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This Is My Thesis 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) Library and Archives Bibliothèque et Canada Archives Canada Published Heritage Direction du Branch Patrimoine de l’édition 395 Wellington Street 395, rue Wellington Ottawa ON K1A 0N4 Ottawa ON K1A 0N4 Canada Canada Your file Votre référence ISBN: 978-0-494-59301-1 Our file Notre référence ISBN: 978-0-494-59301-1 NOTICE: AVIS: The author has granted a non- L’auteur a accordé une licence non exclusive exclusive license allowing Library and permettant à la Bibliothèque et Archives Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par télécommunication ou par l’Internet, prêter, telecommunication or on the Internet, distribuer et vendre des thèses partout dans le loan, distribute and sell theses monde, à des fins commerciales ou autres, sur worldwide, for commercial or non- support microforme, papier, électronique et/ou commercial purposes, in microform, autres formats. paper, electronic and/or any other formats. The author retains copyright L’auteur conserve la propriété du droit d’auteur ownership and moral rights in this et des droits moraux qui protège cette thèse. Ni thesis. Neither the thesis nor la thèse ni des extraits substantiels de celle-ci substantial extracts from it may be ne doivent être imprimés ou autrement printed or otherwise reproduced reproduits sans son autorisation. without the author’s permission. In compliance with the Canadian Conformément à la loi canadienne sur la Privacy Act some supporting forms protection de la vie privée, quelques may have been removed from this formulaires secondaires ont été enlevés de thesis. cette thèse. While these forms may be included Bien que ces formulaires aient inclus dans in the document page count, their la pagination, il n’y aura aucun contenu removal does not represent any loss manquant. of content from the thesis. 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. ii Acknowledgements This research project has been highly collaborative in nature and there are a number of individuals involved who I would like to acknowledge. I would foremost like to express my thanks and gratitude to my graduate supervisor, Kathi Wilson for providing the opportunity to work on this project as well as providing a wonderful learning experience through her continual guidance and feedback. I would like to express my thanks to Scott Bell, the principal investigator (PI) on this project for providing direction and insight throughout the research process. Thank you to Sarah Wakefield for serving on my thesis committee. I appreciate the opportunity to work with you and to learn from you. Thanks to the Canadian Institutes of Health Research (CIHR) for funding this project. Additional acknowledgements are required to the individuals who have provided support and help with the technical side of this research. As a new student to geographic information systems, this help was very much appreciated. Thanks to Andrew Nicholson and Tanya Kenesky of the library at the University of Toronto at Mississauga for the provision of data and technical support. Thank you to Usman Aslam and Alex Werenka at the University of Saskatchewan for the time and effort put forth towards creating the physician database. A final thank you is owed to my family, and especially to Mark. Thank you for your support and your patience. iii 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 iv 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 v 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 vi Chapter 1: Introduction 1.1 Research context and research questions There is an increasing awareness in Canada that access to primary health care is a problem in need of attention (Crooks & Andrews, 2005: 47; Schuurman et al, 2006). In particular there is concern that access to primary care is decreasing and waiting times to see physicians are increasing. This has resulted in decreasing satisfaction with the health care system amongst the Canadian public (Sanmartin et al, 2000). Contributing to this problem is a reduction in overall physician numbers over the past decade in Canada. Peaking in 1993, physician numbers have steadily dropped by 5% since. Reasons for this possible physician shortage include federal funding cuts to the provinces, cuts in the enrollment numbers for medical school, an increase in specialist training at the expense of family doctor training, and a reduction in the number of foreign doctors entering Canada to practice medicine (Wharry & Sibbald, 2002). Given that approximately 4.1 million Canadians do not have a regular family doctor (Nabalamba & Millar, 2007), there are concerns that access to primary health care is an increasing problem. With fewer medical students choosing family practice, disparities in access to care are likely to increase in time as the existing group of family physicians ages and begin to retire. This is particularly problematic, given that the amount of primary care provision is directly associated with public health outcomes, including the prevalence of cancer, heart 1 disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated health (Macinko, Starfield & Shi, 2007). The Canada Health Act (CHA) acknowledges the
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