Access to healthcare impacts in health, and for its importance it has been conceptualized by different theoretical models. Theories tackling social barriers have been established too. Nevertheless, a lack of theorization about healthcare access of immigrants exists, and there is no theory able to integrate all the scientific literature on this and its impact on the health of immigrants. In order to study the factors relating to the access of immigrants and to guide the development and evaluation of public health interventions, an integrative approach is needed. In this regard, from an ecological perspective healthcare access of immigrants would be shaped by interrelated factors in different layers in a hierarchical system. This study is not aimed to re-invent the wheel, this is a proposal to re-organize the factors playing a role in the access to healthcare for immigrants and modelling them to propose an integrative framework to guide future research and policies.
A qualitative design based on four focus groups were being carried out in Valencia (Spain). In the focus groups, 28 agents involved in healthcare provision participated. Based on the ecological model five-levels have guided a heuristic analysis: 1) Patient-level, 2) The relationship between patient-health professionals level, 3) Institutions influencing the healthcare access level, 4) Connectedness between services, community organisations and social networks level, 5) Socio-political Level.
The results are presented by level:
1) Patient-level: the factors determining a role in healthcare access are gender inequities, country of origin, language proficiency, health literacy and acculturation process.
2) The relationship between patient-health professionals level: The cultural competence, racist attitudes and willingness to provide care of health professionals are determinants of healthcare access.
3) Institutions influencing the healthcare access level: The availability of resources as public culturally adapted information and interpreters and cultural mediators facilitate access to care.
4) Connectedness between services, community organisations and social networks level: how the service is integrated into the community, developing and providing services plays a key role to guarantee the accessibility.
5) Socio-political Level: Racism are cultural elements that promote the inclusion or exclusion of immigrants, influencing the rest of levels presented. The legislation establishes definitions of who is beneficiary of the healthcare, giving rights or not. Also, policies define the kind of service that is provided to whom and the co-payment.
This study brings to light the harmony among the different scientific literature that would have been focused on comparing factors from one single level without taking into consideration the differences among all the rest of levels. The ecological framework also suggests that to guarantee access to health services, it is necessary to act through multiple levels of the model at the same time. Further research is needed to explore the relationship between different factors to design more integrative policies and interventions to guarantee equality in healthcare access. Also, the relationship among both origin and host health systems should be explored in order to recognise the factors influencing fully healthcare access of immigrants such as sharing personal medical records.