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Special Issue "Equity, Access and Use of Health Care Services"

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Health Care Sciences & Services".

Deadline for manuscript submissions: 31 July 2022 | Viewed by 11092

Special Issue Editors

Prof. Dr. Rosa Urbanos-Garrido
E-Mail
Guest Editor
Department of Applied Economics, Public Economics and Political Economy, Complutense University of Madrid, Somosaguas Campus, E-28223 Madrid, Spain
Interests: health economics; public health; equity, access and use of health care services
Dr. Alexandrina Stoyanova
E-Mail Website
Guest Editor
Department of Economics, Faculty of Economics and Business, University of Barcelona, 08034 Barcelona, Spain
Interests: health economics; equity, access and use of healthcare services; mental health; health and education

Special Issue Information

Dear Colleagues,

Equity is a major goal for healthcare systems. The guarantee of timely access to affordable and quality services when they are needed is a keystone in the fight against health inequalities. Although significant efforts to reduce inequalities have been made by public authorities in many countries, barriers to accessing healthcare persist. Cost, travel distance and waiting time still are behind most unmet needs reported by people. Moreover, the Great Recession of 2008 forced many governments to implement significant public spending cuts and other reforms with likely negative impact on access to healthcare services. The current COVID-19 pandemic has posed additional challenges to healthcare systems and economies with adverse consequences on access to and use of healthcare services, particularly for vulnerable population groups: undocumented migrants, economically disadvantaged, ethnic minorities, people with mental health problems, etc. Equity in access and effective use of healthcare services is a multi-dimensional issue that may be analyzed from different perspectives—socio-economic, gender or geographic, among others—and with different methodologies. Papers addressing equity in healthcare from any relevant perspective are invited for this Special issue. We especially welcome contributions providing policy recommendations to improve equity goals.

Prof. Dr. Rosa Urbanos-Garrido
Dr. Alexandrina Stoyanova
Guest Editors

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • equity
  • access
  • utilization
  • healthcare services
  • unmet needs

Published Papers (12 papers)

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Research

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Article
Rural–Urban Disparities in Realized Spatial Access to General Practitioners, Orthopedic Surgeons, and Physiotherapists among People with Osteoarthritis in Alberta, Canada
Int. J. Environ. Res. Public Health 2022, 19(13), 7706; https://doi.org/10.3390/ijerph19137706 - 23 Jun 2022
Viewed by 258
Abstract
Rural Canadians have high health care needs due to high prevalence of osteoarthritis (OA) but lack access to care. Examining realized access to three types of providers (general practitioners (GPs), orthopedic surgeons (Ortho), and physiotherapists (PTs)) simultaneously helps identify gaps in access to [...] Read more.
Rural Canadians have high health care needs due to high prevalence of osteoarthritis (OA) but lack access to care. Examining realized access to three types of providers (general practitioners (GPs), orthopedic surgeons (Ortho), and physiotherapists (PTs)) simultaneously helps identify gaps in access to needed OA care, inform accessibility assessment, and support health care resource allocation. Travel time from a patient’s postal code to the physician’s postal code was calculated using origin–destination network analysis. We applied descriptive statistics to summarize differences in travel time, hotspot analysis to explore geospatial patterns, and distance decay function to examine the travel pattern of health care utilization by urbanicity. The median travel time in Alberta was 11.6 min (IQR = 4.3–25.7) to GPs, 28.9 (IQR = 14.8–65.0) to Ortho, and 33.7 (IQR = 23.1–47.3) to PTs. We observed significant rural–urban disparities in realized access to GPs (2.9 and IQR = 0.0–92.1 in rural remote areas vs. 12.6 and IQR = 6.4–21.0 in metropolitan areas), Ortho (233.3 and IQR = 171.3–363.7 in rural remote areas vs. 21.3 and IQR = 14.0–29.3 in metropolitan areas), and PTs (62.4 and IQR = 0.0–232.1 in rural remote areas vs. 32.1 and IQR = 25.2–39.9 in metropolitan areas). We identified hotspots of realized access to all three types of providers in rural remote areas, where patients with OA tend to travel longer for health care. This study may provide insight on the choice of catchment size and the distance decay pattern of health care utilization for further studies on spatial accessibility. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
The Impact of Rural Hospital Closures and Health Service Restructuring on Provincial- and Community-Level Patterns of Hospital Admissions in New Brunswick
Int. J. Environ. Res. Public Health 2022, 19(12), 7258; https://doi.org/10.3390/ijerph19127258 - 14 Jun 2022
Viewed by 303
Abstract
In the early 2000s, the Province of New Brunswick, Canada, undertook health system restructuring, including closing some rural hospitals. We examined whether changes in geographic access to hospitals and primary care were associated with changes in patterns of hospital use. We described three [...] Read more.
In the early 2000s, the Province of New Brunswick, Canada, undertook health system restructuring, including closing some rural hospitals. We examined whether changes in geographic access to hospitals and primary care were associated with changes in patterns of hospital use. We described three measures of hospital use for ambulatory care sensitive conditions (ACSCs) among adults 75 years and younger annually during the period 2004–2013 overall, and at the community scale. We described spatial and temporal patterns in: age-standardized hospitalization rates, age-standardized incidence of hospital admissions, and rates of admissions via ambulance. Overall, rates and incidence of hospitalizations for ACSCs declined while admissions via ambulance remained largely unchanged. We observed considerable regional variation in rates between communities in 2004. This regional variation decreased over time, with rural areas demonstrating the sharpest declines. Changes in hospital service provision within individual communities had little impact on rates of ACSC admissions. Results were consistent across urban and rural communities and were robust to analyses that included older patients and those admitted for reasons other than ACSCs. Our results suggest that the restructuring and hospital closures did not result in substantial changes to regional patterns or rates of service use. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Trends in Health Care Access/Experiences: Differential Gains across Sexuality and Sex Intersections before and after Marriage Equality
Int. J. Environ. Res. Public Health 2022, 19(9), 5075; https://doi.org/10.3390/ijerph19095075 - 21 Apr 2022
Viewed by 474
Abstract
Background: Sexual minority adults experience several health care access inequities compared to their heterosexual peers; such inequities may be affected by LGBTQ+ legislation, such as the 2015 national marriage equality ruling. Methods: Using population-based data (n = 28,463) from the Association of [...] Read more.
Background: Sexual minority adults experience several health care access inequities compared to their heterosexual peers; such inequities may be affected by LGBTQ+ legislation, such as the 2015 national marriage equality ruling. Methods: Using population-based data (n = 28,463) from the Association of American Medical Colleges biannual Consumer Survey of Health Care Access, we calculated trend ratios (TR) for indicators of health care access (e.g., insurance coverage, delaying or forgoing care due to cost) and satisfaction (e.g., general satisfaction, being mistreated due to sexual orientation) from 2013 to 2018 across sexuality and sex. We also tested for changes in trends related to the 2015 marriage equality ruling using interrupted time series trend interactions (TRInt). Results: The largest increases in access were observed in gay men (TR = 2.42, 95% CI 1.28, 4.57). Bisexual men had decreases in access over this period (TR = 0.47, 95% CI 0.22, 0.99). Only gay men had a significant increase in the health care access trend after U.S. national marriage equality (TRInt = 5.59, 95% CI 2.00, 9.18), while other sexual minority groups did not. Conclusions: We found that trends in health care access and satisfaction varied significantly across sexualities and sex. Our findings highlight important disparities in how federal marriage equality has benefited sexual minority groups. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Adjusting the Canadian Healthcare System to Meet Newcomer Needs
Int. J. Environ. Res. Public Health 2022, 19(7), 3752; https://doi.org/10.3390/ijerph19073752 - 22 Mar 2022
Viewed by 441
Abstract
Newcomers’ ability to access healthcare can be impacted by cultural, religious, linguistic, and health status differences. A variety of options are available to support the development of healthcare systems to equitably accommodate newcomers, including the use of basic English and other languages in [...] Read more.
Newcomers’ ability to access healthcare can be impacted by cultural, religious, linguistic, and health status differences. A variety of options are available to support the development of healthcare systems to equitably accommodate newcomers, including the use of basic English and other languages in public health information, engagement with immigrant communities to advise on program development, offering culturally competent health services, interpretation services, and through creating space to collaborate with traditional practitioners. This study employed in-depth interviews with newcomer families from the Healthy Immigrant Children Study that had been living in Regina or Saskatoon, Saskatchewan, Canada, for less than 5 years, as well as with healthcare providers and immigrant service providers to understand how to improve healthcare services. Analysis of participant quotes related to accessible healthcare services revealed five main themes: (1) responsive, accessible services, (2) increasing cultural competence, (3) targeted newcomer health services, (4) increasing awareness of health services, and (5) newcomer engagement in planning and partnerships. An accessible healthcare system should include primary healthcare sites developed in partnership with newcomer service organizations that offer comprehensive care in a conveniently accessible and culturally responsive manner, with embedded interpretation services. The Saskatchewan healthcare system needs to reflect on its capacity to meet newcomer healthcare needs and strategically respond to the healthcare needs of an increasingly diverse population. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Changes in Inequality in Use of Maternal Health Care Services: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007–2015
Int. J. Environ. Res. Public Health 2022, 19(6), 3566; https://doi.org/10.3390/ijerph19063566 - 17 Mar 2022
Viewed by 537
Abstract
Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the [...] Read more.
Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled birth attendance services in Mauritania. The study identifies the inequality determinants and explores its changes over the period 2007–2015. The concentration curve, concentration index, decomposition of the concentration index, and Oaxaca-type decomposition technique were performed to measure socioeconomically-based inequalities in skilled birth attendance services utilization, and to identify the contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007 and 2015. The concentration index for skilled birth attendance services use dropped from 0.6324 (p < 0.001) in 2007 to 0.5852 (p < 0.001) in 2015. Prenatal care, household wealth level, and rural−urban residence contributed most to socioeconomic inequality. The concentration index decomposition and the Oaxaca-type decomposition revealed that changes in prenatal care and rural−urban residence contributed positively to lower inequality, but household economic status had an opposite contribution. Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania, despite a slight decrease during the study period. Policy actions on eliminating geographical and socioeconomic inequalities should target increased access to skilled birth attendance. Multisectoral policy action is needed to improve social determinants of health and to remove health system bottlenecks. This will include the socioeconomic empowerment of women and girls, while enhancing the availability and affordability of reproductive and maternal health commodities. This policy action can be achieved through improving the availability of obstetric service providers in rural areas; ensuring better distribution and quality of health infrastructure, particularly health posts and health centers; and, ensuring user fees removal for equitable, efficient, and sustainable financial protection in line with the universal health coverage objectives. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Dual Use of Public and Private Health Care Services in Brazil
Int. J. Environ. Res. Public Health 2022, 19(3), 1829; https://doi.org/10.3390/ijerph19031829 - 06 Feb 2022
Cited by 1 | Viewed by 652
Abstract
(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study [...] Read more.
(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose–response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Assessing Spatial Accessibility to Primary Health Care Services in Beijing, China
Int. J. Environ. Res. Public Health 2021, 18(24), 13182; https://doi.org/10.3390/ijerph182413182 - 14 Dec 2021
Cited by 4 | Viewed by 899
Abstract
Primary health care has been emphasized as a pillar of China’s current round of health reforms throughout the previous decade. The purpose of this study is to analyze the accessibility of primary health care services in Beijing and to identify locations with a [...] Read more.
Primary health care has been emphasized as a pillar of China’s current round of health reforms throughout the previous decade. The purpose of this study is to analyze the accessibility of primary health care services in Beijing and to identify locations with a relative scarcity of health personnel. Seven ecological conservation districts, which are relatively underdeveloped, were selected in the study. The Gini coefficient and Lorenz curve, as well as the shortest trip time and modified two-step floating catchment area (M2SFCA) approach, are used to quantify inequalities in primary health care resources and spatial accessibility. The Gini coefficient of primary medical services was calculated as high as 0.705, showing a significant disparity in primary care services. A total of 81.22% of communities reached the nearest primary care institution within 15 min. The average accessibility of primary healthcare services, as measured by the number of health professionals per 1000 population, was 2.34 in the 1715 communities of seven ecological conservation districts. Three hundred and ninety-one communities (22.80%) were identified with relatively low accessibility. More primary health professionals should be allocated to Miyun, Mentougou, and Changping Districts. Overall, the primary healthcare resources were distributed unevenly in most districts. According to our study, expanding primary healthcare institutions, increasing the number of competent health professionals, and enhancing road networks will all be effective ways to increase spatial accessibility and reduce primary healthcare service disparity in Beijing. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Diversity Competency and Access to Healthcare in Hospitals in Croatia, Germany, Poland, and Slovenia
Int. J. Environ. Res. Public Health 2021, 18(22), 11847; https://doi.org/10.3390/ijerph182211847 - 12 Nov 2021
Viewed by 1008
Abstract
Diversity competency is an approach for improving access to healthcare for members of minority groups. It includes a commitment to institutional policies and practices aimed at the improvement of the relationship between patients and healthcare professionals. The aim of this research is to [...] Read more.
Diversity competency is an approach for improving access to healthcare for members of minority groups. It includes a commitment to institutional policies and practices aimed at the improvement of the relationship between patients and healthcare professionals. The aim of this research is to investigate whether and how such a commitment is included in internal documents of hospitals in Croatia, Germany, Poland, and Slovenia. Using the methods of documentary research and thematic analysis we examined internal documents received from hospitals in these countries. In all four countries, the documents concentrate on general statements prohibiting discrimination with regard to healthcare provision. Specific regulations concerning ethnicity and culture focus on the issue of language barriers. With regard to religious practices, the documents from Croatia, Poland, and Slovenia focus on dominant religious groups. Observance of other religious practices and customs is rarely addressed. Healthcare needs of patients with non-heteronormative sexual orientation, intersexual, and transgender patients are explicitly addressed in only a few internal documents. Diversity competency policies are not comprehensively implemented in hospital internal regulations in hospitals under investigation. There is a need for the development and implementation of comprehensive policies in hospitals aiming at the specific needs of minority groups. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
Examining Care Assessment Scores of Community-Dwelling Adults in Flanders, Belgium: The Role of Socio-Psychological and Assessor-Related Factors
Int. J. Environ. Res. Public Health 2021, 18(22), 11845; https://doi.org/10.3390/ijerph182211845 - 11 Nov 2021
Viewed by 817
Abstract
One of the primary objectives of health systems is to provide a fair system by providing a comprehensive and holistic approach to caregiving rather than focusing on a single aspect of a person’s care needs. This approach is often embodied by using standardized [...] Read more.
One of the primary objectives of health systems is to provide a fair system by providing a comprehensive and holistic approach to caregiving rather than focusing on a single aspect of a person’s care needs. This approach is often embodied by using standardized care assessments across health and social care settings. These assessments are completed by professional assessors and yield vital information regarding a person’s health or contextual characteristics (e.g., civic engagement, psychosocial wellbeing, environmental characteristics, informal care). However, these scores may be subject to bias that endangers the fairness of the health system. In this study, we investigate to what extent socio-economic and psychological indicators and assessor-related indicators are associated with BelRAI Screener care assessment scores amongst 743 community-dwelling adults nested within 92 assessors in Flanders, Belgium. Findings indicate that there is significant variance in scores at the assessor-level. Socio-psychological characteristics of clients are associated with scores: being fluent in Dutch and providing informal care are associated with low care dependency, while living with children, feelings of depression, and the presence of an informal caregiver during assessment are associated with high care dependency. We discuss the importance of rigorous assessor training and the potential for socio-psychological factors to contribute to the allocation of welfare benefits in light of the Flemish home care system’s potential (lack of) fairness. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
Article
Civil Servants and Non-Western Migrants’ Perceptions on Pathways to Health Care in Serbia—A Grounded Theory, Multi-Perspective Study
Int. J. Environ. Res. Public Health 2021, 18(19), 10247; https://doi.org/10.3390/ijerph181910247 - 29 Sep 2021
Viewed by 753
Abstract
(1) Background: Informal patient payments continue to persist in the Serbian health care system, exposing vulnerable groups to private spending on health care. Migrants may in particular be subject to such payments, as they often experience barriers in access to health care. Little [...] Read more.
(1) Background: Informal patient payments continue to persist in the Serbian health care system, exposing vulnerable groups to private spending on health care. Migrants may in particular be subject to such payments, as they often experience barriers in access to health care. Little is known about migrants paying informally to access health care in Serbia. The study aims to explore pathways of accessing health care, including the role of informal patient payments, from the perspectives of civil servants and non-western migrants in Serbia. (2) Methods: Respondents (n = 8 civil servants and n = 6 migrants) were recruited in Belgrade in 2018, where semi-structured interviews were conducted. The interviews were analysed applying the grounded theory methodological steps. (3) Results: Data reveal different pathways to navigate the Serbian health care system, and ultimately whether paying informally occurs. Migrants appear less prone to paying informally and receive the same or better-quality health care. Locals experience the need to pay informal patient payments, quasi-formal payments and to bring medicine, materials or equipment when in health facilities. (4) Conclusions: Paying informally or using private care in Serbia appear to have become common. Despite a comprehensive health insurance coverage, high levels of out-of-pocket payments show barriers in accessing health care. It is highly important to not confuse the cultural beliefs with forced spending on health care and such private spending should be reduced to not push people into poverty. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Article
COVID-19 and Unmet Healthcare Needs of Older People: Did Inequity Arise in Europe?
Int. J. Environ. Res. Public Health 2021, 18(17), 9177; https://doi.org/10.3390/ijerph18179177 - 31 Aug 2021
Cited by 5 | Viewed by 1391
Abstract
Background: The disruption in healthcare provision due to the COVID-19 pandemic forced many non-urgent medical treatments and appointments to be postponed or denied, which is expected to have huge impact on non-acute health conditions, especially in vulnerable populations such as older people. Attention [...] Read more.
Background: The disruption in healthcare provision due to the COVID-19 pandemic forced many non-urgent medical treatments and appointments to be postponed or denied, which is expected to have huge impact on non-acute health conditions, especially in vulnerable populations such as older people. Attention should be paid to equity issues related to unmet needs during the pandemic. Methods: We calculated concentration indices to identify income-related inequalities and horizontal inequity in unmet needs due to postponed and denied healthcare in people over 50 during COVID-19, using data from the Survey on Health, Ageing and Retirement in Europe (SHARE). Results: Very few countries show significant income-related inequalities in postponed, rescheduled or denied treatments and medical appointments, usually favouring the rich. Only Estonia, Italy and Romania show a significant horizontal inequity (HI) in postponed healthcare, which apparently favours the poor. Significant pro-rich inequity in denied healthcare is found in Italy, Poland and Greece. Conclusions: Although important income-related horizontal inequity in unmet needs of European older adults during the early waves of the COVID-19 pandemic is not evident for most countries, some of them have to carefully monitor barriers to healthcare access. Delays in diagnosis and treatments may ultimately translate into adverse health outcomes, reduced quality of life and, even, widen socio-economic health inequalities among older people. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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Review

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Review
Changes in Access to Health Services during the COVID-19 Pandemic: A Scoping Review
Int. J. Environ. Res. Public Health 2022, 19(3), 1749; https://doi.org/10.3390/ijerph19031749 - 03 Feb 2022
Cited by 1 | Viewed by 1287
Abstract
The COVID-19 pandemic and the measures adopted are having a profound impact on a major goal of public healthcare systems: universal access to health services. The objective is to synthesize the available knowledge on access to health care for non-COVID-19 conditions and to [...] Read more.
The COVID-19 pandemic and the measures adopted are having a profound impact on a major goal of public healthcare systems: universal access to health services. The objective is to synthesize the available knowledge on access to health care for non-COVID-19 conditions and to identify knowledge gaps. A scoping review was conducted searching different databases (Medline, Google Scholar, etc.) for original articles published between December 2019 and September 2021. A total of 53 articles were selected and analyzed using the Aday and Andersen framework as a guide. Of these, 37 analyzed changes in levels of use of health services, 15 focused on the influencing factors and barriers to access, and 1 studied both aspects. Most focused on specific diseases and the early stages of the pandemic, based on a review of records. Analyses of the impact on primary care services’ use, unmet needs or inequalities in access were scarce. A generalized reduction in the use of health services was described. The most frequent access barrier described for non-COVID-19 conditions related to the services was a lack of resources, while barriers related to the population were predisposing (fear of contagion, stigma, or anticipating barriers) and enabling characteristics (worse socioeconomic status and an increase in technological barriers). In conclusion, our results show a general reduction in services’ use in the early stages of the pandemic, as well as new barriers to access and the exacerbation of existing ones. In view of these results, more studies are required on the subsequent stages of the pandemic, to shed more light on the factors that have influenced access and the pandemic’s impact on equity of access. Full article
(This article belongs to the Special Issue Equity, Access and Use of Health Care Services)
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