title: Improving access to high-quality primary care for socioeconomically disadvantaged older people in rural areas: a mixed method study protocol.
abstract: BACKGROUND
  The UK has an ageing population, especially in rural areas, where deprivation is high among older people. Previous research has identified this group as at high risk of poor access to healthcare. The aim of this study is to generate a theory of how socioeconomically disadvantaged older people from rural areas access primary care, to develop an intervention based on this theory and test it in a feasibility trial.
  
  
  METHODS
  On the basis of the MRC Framework for Developing and Evaluating Complex Interventions, three methods will be used to generate the theory. First, a realist review will elucidate the patient pathway based on existing literature. Second, an analysis of the English Longitudinal Study of Ageing will be completed using structural equation modelling. Third, 15 semistructured interviews will be undertaken with patients and four focus groups with health professionals. A triangulation protocol will be used to allow each of these methods to inform and be informed by each other, and to integrate data into one overall realist theory. Based on this theory, an intervention will be developed in discussion with stakeholders to ensure that the intervention is feasible and practical. The intervention will be tested within a feasibility trial, the design of which will depend on the intervention. Lessons from the feasibility trial will be used to refine the intervention and gather the information needed for a definitive trial.
  
  
  BACKGROUND
  Ethics approval from the regional ethics committee has been granted for the focus groups with health professionals and interviews with patients. Ethics approval will be sought for the feasibility trial after the intervention has been designed. Findings will be disseminated to the key stakeholders involved in intervention development, to researchers, clinicians and health planners through peer-reviewed journal articles and conference publications, and locally through a dissemination event.
authors.affiliation: Department of Public Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: John A
authors.initials: JA
authors.lastname: Ford
authors.affiliation: Department of Public Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Jones
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, London, UK.
authors.forename: Geoff
authors.initials: G
authors.lastname: Wong
authors.affiliation: Department of Public Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Allan B
authors.initials: AB
authors.lastname: Clark
authors.affiliation: Department of Public Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Porter
authors.affiliation: Department of Public Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Shakespeare
authors.affiliation: Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Ann Marie
authors.initials: AM
authors.lastname: Swart
authors.affiliation: Department of Public Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Steel
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017144:Focus Groups; D006297:Health Services Accessibility / Q000592:standards*; D006299:Health Services for the Aged / Q000592:standards*; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D011320:Primary Health Care / Q000592:standards*; D019035:Rural Health Services / Q000592:standards*; D012424:Rural Population; D012959:Socioeconomic Factors; D006113:United Kingdom; D035862:Vulnerable Populations
keywords: HEALTH SERVICES ADMINISTRATION & MANAGEMENT; PRIMARY CARE; PUBLIC HEALTH