances have been used in the literature, and such distances have been quoted as representing “adequate” travel distances to care, the mode of travel has yet to have been specified. This is a considerable gap in the literature, given that not all individuals travel by car, and a distance that is adequate for one individual by one mean of transportation may not be adequate by another who travels by different means. This research helps fill this gap in knowledge by demonstrating how the size of the buffer used in the 3SFCA can be altered to represent driving distance versus walking distance. It further demonstrates differential results between the two scales examined. One limitation of this research is that it was unable to consider travel distances by bus, as a detailed digital GIS file of the Mississauga public Transit network was not available. It is recommended that future research adapt FCA based methods for the analysis of access by public transportation by using transit network files, when available, as the network on which to create catchments.
An additional contribution of this research stemming from the use of the 3SFCA method and available physician data is the demonstration of how additional dimensions of access to care can be investigated. Within the literature, quantitative studies on access to care tend to focus on the spatial dimensions of access. Furthermore, such investigations typically focus on only one spatial dimension of access (i.e. access to all PCPs by the general population). It is rare for research to examine additional dimensions of access, such as access to walk-in facilities or physicians accepting patients. This research fills a gap in the literature by developing and using a methodology that is able to address alternative dimensions of access to care, thus providing a more comprehensive and holistic picture of potential access.
This research is exploratory in demonstrating how multiple measures of accessibility can be combined into cumulative indices of accessibility. There may be several benefits in creating such an index. One underlying objective of this project is to identify neighbourhoods of interest for future research. Perhaps the most logical concluding step to this research is to identify neighbourhoods which are repeatedly demonstrating poor access and those that repeatedly demonstrate high access. One could do this by visually inspecting maps showing separate measures of access, but this would be more greatly prone to error (Odoi et al, 2005). The use of an index demonstrates a more conclusive method to accomplish this goa method to accomplish this goal.
5.2.3 Aspatial Dimensions of Access to Care
Within the body of literature focusing on potential access to care, there has been little attention paid to how potential access may differ based on aspatial/social characteristics of the population, including language and 101 immigrant status. Such inquiries are much more common in studies of realized access where the use of care is the focus. Recently, several inquiries into access to care for linguistic groups and immigrants have been made within Canada (Asanin & Wilson, 2008; Wang, 2007). There is clearly a need for additional research into this line of inquiry. This research contributes to the very small body of literature on this subject by examining access to care for specific linguistic groups within Mississauga as well as for recent immigrants. Such contributions help to further the dialogue of neighbourhood-level health research by shedding light on the relationships between spatial and social dimensions of access to care.
It may have been expected that the spatial pattern of access would differ between the general population and specific linguistic minority groups. However, for the most part, this was not found. Primarily, neighbourhoods of low access for the general population were also of low accessibility for linguistic minorities. What is important to note is that the levels of access differed significantly between the six linguistic groups examined. This is demonstrated by accessibility ratios that are relatively high for the French speaking population but quite low for other linguistic groups including Tagalog and Polish. While the equalization of access between the official Canadian languages of English and French remains a federal policy focus (Health-Canada, 2009), this research demonstrates a need to address disparities in language-specific access to health care for non official languages.
5.3 Research Limitations
Before concluding the discussion of this research, it is pertinent to acknowledge that the methods chosen here do have several limitations and assumptions inherent in their design. These limitations include the choice of buffer distances of 3Km and 800m, problems with using small DA units of analysis, and potential edge effects that may occur in this municipal setting. Each of these limitations will be explored further below.
The use of a buffering technique to count provider-to-population ratios has several limitations. Firstly, this technique inevitably makes the assumption that individuals falling within a facility catchment have equal access, and those outside of it do not have access at all. This is an oversimplification, where in reality there is generally a gradation of access based on distance, and not an absolute cut-off. Additionally, the use of buffers requires choosing a radius that represents an ‘acceptable’ distance. While a distance of 800m is commonly used in the literature to represent an acceptable walking distance to services (Sallis et al, 2004; Lovett et al, 2002), it must be recognized that this distance is not walkable by all. Individuals with mobility problems, elderly persons, and those who are ill (and hence needing health care) may have difficulties traveling this distance. A distance of 3 Km as a driving distance may also pose problems. The time taken to traverse this distance may differ significantly depending on the location in the city, the presence of traffic congestion, road types, construction, and time of day. Such differences are impossible to take into account with the available data. This illustrates why the continual production and enhancement of digital data is essential to the accuracy of such access studies.
An additional limitation to this study is in using dissemination areas as the unit to obtain population data from. This was done because smaller units tend to show greater between-region variability in access to care (Apparicio et al, 2008). However, the population numbers of DA’s, as with other census units, are rounded to preserve confidentiality. Because there are more DA’s than census tracts, the overall amount of rounding that occurs is greater, resulting in a greater degree of inaccuracy. Additionally, when the population being studied is particularly small, there is a chance the population total may be reduced significantly or eliminated altogether through rounding. This is particularly problematic when studying minority populations with small numbers. The minority languages studied here comprise the city’s largest (non-English) linguistic groups, and rounding error should be of minimal influence. However, this problem should be kept in mind if the three-step method were to be used for very small population subgroups.
One final limitation of this study relates to potential edge effects that may have occurred when conducting the analysis. This study considered population and physician data for the city of Mississauga alone, and did not consider data for neighbouring municipalities. However, because Mississauga is bordered on three sides by other municipalities, this could be problematic. In reality, it is highly plausible that individuals in the peripheral neighbourhoods of the city may choose to seek care in other municipalities rather in their neighbourhood of residence. Additionally, it is plausible that individuals living outside of the city may choose to access care within neighbourhoods of Mississauga. This may have the effect of underestimating health care (and access ratios) for those living in the peripheral neighbourhoods of the city on the three sides bordered by other municipalities. Such problems would be less likely to occur in the analysis of cities that are more isolated and surrounded by sparsely populated rural areas.
5.4 Recommendations for Future Research
This research has provided valuable information on potential access to primary care. This information may be used in future research to further the dialogue of neighbourhood-level access to care, as well as to further methodology used to examine potential access. First and foremost, this research demonstrates the importance of focusing on intra-urban variations in access to care. While the majority of existing research has found little neighbourhood-level variation in access to health care, these findings may result from an over-reliance on the use of statistical units as proxy for neighbourhoods. Research should continue to examine local level variations in access to care using neighbourhood boundaries that are recognized by residents, used in city planning, and are more likely to correspond to the scale that health related processes occur at.
Secondly, as a neighbourhood-level study, this research demonstrates the importance of examining more nuanced dimensions of potential access. Furthermore, it has demonstrated that such dimensions of access can be examined using a readily available data set without the need to expend time and money obtaining additional data. Future research should build upon this example and begin to investigate the dimensions of access examined here in other Canadian and possibly in international settings. Additionally, dimensions of access that further explore the availability of physicians such as by full time equivalencies (FTEs) and the potential need of the population as adjusted for age, gender, ethnicity and other demographic characteristics would further this research. Thirdly, this research has demonstrated disparities in access to care for the city of Mississauga, Ontario. There is a large opportunity for future studies that focus on this city, as well as other cities within Canada. While the literature on access to care is dominated by US and other international studies, there is a need for Canadian research so that health care provision and policy can be amended accordingly. Lastly, it is recognized that while potential access is a fundamental component of access to care, it is only one factor that may lead to realized use of health services. Additional individual characteristics including age, gender, ethnicity, socioeconomic status, beliefs about health and the actual need for care will also determine whether and where an individual seeks care (Gatrell, 2001: 155; Aday & Anderson, 1974). There is a need for ongoing research demonstrating how potential access is related to realized access, and how it is moderated by individual characteristics to influence decision making and overall health outcomes.
5.5 Policy Recommendations
This study reveals a number of significant findings that could be used in public policy to alleviate inequities in access to health care. While health care in Canada is funded by provincial governments, it is increasingly becoming a concern of municipalities. As previously mentioned, the state of health care in Canada is in transition. Federal funding cuts to provinces and decreases in the numbers of practicing family doctors in recent decades has resulted in a restructuring in the way health care is being delivered, particularly with respect to primary health care (Iglehart, 2000). The focus and responsibility of primary health care delivery is increasing on the local (i.e. sub-municipal) level. Municipalities are becoming responsible for funding a greater number of services that were previously a provincial concern (Elliott et al, 2000). As a result, municipalities are becomingly increasingly responsible for the quality of primary care delivery. This following section will address some of the ways in which municipalities can address and alleviate inequitable health care distribution.
5.5.1 Municipal Policy Intervention
In general, policy interventions that may improve access to health services can be discussed as those that bring people to services, those that move services closer to people and those that reduce barriers other than distance (Haynes, 2003: 26). An example of the former would include the improvement of existing transportation systems. For example, additional public transportation routs to areas with abundant health care services could be added in neighbourhoods with the poorest geographical access to health care, particularly in the north end of the city. Such a strategy was undertaken in the UK, where government subsidies for conventional bus services were increased in 1997 and following years, in attempts to increase access for individuals without vehicles (Haynes, 2003: 26). Additionally, new means of transportation could be created which would focus on shuttling those in need to a point of health care. The establishment of a community car scheme (Haynes, 2003: 27) in the poorest access neighbourhoods could help those without transport, as well as those with disabilities and the elderly who may have difficulty with public transportation. This may be of particular use in the north end of Mississauga, an area which was of low accessibility by all measures examined.
The primary strategy that could be used to bring health care closer to the neighbourhoods in need would be a municipal effort to bring about shift in the current distribution to one that is more equitable. Such efforts may be in the form of positive (e.g. tax) incentives for physicians to locate in the northern neighbourhoods where geographical access is poor, and for physicians with second language capabilities to locate in neighbourhoods where access to those languages is low and the population in need is the highest. These strategies, as mentioned, would have to work around existing zoning and land use constraints. Municipal strategies could also be regulatory in nature. Restrictions on the areas where new physicians may practice (such as maximizing the number of physicians who are able to practice in a medical complex) or where existing physicians may move to can be placed so that additional primary care does not locate in areas that are already of high access, and instead are funneled into neighbourhoods that are low access. These redistributive efforts would take time, but over the course of years, a gradual increase in the equitability of provision should occur.
Strategies aimed at reducing social differences in access to health care could be focused on eliminating language barriers in access to care. This research identified that access to physicians based on language abilities is potentially a larger problem for minority languages than it is for the Frenchspeaking population. Thus, there is a need for policy to shift focus from creating equal access between the two official Canadian languages and begin to focus on the non-official minority languages. Ways to mediate this without redistributing physicians could involve the inclusion of interpreter services in family practice settings (Brach and Frasierector, 2000). While such translation services may be available in hospitals, particularly in the emergency ward, they are rarely present in other primary care settings (Wang et al, 2008; Barr & Wanatt, 2005). The ability to receive quality care at the neighbourhood level from a GP may reduce the need for individuals to overuse emergency care (Asanin & Wilson, 2008). Perhaps the most appropriate way to target such services is to identify neighbourhoods where the language-specific access ratios are lowest and the population speaking that language is the highest. This would then be an appropriate location for the provision of translator services. Additionally, the inclusion of information in non-official languages at family practices and health care centres would enhance the quality of care for individuals speaking those languages and increase the likelihood that their health care needs are met. Such languages could be chosen based on those spoken most frequently within a neighbourhood.
5.5.2 Other Sources of Primary Care: Development of LHINs
As mentioned in Chapter 3, there are a number of settings in which primary health care can be administered. One such setting is the Local Health Integration Network (LHIN). LHINs are a recent addition to local level primary health care delivery, and have been operating in Canada since April 1 of 2006 (OLHIN, 2009). LHINs offer a much broader and comprehensive range of primary care than do family practices by integrating and coordinating services such as community health services, addiction and mental health counseling and long-term care (Elson, 2006). These primary services are no longer the responsibility of the provincial Ministry of Health, demonstrating an increasingly municipal and local focus on primary care in Canada. However, individual GP/FP practices remain under provincial control under this new system (Elson, 2006).
Given the multiple levels of regulatory control over primary care in Canada, there is a need to conceptualize how different modes of primary care delivery can work together to optimally provide services at the local level (Elson, 2006). LHINs, similar to Walk-in health care services, were created during a time when public dissatisfaction with the quality and waiting times for GP/FP provision was increasing. The intention with these added services was to fill a gap in the 110 provision of primary care at the local level that family practices were failing to address. However, these alternative modes of delivery for primary care are not intended to take the place of having a dedicated family doctor. Individuals who use community based primary care such as walk-in services still tend to prefer to consult with family doctors, and appreciate the added quality of service provision that occurs when a physician knows a patient and understands their specific medical history (Brown et al, 2002). Such benefits of GP/FP provision in family practice are not trivial. As such, the municipal policy focus on primary care should not ignore the ways in which family care provision can be optimized municipally in favour of new modes of delivery such as LHINs. Instead, municipal policy focus should begin to focus on how primary health care can be optimized considering the multiple delivery systems that are now operating at the local level, including family practices, walk-in clinics, and LHINs. Such a task has yet to be adequately addressed (Levitt, McMullan & Freeman-Collins, 2005), and will be of increasing importance in future years as the emphasis on LHINs and municipal control over neighbourhood level health care increases.
5.5.3 Constraints of Urban Form in Policy Intervention
At this point it is pertinent to include a comment regarding constraints that may exist when attempting to implement municipal-level policy to alleviate health provision shortages. It was determined by this research that the provision of health care significantly varied across Mississauga by all conceptualizations (e.g. spatial, aspatial and by scale) examined here. There may be multiple causes of this varied picture of accessibility, but all relate to the distribution of physicians relative to the distribution of the population. There are two main determinants of physician distribution recognized in the literature. First, the location where a physician may practice is heavily constrained by the existing urban form of the city, and particularly by the existing zoning and land use allowances. This zoning may play a large role in the reasoning why several of Mississauga’s neighbourhoods (e.g. Gateway, Northeast 2, Sheridan Park, Southdown) were consistently of low accessibility by all measures examined. For example, if these neighbourhoods are primarily industrial or green-space, they will not contain sites where health care practices may be situated, nor will they contain adequate residential settlements requiring such care. More investigation is required to determine if this is the case. In such a scenario, municipal policy will have little effect at redistributing health care into such areas. Additionally, there may not be a need to do so. However, a second key factor affecting the distribution of physicians is the actual choice of the physicians themselves in where to locate their practice. Research indicates that physicians tend to choose to locate practices near their place of residence. Additionally, physicians prefer to locate in areas where support can be received, such as in a practice with other physicians or near a hospital (Szafran, Crutcher & Chaytors, 2001). This element of choice allows for policy intervention to mediate inequities in health care distribution, and additional research is required to determine the optimal way to do so.
5.6 Conclusions
This analysis has revealed significant intra-urban variability in potential access to primary health care, considering multiple measures of access, population groups, and at multiple distances. These findings were made possible through the development of a GIS methodology that is appropriate for this research setting, and through careful consideration of the appropriate neighbourhood units to use. There is a need for ongoing examination of neighbourhood-level access to primary care using appropriate methodology and neighbourhood units. In particular, examination of access to primary care in additional Canadian cities will help to further the understanding how access to care differs in the context of increasing concerns over the state of primary health care in Canada.
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