title: Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups.
abstract: BACKGROUND
  Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis.
  
  
  RESULTS
  Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research.
  
  
  CONCLUSIONS
  By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.
authors.affiliation: Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester LE1 6TP, UK. md11@le.ac.uk
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Debbie
authors.initials: D
authors.lastname: Cavers
authors.forename: Shona
authors.initials: S
authors.lastname: Agarwal
authors.forename: Ellen
authors.initials: E
authors.lastname: Annandale
authors.forename: Antony
authors.initials: A
authors.lastname: Arthur
authors.forename: Janet
authors.initials: J
authors.lastname: Harvey
authors.forename: Ron
authors.initials: R
authors.lastname: Hsu
authors.forename: Savita
authors.initials: S
authors.lastname: Katbamna
authors.forename: Richard
authors.initials: R
authors.lastname: Olsen
authors.forename: Lucy
authors.initials: L
authors.lastname: Smith
authors.forename: Richard
authors.initials: R
authors.lastname: Riley
authors.forename: Alex J
authors.initials: AJ
authors.lastname: Sutton
mesh_terms: D006297:Health Services Accessibility; D006302:Health Services Research / Q000379:methods*; D006801:Humans; D015201:Meta-Analysis as Topic; D010342:Patient Acceptance of Health Care; D012107:Research Design; D040841:Resource Allocation; D012494:Sampling Studies; D012959:Socioeconomic Factors; D013222:State Medicine; D006113:United Kingdom; D035862:Vulnerable Populations