The geographical dimension of access represents the ease of traveling to healthcare provider locations. The geographical dimension of access is of particular importance to rural populations, although travel can also be an important issue for congested urban areas and for those who lack personal forms of transportation. Actual geographic access includes the road travel distance and time to the nearest provider22
or to the nearest facility with telemedicine equipment.23
The degree of local provider choice (e.g., number of providers within 30 minutes) may also be an important dimension of actual geographical access.24
Perceived geographic access represents the self-reported ease of traveling to healthcare providers and tele-providers.
Temporal The temporal dimension of access includes the time required to receive services and the opportunity cost of that time. Another temporal dimension includes the time delay between when the services are needed and how long it takes to get an appointment or to communicate digitally with the provider. Actual temporal access includes time spent waiting in the reception area, the time spent receiving treatment, and the time spent on subsequent self-care activities, as well as the wait-time for the next available appointment or digital communication. Perceived temporal access represents the self-reported time burden and temporal convenience of receiving services. If services and communications are only available when the patient has other responsibilities (e.g., work or childcare), the perceived time burden will be associated with higher opportunity costs.
Financial The financial dimension of access includes healthcare system eligibility issues and the cost of utilizing healthcare services. Actual financial access includes eligibility (e.g., entitlement to VA services), insurance premiums, out-of-pocket costs for face-to-face and digital encounters, opportunity cost for lost work time (for those without paid sick leave), as well as the cost of digital connectivity, and the cost of remote monitoring devices and computer health applications. Perceived financial access represents misinformation about eligibility and the complexity of the application process, as well as the affordability of out-of-pocket costs and opportunity cost relative to household annual income. Perceptions about financial access will be greatest for those with low incomes, unpaid sick leave, as well as those living or in rural areas where digital connectivity is more expensive.
The cultural dimension of access represents the acceptability of health services. Actual cultural access includes whether services are offered in a language in which the patient is comfortable communicating (e.g., native language). For stigmatizing illnesses, actual cultural access also reflects whether services are offered by providers who do not discriminate against the patient. Perceived cultural access represents whether patients report that they understand their provider, agree with the diagnosis, and trust their treatment plan. Both patient health literacy and provider cultural competency are critical factors impacting understandability.25
The mode of communication (e.g., face-to-face, interactive video, text message, etc.) may also influence understandability. For stigmatizing illnesses, perceived cultural access may also include the degree to which a patient internalizes any provider discrimination or public stigma.
Digital The digital dimension of access includes the connectivity that enables synchronous or asynchronous digital communications with formal providers, informal caregivers, peers, and computerized health applications. The digital dimension must consider patients uploading information to providers and providers downloading information (e.g., lab results, tailored health information) to patients. Actual digital access includes whether patients own or have the right to use digital channels of communication, remote monitoring devices, and computer health applications. It also includes whether the patient’s providers and peers have access to digital channels of communication. Perceived digital access represents perceptions about the opportunity and simplicity of interacting digitally with providers. It also represents usability problems, provider responsiveness, as well as security and privacy concerns associated with digital communications.