Background Our previous realist review and qualitative research found that socio-economically disadvantaged older people in rural areas face personal, community and health care barriers to obtaining an appointment in primary care. We described these barriers with context-mechanism-outcome (CMO) configurations. Example contexts were lifelong poverty, education, previous healthcare experience, transport, mechanisms were health literacy, assertiveness and convenience, and the outcome was obtaining an appointment. We aimed to explore these CMO configurations using Structural Equation Modelling (SEM) in a national linked dataset.
Methods Individual patient data from Wave 6 of the English Longitudinal Study of Ageing (ELSA) was linked with practice data from the GP Patient Survey (GPPS). Participants in the lowest socio-economic group and living in a rural area were included. Variables from ELSA and GPPS were available for nine complete CMOs. Confirmatory factor analysis was used to generate seven latent variables for unobserved concepts such as lifelong poverty and previous healthcare experience. CMOs were analysed in one overall SEM with multiple mediation paths; contexts were treated as the exposure, mechanisms as the mediator, and the common outcome was ability to obtain an appointment. Stata and MPlus was used to estimate standardised coefficients and 95% confidence intervals using robust maximum likelihood.
Results 276 patients from 178 different GP surgeries were included. We found statistically significant direct or indirect effects for two of the nine CMOs. The ease of getting through to the surgery was statistically significantly associated with being able to get an appointment (β 0.52, 0.42 to 0.61) with an indirect, statistically significantly, mediated effect through convenience (β 0.14, 0.07 to 0.21). Health care experience was not directly associated with getting an appointment (β −0.04,–0.19 to 0.12), but a statistically significant indirect effect through convenience existed (β 0.10, 0.04 to 0.16). Model fit showed mixed results (RMSEA 0.05, CFI 0.923, TLI 0.901) Analysis was limited because there were not data for all theoretical concepts. Furthermore, continuous variables were only included to obtain adequate model fit.
Conclusion We found that obtaining an appointment was both directly associated with the ease of the booking system, and mediated through the mechanism of perceived convenience. We also found a mediated effect from previous health care experience to obtaining an appointment through perceived convenience.
Structural equation modelling proved a useful method for exploring and quantifying realist theory. The analysis was limited by available data; therefore future research would benefit from primary data collection.
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