Assessment of Perceived Healthcare Access in a

Rural Community in Rizal: A Cross-sectional

Study

KATHYRINE A. CALONG CALONG, MA, RN JUDALYN S. COMENDADOR, MA, RN

[Link] [Link]

San Beda University, Manila, Philippines

Corresponding author’s email: kcalongcalong@[Link]

Abstract

Background: Access to health care is considered a basic right and integral to human life. However,
this still remains a challenge especially in developing countries where the majority of the poor reside
and suffer from a disproportionate amount of disease. The study determined the six key components
of health care access: approachability, availability, accessibility, affordability, acceptability, and
accommodation, as perceived by a rural community in Taytay, Rizal, Philippines.

Methods: This descriptive-cross sectional study included a convenience sample of 62 participants.

The Perceived Access to Health Care Instrument was utilized. Frequency, percentage, mean,
standard deviation, and univariate linear regression were used to analyze the data.

Results: The study revealed that health care access was rated as good in terms of approachability,
availability, affordability and acceptability. On the other hand, accessibility and accommodation was
rated as fair. It was also revealed that none of the demographic profiles significantly predicted the
perceived access to health care

Conclusion: Assessment of health care access is an important measure of health care equity and
despite several factors previously shown to affect health care access, the results of this study
showed that the participants have good access to health care in their community.

Keywords: Healthcare services, perceived access, rural community

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 Introduction

T
he 1946 constitution of the World Health Organization (WHO) states that “the enjoyment of the
highest attainable standard of health is one of the fundamental rights of every human being
without distinction of race, religion, political belief, economic or social condition. The health of
all people is fundamental to the attainment of peace and security and is dependent upon the fullest
cooperation of individuals and states” (p. 1). These statements magnify the link between peace and
health especially with the acceptance of peace as a social determinant of health in the 1980s and the
connection can be interpreted as bidirectional and dynamic in nature (Canadian Nurses Association
[CNA], 2009), one cannot exist without the other. Thus, the concept of “peace through health
programs” coined by Santa Barbara and MacQueen (2000), refers to “any initiative that is intended
to improve the health of a population and to simultaneously heighten that population’s level of peace
and security.”

The Universal Declaration of Human Rights (UDHR) Article 25 states that “Everyone has
the right to a standard of living adequate for the health and well-being of himself and of his family,
including food, clothing, housing and medical care and necessary social services….” The declaration
asserts that health is an important goal of human rights and integral to the right to life (Perry,
Fernandez & Puyana, 2015). Thus, it is the responsibility of the state to provide basic health services
to its citizenry without prejudice to their social status, race, religion, etc. This paved the way to the
development and implementation of public health programs with the goal of improving the health of
people and communities.

An individual’s access to healthcare as defined by Levesque, Harris and Russell (2013) is

the opportunity to identify healthcare services and to actually have a need for services fulfilled.
Galama and van Kippersluis (2013) added that having access to effective healthcare is considered a
fundamental component of human capital that ensures healthy living, general well-being and good
quality of life. However, data from the World Health Organization (2017) revealed that at least half of
the world’s population cannot obtain essential health services. A report by Wan and Francisco (2009)
on the access of basic services in the developing countries in Asia stated that health services fail to
reach majority of the poor, who suffer from a disproportionate amount of disease. Further, Dalton and
Peacock reported that poor households are five times more likely to become sick than richer
households and are less likely to receive basic health services (Peters et al., 2008; Barat et al., 2004;
Pillai et al., 2003). Yazbeck et al. (2005) and Wagstaff (2002) added that poor children are usually
less likely to be fully immunized even in countries where national immunization programs are in place.

According to the Institute for Economics & Peace (2018), “peaceful countries tend to ensure
equity in access to resources such as education, health…” (p. 8). However, literatures have revealed
that marginalized and vulnerable groups are facing challenges with access to healthcare which in
turn can affect one of the eight pillars of peace which is equitable distribution of resources and

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ultimately the sustainable development goals.

In the Philippines, Filipinos suffer from dismal access to health services where eight out of
ten people reported to have never undergone a medical examination (Van Gijsel, 2016). Further, the
current doctor to patient ratio is 1:33, 000 which is significantly higher than the global average of 1:6,
600 (Pennington, 2019). These only highlights that the delivery of basic health services remains a
challenge in developing countries like the Philippines. Thus, the study was conducted to determine
the perceived access to healthcare among residents in a rural area in Rizal in terms of
approachability, availability, accessibility, affordability, acceptability and accommodation of
healthcare services.

Methods

Study Design and Sampling Technique

The study utilized a cross-sectional research design in order to determine the perceived
access to healthcare among the participants in a rural area of Rizal, Philippines. The area is situated
inside a subdivision owned by a renowned real estate developer in the Philippines and the lots were
donated to the local people living in the community. The said area was selected since it is the adopted
community of a College of Nursing in Manila. In order to select the participants, a convenience
sampling design was used and a total of 62 participants were recruited. The data were collected from
November 2019 to December 2019.

Participants of the Study

The participants included community members in a rural area in Taytay, Rizal, Philippines
who are 18 years old and above, male or female, have been living in the community for more than a
year and agreed to participate in the study.

Measurement and Instrumentation

The study utilized the Access to Health Care (AHC) Instrument developed by Zandam, Juni,
Hayati and Anisah (2017) and was translated to Filipino following the World Health Organization
guidelines (WHO, n.d. as cited by Soriano & Calong Calong, 2019). The forward translation was done
by a bilingual healthcare professional while back-translation was done by another translator who is
an English language teacher but has no knowledge of the instrument. Afterwards, a pretesting and
cognitive debriefing was done among selected participants who met the inclusion criteria. No
problems were encountered during the conduct of the interview and the intent of the questions.
The AHC instrument is a 25-item instrument consisting of six subscales pertaining to

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 approachability (6 items), availability (3 items), accessibility (3 items), affordability (3 items),
acceptability (5 items) and accommodation (5 items) with Cronbach’s alpha of 0.799, 0.782, 0.679,
0.751, 0.753 and 0.752 respectively which met the criteria set by Polit and Beck (2014 as cited by
Soriano & Calong Calong, 2019). Further, the translated tool was shown to be content valid having
an Item Content Validity Index (I-CVI) ranging from 0.90 to 1.0 and Scale Content Validity Index
(S-CVI) of 0.94 which met the criteria set by Polit & Beck (2006 as cited by Soriano, 2019). The
survey instrument also collected demographic data on the participants, including age, sex, marital
status, educational attainment, employment status, family income, and family size.

Operational Definitions

Healthcare access was defined in terms of six components including

approachability, availability, accessibility, affordability, acceptability, and accommodation.
Approachability is when people facing health needs are aware of certain healthcare services at
hand and have an impact on the health of the individual (Levesque et al., 2013) while availability is
the extent to which the supply and services are made readily available in terms of the
adequacy of facilities and healthcare professionals (Levesque et al., 2013; Penchasky &
Thomas, 1981). Another aspect is accessibility which refers to the geographic location of patient to
the location of facilities like perception on spatial distance and travel time to reach the facility
(Obrist et al., 2007; Penchasky & Thomas, 1981). Affordability, in turn, refers to the
perception costs associated with healthcare visits such as consultation fee, travel and
medical costs which can have an impact on the overall access to healthcare (Levesque et
al., 2013; Peters et al., 2008). Acceptability, on the other hand, is the provision of quality
services and personal treatment by healthcare providers (Peters et al., 2008; Levesque et al.,
2013). Lastly, accommodation refers to the relationship between the manner in which the supply
resources are organized to accept clients (including building facilities, appointment systems,
hours of operation, walk-in facilities, telephone services), clients’ ability to accommodate to these
factors, and clients’ perceptions of their appropriateness (Levesque et al., 2013; Obrist et al., 2007).

Data Analysis

The data were analyzed using frequency, percentage, mean, standard deviation.
Univariate linear regression was used to determine the influence of the demographic profile on the
perceived access to healthcare.

Result

The demographic profile of the participants (Table 1), revealed that the mean age was 33.4
(±13.27), the majority were female (n=39 or 65%), married (n=34 or 56.7%) and with a high school
education (n=35 or 58.3%). Further, most were employed (n=35 or 56.5%) with family income of
<Php19, 999 (n=56 or 90.3%) and family size of 4 to 6 members (n=32 or 51.6%).

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Table 1. Demographic Profile of the Participants (n = 62)
Characteristics Frequency (f) Percentage (%) Mean (SD)
Age (Years) 33.4 (±13.27)
Sex
Male 22 35.48%
Female 40 64.52%
Marital Status
Single 27 43.55%
Married 35 56.45%
Education
Elementary Graduate 26 41.9%
High School Graduate 36 58.1%
Employment
Employed 35 56.50%
Unemployed 27 43.50%
Income
<Php19, 999 56 90.30%
>Php20, 000 6 9.70%
Family Size
1 to 3 individuals 23 37.10%
4 to 6 indiivuduals 39 62.90%

Table 2 shows the descriptive statistics of perceived access to healthcare among the
participants. The results revealed that overall, the participants had fair access to healthcare (M= 3.57;
SD= ±0.35). In terms of approachability, the mean score was 3.81 which can be interpreted as good,
whereas the mean score for availability was 3.47 which can be interpreted as good. The accessibility
was rated as fair (M=3.48) and the affordability was rated as good (M=3.75), Furthermore, the mean
score of acceptability was 3.45 which can be interpreted as good while accommodation was rated as
fair (M=3.35).

Table 2. Descriptive Statistics of Perceived Access to Health Care (n = 62)

Mean Standard Deviation Interpretationa
Perceived Access to Health Care 3.57 ±0.35 Good
Approachability 3.81 ±0.54 Good
Availability 3.47 ±0.57 Good
Accessibility 3.48 ±0.68 Fair
Affordability 3.75 ±0.58 Good

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 Mean Standard Deviation Interpretationa
Acceptability 3.45 ±0.47 Good
Accommodation 3.35 ±0.56 Fair
aLegend: Very Poor = 1.00 to 1.79 Poor = 1.80 to 2.59
Fair = 2.60 to 3.39 Good = 3.40 to 4.19
Excellent = 4.20 to 5.00

The results of the univariate linear regression analysis of the influence of the demographic
characteristics on perceived access to healthcare of the participants is depicted in Table 3. None of
the demographic characteristics significantly predicted perceived access to healthcare.

Table 3. Univariate linear regression of perceive access to healthcare (n=62)

Regression
Source SE B p value R squared
Coefficient
Age 0.004 0.169 0.581 0.016
Sex -0.004 0.136 0.975 0.000
Civil Status 0.040 0.120 0.740 0.002
Perceived Access to
Education -0.169 0.132 0.207 0.026
Health Care
Employment 0.030 0.135 0.219 0.001
Income 0.060 0.227 0.794 0.001
Family Size -0.201 0.136 0.146 0.035
Regression equation: Y’=4.30+0.004-0.004+0.040-0.169_0.030+0.060-0.201

Discussion

The study was conducted in order to assess perceived access in healthcare among
residents of a rural area in Rizal, Philippines. The findings revealed that there was a good
approachability of healthcare access; meaning that the participants are well aware of the healthcare
services in the community. This is likely attributed to the community being one of the adopted
communities of a university in Manila. As an adopted community, they received healthcare services
and outreach programs as well as information drives which is conducted in partnership with the local
government. This may also be the reason why the participants rated availability of healthcare as
good. Asasira and Ahimbisibwe (2018) stated that partnership arrangement between public and
private organizations will enable adequate delivery of healthcare services to the clients.

The influence of geography has been shown to affect access to healthcare (Arcury et al.,
2005); healthcare facilities that are 30 minutes within the community are considered as accessible
(Famorca, Nies, & McEwen, 2013). It can be noted that the accessibility of healthcare was rated by
the participants as fair. This means that distance from the health facility did not pose a problem and

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that the health facility was within a reasonable distance from the catchment population it was intended
to serve.

In terms of affordability, the literature has revealed that poor people with lower level of
education would perceive access to healthcare to be more challenging than those with higher
education and higher income (Borders, Aday & Xu, 2004; Moss, 2000). However, this was not the
case in this study; since monthly income and education were not shown to be predictors of perceived
access. It was interesting to note that the affordability of healthcare services was rated by the
community as good, since ensuring the affordability of healthcare remains an important factor in
achieving access to high-quality healthcare (Agency for Healthcare Research and Quality, 2017).

The participants of the study rated acceptability of healthcare services as good. Acceptability
is essential since it encompasses patient satisfaction with the care received. Studies have shown that
patients who are satisfied with quality of care are more likely to continue with care, adhere to medical
instructions, and are also unlikely to patronize non-professional medical practitioners (Pascoe, 1983;
Vuori, 1987).

Accommodation, on the other hand was rated by the participants as fair, suggesting that the
structures and facilities present in the healthcare facilities were successfully accommodating the
number of people in the community.

Overall, the participants have revealed a good access in healthcare services. This finding
can be attributed to the implementation of Universal Health Care Program by the Aquino government
in 2016. This program was developed with the goal of providing equitable access to affordable and
quality health services thereby addressing inequity in healthcare system.

The study had the following limitations: (1) although there are supply-side features of the
health system and organization and demand side features of populations (Levesque et al., 2013), the
study only explored the supply side without attempting to assess the demand side of the population,
(2) a convenience sample was used, hence, generalizability of the results is limited, (3) lastly, the
study only focuses on the perception of healthcare access without attempting to measure the
healthcare seeking behaviors and healthcare utilization of the participants.

Conclusion

Assessment of health care access is an important measure of health care equity and despite
several factors previously shown to affect health care access. Results of this study showed that the
participants have a good access to health care in their community.

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 Funding

This study is funded by San Beda University through its Research and Development
Center, AY 2019-2020 Research Grants.

References
Agency for Healthcare Research and Quality (2017). 2016 National Healthcare Quality and Disparities Report.
Retrieved from: [Link]
Arcury, T., Gesler, W., Preisser, J., Spencer, J., & Perin, J. (2005). The Effects of Geography and Spatial
Behavior on Health Care Utilization among the Residents of a Rural Region. Health Services
Research, 40(1), 135-156. doi: 10.1111/j.1475-6773.2005.00346.x
Asasira, J. & Ahimbiisbwe, F. (2018). Public-Private Partnership in Health Care and Its Impact on Health
Outcomes: Evidence from Ruharo Mission Hospital in Uganda. International Journal of Social
Science Studies, 6(20), 79-87. doi: 10.11114/ijsss.v6i12.3911
Barat, L. M., Palmer, N., Basu, S., Worrall, E., Hanson, K., & Mills, A. (2004). Do Malaria Control Interventions
Reach the Poor? A View Through the Equity Lens. The American Journal of Tropical Medicine and
Hygiene, 71(2), 174–178.
Borders, T. F., Aday, L. A., & Xu, K. T. (2004). Factors Associated With Health‐Related Quality of Life Among
an Older Population in a Largely Rural Western Region. The Journal of Rural Health, 20(1),
67-75. doi 10.1111/j.1748-0361.2004.tb00009.x
Canadian Nurses Association (2009). FactSheet: Peace and Health. Retrieved from: [Link]
[Link]/~/media/cna/page-content/pdf-fr/fs27_peace_health_ 2009_e.pdf? la=en
Famorca, Z., Nies, M., & McEwen, M. (2013). Nursing Care of the Community. Singapore: Elsevier Saunders
Galama, T. J., & van Kippersluis, H. (2013). Health Inequalities through the Lens of Health Capital Theory:
Issues, Solutions, and Future Directions. Research on Economic Inequality. 21, 263–284. doi:
10.1108/S1049-2585(2013)0000021013
Institute for Economics & Peace. (2018) Positive Peace Report 2018: Analysing the factors that Sustain Peace.
Retrieved from: [Link]
Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centered access to healthcare: conceptualizing
access at the interface of health systems and populations. International Journal for Equity in Health, 12,
18. doi: 10.1186/1475-9276-12-18
Moss, N. (2000). Socioeconomic disparities in health in the US: an agenda for action. Social Science &
Medicine, 51(11), 1627-1638. doi: 10.1016/S0277-9536(00)00058-7
Obrist, B., Iteba, N., Lengeler, C., Makemba, A., Mshana, C., Nathan, R., … Mshinda, H. (2007). Access to
health care in contexts of livelihood insecurity: a framework for analysis and action. PLoS Medicine,
4(10), 1584–8. doi: 10.1371/[Link].0040308
Pascoe, G. (1983). Patient satisfaction in primary health care: a literature review and analysis. Evaluation and
Program Planning. 6(3):185-210
Penchansky, R., & Thomas, J. W. (1981). The concept of access: definition and relationship to consumer
satisfaction. Medical Care, 19(2), 127–40. Retrieved from [Link]

107
Pennington, J. (2019). Healthcare for all in the Philippines – but is there a catch? Retrieved from:
[Link]
Perry, D., Fernadez, C., & Puyana, D. (2015). The Right to Life in Peace: An Essential Condition for Realizing
the Right to Health. Health and Human Rights Journal, 17(1)
Peters, D. H., Garg, A., Bloom, G., Walker, D. G., Brieger, W. R., & Rahman, M. H. (2008). Poverty and
access to health care in developing countries. Annals of the New York Academy of Sciences, 1136,
161–171. doi: 10.1196/annals.1425.011
Pillai, R. K., Williams, S. V., Glick, H. A., Polsky, D., Berlin, J. A., & Lowe, R. A. (2003). Factors Affecting
Decisions to Seek Treatment for Sick Children in Kerala, India. Social Science & Medicine. 57(5),
783–790.
Santa Barbara, J. & MacQueen, G. (2004). Peace through health: key concepts. Lancet. 364, 384–386.
Soriano, G. P. & Calong Calong, K. A. (2019). Psychometric Evaluation of Filipino Version of Patient
Satisfaction Instrument. Belitung Nursing Journal, 5 (6), 251-256. doi: 10.33546/bnj.867
Soriano, G. & Calong Calong, K. (2019). Construct Validity and Reliability of Caring Nurse Patient Interaction
Scale-Nurse among Filipino Nurses. International Journal of Caring Sciences, 12(2), 1017-1022
Soriano, G. (2019). Psychometric Evaluation of the Filipino Version of Caring Nurse Patient Interaction Scale
Patient. International Journal for Human Caring, 23(4), 329-333. doi: 10.20467/1091-5710.23.4.329
Universal Declaration of Human Rights. (1948). Art. 25. Retrieved from: [Link]
/en/udhrbook/pdf/udhr_ booklet_en_web.pdf
Van Gijsel, N. (2016). Health Care Access in the Philippines. Third World Health Aid. Retrieved from:
[Link]
s_eng_0.pdf
Vuori, H. (1987). Patient satisfaction--an attribute or indicator of the quality of care? QRB Quality Review
Bulletin.13(3):106-8.
Wagstaff, A. (2002). Poverty and Health Sector Inequalities. Bulletin of the World Health Organization. 80(2),
97–105
Wan, G., & Francisco, R. (2009). Why is Access to Basic Services Not Inclusive? A Synthesis with a Special
Focus on Developing Asia. ADB Sustainable Development Working Paper Series. Mandaluyong,
Metro Manila: Asian Development Bank
World Health Organization (2017). Half the world lacks access to essential health services, 100 million still
pushed into extreme poverty because of health expenses. Retrieved from: [Link]
room/detail/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health
services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses
Yazbeck, A.S., Gwatkin, D. Wagstaff, A., & Qamruddin, J. (2005). Reaching the Poor with Health Nutrition, and
Population Services: What Works, What Doesn’t and Why. Washington, DC: World Bank.
Zandam, H., Juni, M. Hayati, K., Anisah, B. (2017). Development and Validation of Perceived Access to Health
Care Measurement Instrument. International Journal of Public Health and Clinical Sciences, 4(5),
158-171

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 About the Authors

Kathyrine A. Calong Calong, MA, RN is a graduate of Bachelor of Science in Nursing from the
Metropolitan Medical Center-College of Arts, Science and Technology and received her Master of
Arts in Nursing Degree Major in Leadership and Management from Centro Escolar University. She
has worked as a staff nurse in several institutions including Metropolitan Medical Center and Manila
Medical Center. Currently, she is the Level 1 Coordinator of San Beda University-College of Nursing.
Her master’s research is focused on the caring behaviors among nurses working in Level 3
hospitals. She is pursuing her Doctor of Philosophy in Nursing Education at St. Paul University of
the Philippines Manila. She is a member of the Philippines Nurses Association and Philippine
Nursing Research Society.

Judalyn S. Comendador, MA, RN is an experienced nurse clinician in emergency nursing and

major disaster response locally and abroad. She is also a nurse educator and had taught in top
universities in the Philippines. She is one of the pioneer leaders in nursing education and staff
development in military hospitals abroad. With skillful knowledge in competency-based assessment
and experience in multicultural nursing leadership and management. She is currently working in San
Beda University as Skills Laboratory Manager, Lecturer, and Clinical Instructor.

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