Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Danielle Edwards

Bon Secours Memorial College of Nursing

Christine Turner, PhD

NUR 4122: Nursing Research

April 22, 2018

Honor Code: “ I pledge”

INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to identify how monthly income influences

access to care among elderly patients.

Background: Improving the quality and value of life is a pressing issue within healthcare

globally. To improve the quality and value of life, you must start by improving access to

healthcare. There are barriers that impede an individual from being able to receive access to

care. Access to healthcare is particularly pertinent to vulnerable populations such as the elderly.

Income is a reoccurring barrier that seems to affect access to care among the elderly.

Method: This paper is an integrative review that includes a collection of articles from online

nursing databases. The articles within this review are both quantitative studies and systematic

reviews. Each study was chosen based on specific criteria. This information was then used to

examine the relationship between monthly income among the elderly and their access to

healthcare.

Limitations: The most significant limitation of this paper is the author’s limited experience in

conducting an integrative review of literature.

Results and Findings: The research complied for this integrative review supports the idea that a

higher monthly income among the elderly presents a greater access to care in comparison to

those with a lower monthly income. Other variables coupled with income were found as

contributing factors affecting access to healthcare.

Implications and Recommendations: The implication of the integrative review is identifying

that having a high monthly income will increase access to healthcare among the elderly. It is

recommended that further research be conducted to examine the correlation in more depth to

discover more concrete evidence.

INTEGRATIVE LITERATURE REVIEW 3

Integrative Literature Review

The purpose of this integrated review is to identify how monthly income influences

access to care among elderly patients. An increasing number of elderly patients are refraining or

delaying their care due to the financial burdens that are in congruence with healthcare cost. As a

result many elderly patients are left with unmet healthcare needs, which can negatively affect

health outcomes. Improving the quality and value of life is a pressing issue within healthcare

globally. In order to improve the quality and value of life, you must start by improving access to

high quality healthcare (Kurichi et al., 2017).

There are barriers such as finances, transportation and comorbidities, that impede an

individual in being able to receive access to care. Access to healthcare is particularly pertinent to

vulnerable populations such as the elderly (Lee, Hamid, Pati, Atum & Millett, 2015). It is

important to address factors such as income to understand how vast an impact that income has on

access to care. The aim of this integrative review is to examine and discuss published research

related to the researcher’s PICOT question: Does monthly income influence access to care

among elderly patients?

Design, Search Methods, Search Outcomes

The research design is an integrative review and is focused on five research articles. The

articles specifically pertain to the researcher’s PICOT question,” Does monthly income influence

access to care among elderly patients?” The method utilized by the researcher began with an

initial search using PubMed, Academic Search Complete, and EBSCO’s Nursing Center

Reference databases. The search words were barriers to healthcare, aging and healthcare

access, equity and equality in health, socioeconomic factors and elderly healthcare access, and

income inequalities.
INTEGRATIVE LITERATURE REVIEW 4

The results yielded over 1,200 articles. The articles were then filtered according to year

and relevance to PICOT question. In regards to date, the articles were limited to the years 2013-

2018. Many articles were eliminated due to the date and relevancy requirement. Full text

availability and peer reviewed articles were other filters that were applied. Relevant and

qualified authors were then prioritized. Examples of appropriate qualifications included authors

who are registered nurses (RN), have a Master of Science in Nursing (MSN), or other

professions within or related to healthcare. The use of filters allowed for five articles to be

selected for inclusion in this integrative review. Four articles are reports of quantitative studies

(Kurichi et al., 2017; Lee et al., 2015; Penning & Zheng, 2016; Yamanda et al., 2015) and one

systematic review study (Khanassov et al., 2016).

Findings/ Results

The results and findings of the articles identify a positive correlation between monthly

income among the elderly and their access to healthcare (Khanassov et al., 2016; Kurichi et al.,

2017; Lee et al., 2015; Penning & Zheng, 2016; Yamanda et al., 2015). A summary table of all

five articles researched is located in the Appendix at the end of the paper. Below is a brief

overview of the findings and results from each of the articles researched.

Kurichi et al (2017) sought to assess the relationship between perceived facilitators and

barriers to healthcare and actual receipt of recommended medical care among elderly

beneficiaries. The design was a quantitative study focusing on measures of beneficiaries’

satisfaction with features of their healthcare delivery system and reported barriers to receiving

healthcare. The study was conducted using surveys from The Medicare Current Beneficiary

Survey (MCBS). The survey included 24, 607 participants of the age of 65 or older. The MCBS

contained a systematic, representative sample that allowed them to generalize their results to the
INTEGRATIVE LITERATURE REVIEW 5

entire elderly Medicare population. The respondent, either the sample person or proxy was

interviewed three times a year over a course of four years. 38 indicators were discovered and

examined independently. The findings were both independently and inversely associated with

the actual receipt of recommended medical care. Finance played a major role in the access to

healthcare. Other themes identified were transportation, care coordination and quality,

satisfaction with care, and no usual source of care.

In a quantitative study, Yamada et al (2015) used an empirical framework and the PP

Model method of data analysis. Yamada wanted to investigate healthcare access disparity that

cause delayed and unmet healthcare needs for the elderly. Also to examine health inequality,

data was collected from a large collection of the Community Tracking Study Household Survey

from 2003-2004. Reliability and construct validity was examined for internal consistency and

estimation of disparity and inequality. Information was contained from approximately 46, 587

individuals. Another sample size was conducted with 17,797 individuals in 2007. The survey

was administered by telephone, using list-assisted telephone interviewing technology. The data

collected were self-reported data from the participants of their perceived factors related to

delayed un-met healthcare needs. The data was then analyzed using reversion. The common

themes that were identified were unmet healthcare needs, delayed in healthcare access and,

health disparity.

In another quantitative study conducted by Lee et al (2014) the impact of non-

communicable disease (NCD) multi-morbidity on healthcare utilization and out of pocket

expenditures in six middle-income countries were assessed. Lee used multiple logistic

regression to determine socio-demographic correlates of multi-morbidity. Association between

the number of NCD’s and healthcare utilization as well as out of pocket spending was also
INTEGRATIVE LITERATURE REVIEW 6

assessed using logistic, negative binomial and log-linear models. Cross sectional data was

collected from participants in the World Health Organization (WHO) study on global aging and

adult health (SAGE) from 2001-2010 in six middle income countries. The data was collected

simultaneously and the sample size varied in each country. The participants self reported on

health problems, disability, healthcare utilization, and subjective well-being. The results yielded

that the prevalence of multi-morbidity in the adult population varied. Other significant findings

revealed an association with higher levels of healthcare utilization and greater financial burden

for individuals in middle-income countries. The study supports WHO’s call for universal health

insurance and health service coverage in lower middle-income countries.

Khanassov et al (2016) conducted a systematic review using the Patent Centered Access

to Healthcare conceptual framework. The purpose was to map the existing evidence on

organizational interventions that improve access to primary care services for vulnerable

populations. Several relevant studies, quantitative and qualitative, were mapped to gather the

information. Scoping reviews were used to identify knowledge gaps, set research agendas, and

identify implications for decision-making. The aim of the scoping review was to explore the

breadth of available evidence in a research domain. The criteria for the study came from a three

step qualitative synthesis. Which included a classification of organizational interventions, a

classification of access dimensions, outcomes of interventions and a dimension of outcome

pattern analysis. An interative process was completed to search through the literature to refine

the studies and articles. 39 studies in total were reviewed. The survey revealed that there is

limited breadth of research in this area. However three dimensions of access were identified,

they were approachability, availability, and affordability.

INTEGRATIVE LITERATURE REVIEW 7

Penning and Zheng (2015) examined the impact of income on physician and hospital

utilization from 1992-2002 among adults aged 50 and older in British Columbia. The data was

collected over 11 years from an average of 1.1 million individuals using appraised data approved

from several healthcare committees and organizations. The analyses drew on provincial

administrative health data regarding the use of physician and hospital services. Multivariable

analyses were conducted using the SAS regression software to compare and categorize findings.

The information was pulled from the sample size at random. Then the findings were put in table

format for easier comparison. Findings yielded a decline in hospital-care access accompanied by

increasing income related disparities in physician services access, which show that inequalities

are increasing with in their health care system. The findings of this study corroborate the

findings that were reported in several other studies for the population as a whole and conducted

during the same time.

Discussion/Implications

The articles selected for this review show a correlation between monthly income among

the elderly and access to healthcare. The articles reviewed were framed by common themes such

as finances (income), health insurance, and interventions. The following section is a discussion

on the implications of the articles and their common themes as they correlate to the PICOT

question.

Finance

Finance is a topic that was discussed in all five articles reviewed (Khanassov et al., 2016;

Kurichi et al., 2017; Lee et al., 2015; ; Penning & Zheng, 2016; Yamanda et al., 2015). Over the

past few years healthcare cost has been on a constant rise. “As healthcare costs rises, more of the

increasing costs are transferred to certain disadvantaged populations, and patients have to spend
INTEGRATIVE LITERATURE REVIEW 8

a considerable share of their healthcare cost out-of-pocket” (Yamanda et al., 2015, p. 1747). It

was discovered that individuals with lower incomes had a decreased chance of accessing

healthcare, especially, specialist services in comparison to those with higher incomes (Yamanda

et al., 2015). Financial burdens and inequalities are some of the leading reasons why individuals

have trouble or delayed access to healthcare and, “a lack of adherence to treatment

recommendations” (Kurichi et al., 2017, p.49). The information obtained from these articles is

important to the PICOT question as they support the notion that there is a correlation between

having a higher income and receiving access to healthcare. Data analysis of finances among the

elderly was assessed via patient surveys or by legally obtaining Medicare or health insurance

records. All the articles are overwhelmingly in agreement that having a higher income plays a

major role in access to healthcare. However the authors of the articles also believe that further

research is needed in order to properly address the disparity and inequality gap. These studies

provide evidence to help develop polices and interventions that specifically address income as it

relates to healthcare access.

Health Insurance

In two of the studies, the authors addressed health insurance as a subset to finances to

address how it also affects access to healthcare among the elderly (Lee et al., 2015; Yamanda et

al., 2015). The number of uninsured individuals, insufficient insurance coverage, lack of

reasonable cost, and the widening disparity has adversely affected the elderly population

(Yamanda et al., 2015). These factors have led to delayed or limited access to healthcare

increasing the unmet health needs of the elderly. Health insurance does not directly relate to the

PICOT question, however, it indirectly affects finances and access to healthcare. Health

insurance is designed to lessen financial burdens on individuals and allow them the opportunity
INTEGRATIVE LITERATURE REVIEW 9

to receive medical care. The benefits of these two studies on the discussion of health insurance

bring the attention to policy makers. It forces policy makers to develop interventions that pertain

to making healthcare more accessible and affordable. As a result reducing the inequalities and

burden of healthcare. A recommendation for future research is to conduct a study that examines

broadening health insurance coverage and reducing cost. These studies would then assess the

impact on access, utilization, policies on healthcare and the impact on an individual’s health.

Interventions

The interventions for the financial burdens faced by the elderly, whether related to low

monthly income or health insurance are aimed at reforming current polices and obtaining

affordable health insurance. Common interventions mentioned in all five articles were the need

to implement more studies aimed at discovering the factors affecting income inequality among

the elderly (Khanassov et al., 2016; Kurichi et al., 2017; Lee et al., 2015; ; Penning & Zheng,

2016; Yamanda et al., 2015). Further studies would allow researchers to uncover the impact that

income inequalities have on access to healthcare (Penning & Zheng, 2016). It is also imperative

for policy makers to address the varying issues in relation to healthcare in order to make if more

affordable and accessible (Yamanda et al., 2015). As a result there will be a reduction in the

inequality of income and access to healthcare.

Lastly, it was mentioned by Lee et al that they support WHO’s view to implement

universal healthcare coverage for vulnerable populations such as the elderly (2015). It is

believed that universal healthcare will lower the cost of coverage allowing for better access to

healthcare as well as utilization of care. However, more research is needed to address the

overwhelming financial burden that universal healthcare poses to governmental budgets.

Limitations
INTEGRATIVE LITERATURE REVIEW 10

While compiling this integrative review, the researcher faced many limitations. A major

contributing factor is the researcher’s lack of experience and knowledge about an integrative

review process. In addition, the researcher lacks the qualifications to contribute reliable input to

this subject, due to the fact that the author’s background is limited to a nursing student. As a

result, the researcher’s ability to provide insight on the topic solely in relation to the PICOT

question was restricted.

Another limitation the researcher faced was selecting articles for the review. The

researcher experienced trouble gaining access to certain articles. In addition, being limited to

only five articles with a five-year time frame failed to provide information that would make the

review of literature more comprehensive. The lack of research on the subject also posed as a

limitation. Collectively these factors greatly decreased the ability to provide expansive

information in relation to the subject.

Conclusion

The evidence gathered for this integrative review supports the notion that there is a

correlation between income and access to care among the elderly (Khanassov et al., 2016;

Kurichi et al., 2017; Lee et al., 2015; Penning & Zheng, 2016; Yamanda et al., 2015). Access to

care among the elderly is directly related to income and indirectly related to health insurance.

Lower income among the elderly reflected delayed, limited access or no access to healthcare in

comparison to those with a higher income (Yamanda et al., 2015). Addressing the disparities

with income and access to healthcare is imperative so that the elderly can continue to age without

the burdens of unmet healthcare needs (Yamanda et al., 2015). For future implementation

interventions such as addressing income inequalities, affordable health insurance, access to

health insurance, and advocating for policy changes will greatly impact access to healthcare
INTEGRATIVE LITERATURE REVIEW 11

among the elderly population. In relation to the PICOT question addressed, monthly income

affects access to care among the elderly population, the literature supports a correlation between

income and access to healthcare within the elderly population.

INTEGRATIVE LITERATURE REVIEW 12

References

Khanassov, V., Pluye, P., Descoteaux, S., Haggerty, J. L., Russell, G., Gunn, J., & Levesque, J.

(2016). Organizational interventions improving access to community-based primary

health care for vulnerable populations: a scoping review . International Journal for

Equity in Health, 15(158), 1-34. http://dx.doi.org/10.1186/s12939-016-0459-

Kurichi, J. E., Pezzin, L., Streim, J. E., Kwong, P. L., Na, L., Bogner, H. R., ... Hennessy, S.

(2017, May 18). Percieved barriers to healthcare and recipt of recommended medical care

among elderly medicare beneficiaries []. Archives of Gerontology and Geriatrics, 72, 45-

51. http://dx.doi.org/10.1016/j.archger.2017.05.007

Lee, J. T., Hamid, F., Pati, S., Atun, R., & Millett, C. (2015, July 8). Impact of

noncommunicable disease multimorbidity on healthcare utilisation and out-of-pocket

expenditures in middle income countries: cross sectional analysis []. PLOS ONE, 10(7),

1-18. http://dx.doi.org/10.137/journal.pone.0127199

Penning, M. J., & Zheng, C. (2016). Income inequities in health care utilization among adults

aged 50 and older []. Canadian Journal on Aging/ La Revue canadienne du

vieillissement, 35(1), 55-69. http://dx.doi.org/10.1017/S07 149808150000562

Yamanda, T., Ching Chen, C., Murata, C., Hiarai, H., Ojima, T., Kondo, K., & Harris III, J. R.

(2015, January 21). Access disparity and health inequality of the elderly: unmetneeds and

delayed healthcare []. International Journal of Enviornmental Research and Public

Health, 12, 1745-1772. http://dx.doi.org/10.3390/ijerph120201745

INTEGRATIVE LITERATURE REVIEW
First Author (Year)/Qualifications
Penning, M. J., & Zheng, C. (2016). Income inequities in health care utilization among adults
Background/Problem Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
13
 Penning (2015)- PH.D, Department of Sociology, University of Victoria
aged 50 and older []. Canadian Journal on Aging/ La Revue canadienne du
vieillissement, 35(1), 55-69. http://dx.doi.org/10.1017/S07 149808150000562
 Equal access to and utilization of health services in countries
 Financial barriers in regards to equity in the use of health care services in Canadian
health
 This study addressed the impact of income on physician and hospital utilization from
1992-2002 among adults aged 50 and older in British Columbia
 Lower income vs. higher income
 Not mentioned
 Analyses drew on provincial administrative health data regarding the use of physician
and hospital services (i.e medical services plan, physician payment information and
hospital discharge abstract database)
 Use of data was approved by the British Columbia Ministry of Health, British
Columbia Linked Health Database, Data Stewards and the University of Victoria
Human Research Ethics Committee.

 All adults aged 50 and older who were residents in province of British Columbia and
registered to receive health services between January 1, 1992 and December 31, 2002.
 Over an 11 year study
 Overall data was available for an average of 1.1 million individuals
 Health service was the dependent variable
 Income and year were the primary independent variable
 Age, gender, rural-urban residence and health status were included as control variables
INTEGRATIVE LITERATURE REVIEW 14

Measurement Tool/Data Collection

Method  Tables were utilized to report frequency distributions for all variables
 Key words were utilized in an academic search

Data Analysis
 Multivariable analyses were conducted using SAS logistic regression software to
compare and categorize findings
 Information was pulled from sample at random

Findings/Discussion
 Findings of declines in hospital-care access, accompanied by increasing income related
disparities in physician services access, show that inequalities are increasing with in
Canada’s health care system.
 Findings indicate that with health status differences taken into account, those with
lower incomes were less likely to access hospital services than those with higher
incomes.
 The findings corroborate the findings that were reported in several other studies for the
population as a whole and conducted during the same time.
 Their findings of health status were limited to co-morbid chronic conditions, which
could have limited the findings
 Several other limitations were noted

Appraisal/Worth to practice  This study focused on the access to and utilization of healthcare
 The article was limited to Canada
 Health status, age, income, gender, year, and rural-urban variables were compared to
analyze the problem stated.

First Author  Khanassov (2016)

(Year)/Qualifications
INTEGRATIVE LITERATURE REVIEW 15

Khanassov, V., Pluye, P., Descoteaux, S., Haggerty, J. L., Russell, G., Gunn, J., & Levesque, J.

(2016). Organizational interventions improving access to community-based primary health

care for vulnerable populations: a scoping review []. International Journal for Equity in

Health, 15(158), 1-34. http://dx.doi.org/10.1186/s12939-016-0459-

Background/Problem
Statement  Health systems are struggling to provide equitable access to community-based primary
health care
 The access to primary care services is worse for populations in situations of vulnerability.
 Focuses on indicators such as the way care is offered as well as the ability of people to seek
and engage in the care.
 The purpose of this study was to map the existing evidence on organizational interventions
that improve access to primary care services for vulnerable populations
Conceptual/theoretical  Study was a part of the Australian-Canadian IMPACT program (Improving Models
Framework Promoting Access to Care Transformation)
 Used the Patient Centered Access to Healthcare conceptual framework and the classification
of interventions of the Cochrane Effective Practice and Organization of Care
Design/  Mapped relevant studies
Method/Philosophical  Scoping reviews were used to identify knowledge gaps, set research agendas and identify
Underpinnings implications for decision making
 Scoping reviews are aimed to explore the breadth of available evidence in a research domain
 An interative process was completed to search through literature to refine their studies and
articles
Sample/ Setting/Ethical  There was no sample size noted
Considerations  The criteria came from organizational interventions in Organization for Economic
Cooperation and Development countries aiming to improve access to primary care for
vulnerable populations
 All studies and articles published from 200 in English or French, reporting at least one
INTEGRATIVE LITERATURE REVIEW
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
16
outcome
 39 studies were reviewed
 No variables were stated in the article
 A three step qualitative synthesis specifically theory driven to classify interventions,
dimensions and outcomes for each study
 Key words were searched in academic databases to specify the search.
 Findings of the study were complied and organized in charts, graphs and tables
 Each study
 Out of 8,694 records 6,943 were not eligible based on the title and or the abstract, and 1,721
were excluded based on full text publications

 There is limited breadth of research in this area
 It is suggested to conduct a full systematic review of studies on the effectiveness of the
formal integration of services to improve access to primary care services for vulnerable
populations
 Three dimensions of access were identified (approachability, availability, and affordability)
 The review of this study was to review interventions aimed at improving access to care to
primary care for vulnerable populations
 Limited number of published research studies
 More research needs to be completed
INTEGRATIVE LITERATURE REVIEW 17

First Author  Kurichi (2017), Department of Biostatics and Epidemiology, The Center for Clinical
(Year)/Qualifications Epidemiology and Biostatistics, and Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA
Kurichi, J. E., Pezzin, L., Streim, J. E., Kwong, P. L., Na, L., Bogner, H. R., ... Hennessy, S. (2017,

May 18). Percieved barriers to healthcare and recipt of recommended medical care among

elderly medicare beneficiaries []. Archives of Gerontology and Geriatrics, 72, 45-51.

http://dx.doi.org/10.1016/j.archger.2017.05.007

Background/Problem
Statement  Medicare beneficiaries perceived barriers to receiving healthcare.
 To examine survey respondents ratings of satisfaction with health system features that can
facilitate care, plus perceived barriers to care.
 The objective was to assess the relationship between perceived facilitators and barriers to
healthcare and actual receipt of recommended medical care among elderly beneficiaries.
Conceptual/theoretical
Framework

Design/  A cohort study using data from the 2001-2008 entry panels of the Medicare Current
Method/Philosophical Beneficiary Survey
Underpinnings  The Medicare Current Beneficiary Survey (MCBS) was used to contain a systematic,
representative sample that allowed them to generalize their results to the entire elderly
Medicare population
 Survey included 24, 607 of the age of 65 or older.
 A literature review was done using key words conducted in an academic database.
Sample/ Setting/Ethical  Several references were utilized for this study
Considerations  Respondent, either the sample person or proxy was interviewed three times a year over the
course of four years.

INTEGRATIVE LITERATURE REVIEW 18

Major Variables Studied (and  Measures of beneficiaries’ satisfaction with features of their healthcare delivery system, and
their definition), if reported barriers to receiving healthcare.
appropriate

Measurement Tool/Data  Client perceived barriers to access to healthcare based off surveys
Collection Method

Data Analysis  Examined 38 indicators, each indicator was examined separately

 Findings from the study is organized in table form with headers.

Findings/Discussion
 The findings were both independently and inversely associated with the actual receipt of
recommended medical care.
 Finance played a major role in access to healthcare among several other themes;
transportation, care coordination and quality, and no usual source of care.
 Satisfaction with care

Appraisal/Worth to practice
 Focused specifically on Medicare Beneficiaries in one community
 Limited to patient-reported satisfaction with health services and perception of barriers to
healthcare are subjective
 Future studies need to be conducted

First Author  Lee (2014) Department of Primary Care and Public Health, School of Public Health,
(Year)/Qualifications Imperial College of London, London, United Kingdom
Lee, J. T., Hamid, F., Pati, S., Atun, R., & Millett, C. (2015, July 8). Impact of noncommunicable

disease multimorbidity on healthcare utilisation and out-of-pocket expenditures in middle

INTEGRATIVE LITERATURE REVIEW
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
19
income countries: cross sectional analysis []. PLOS ONE, 10(7), 1-18.
http://dx.doi.org/10.137/journal.pone.0127199
 Burden of non-communicable disease (NCD’s) has grown rapidly in low and middle income
countries, where populations are ageing, with rising prevalence of multi-morbidity.
 Assessed the impact of NCD multi-morbidity on healthcare utilization and out of pocket
expenditures in six middle income countries.
 Not mentioned
 Used multiple logistic regression to determine socio-demographic correlates of
multimorbidity.
 Association between the number of NCDs and healthcare utilization as well as out of pocket
spending was assessed using logistic, negative binomial and log-linear models
 Representative population surveys in six middle income countries
 Self-reported health problems, disability, healthcare utilization and subjective well being.
 Cross sectional data from adult participants older than 18 in WHO study on global aging and
adult Health (SAGE) 2007-2010
 Data collected simultaneously
 Approval for human subject testing from research review boards local to each participating
site and from the WHO ethical review committee.
 If respondents had more than one NCD
 Other use of outpatient and inpatient services
 Multiple logistic regression to analyze the findings of the study
 Key words were used in an academic search
INTEGRATIVE LITERATURE REVIEW
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Yamanda, T., Ching Chen, C., Murata, C., Hiarai, H., Ojima, T., Kondo, K., & Harris III, J. R.
Background/Problem
20
 The prevalence of multimorditiy in the adult population varied
 Findings were categorized and organized in chart, table and graph form
 Multimorbidity is associated with higher levels of healthcare utilization and greater financial
burden for individuals in middle- income countries
 The study supports WHO’s call for universal health insurance and health service coverage in
LMIC’s, specifically for vulnerable populations.
 Study discovered a greater financial burden for those with NCD multimorditiy in LMI’s
 This study provides further evidence for policies and targeted interventions to tackle and
grow.
 Acknowledges the need for advocacy for vulnerable populations.
 Yamada (2015), Department of Economics, Center for Children and Childhood Studies at
Rutgers University, The State of New Jersey
(2015, January 21). Access disparity and health inequality of the elderly: unmetneeds and
delayed healthcare []. International Journal of Enviornmental Research and Public Health,
12, 1745-1772. http://dx.doi.org/10.3390/ijerph120201745
 The purpose of the study is to investigate healthcare access disparity that will cause delayed
INTEGRATIVE LITERATURE REVIEW 21

Statement and unmet healthcare needs for the elderly and to examine health inequality.
 Healthcare costs rises, more of the increasing costs are transferred to certain disadvantaged
populations

Conceptual/theoretical  Empirical Framework: PP Model

Framework  Adapted a modified Precede-Proceed model for framing theoretical and experimental
approaches
Design/  Data was collected from a large collection of the Community Tracking Study Household
Method/Philosophical Survey 2003-2004 of he USA
Underpinnings  Reliability and construct validity are examined for internal consistency and estimation of
disparity and inequality are analyzed by using probit/ ols regression
Sample/ Setting/Ethical  Contains information from approximately 46,587 individuals in 25,419 families from the
Considerations Community Tracking Study Household Survey
 Another sample size was conducted with 17,797 individuals with only 12 metropolitan areas
in 2007
 Sample is clustered in 60 CTS sites: 51 metropolitan areas and nine nonmetropolitan areas,
which were randomly selected
Major Variables Studied (and  Dependent variables: measures of delayed healthcare and unmet needs
their definition), if  There were also several independent variables and other variables discovered.
appropriate

Measurement Tool/Data
Collection Method  Key words were used
 The survey was administered by telephone, using computer assisted random digit dialing.

Data Analysis  Findings were well identified and organized in chart, table and graph form
 Common themes discovered were unmet healthcare needs, delayed in healthcare and access
and health disparity.

Findings/Discussion  The results show that predisposing factors (attitude, beliefs, and perception by socio-
demographic differences) are negatively associated with delayed healthcare.
INTEGRATIVE LITERATURE REVIEW 22

 The results also discovered some enabling factors (availability of health insurance coverage,
and usual sources of healthcare providers)
 Income, health status, and health inequality are exogenously determined.

Appraisal/Worth to practice
 The purpose of this study was to examine healthcare access disparity that will cause delayed
and unmet healthcare needs for the elderly and to examine health inequality and healthcare
cost burden for the elderly
 There were three main objectives for this study