Perceived Access to Health Care Questionnaire

Abstract

The Perceived Access to Health Care Questionnaire is a standardized, multidimensional psychometric instrument developed to evaluate how individuals subjectively perceive, navigate, and experience systemic and personal barriers to healthcare services. While conventional public health monitoring frameworks have historically relied on macro-level objective metrics—such as geographic distance to facilities, bed-to-population ratios, or provider densities—these structural parameters often fail to explain disparities in actual health-seeking behaviors. Rooted in the psychological reality of the healthcare consumer, this questionnaire operates on the empirical foundation that physical availability does not inherently translate into service utilization. Instead, utilization is moderated by cognitive appraisals, financial perceptions, organizational alignment, and sociocultural acceptability.

Methodologically constructed by integrating Penchansky and Thomas’s foundational taxonomy of access with Saurman’s contemporary conceptual expansion incorporating information literacy, the scale measures six distinct operational dimensions: Availability, Accessibility, Affordability, Accommodation, Acceptability, and Awareness. Comprising 30 items evaluated via a 5-point Likert scale ranging from strongly agree to strongly disagree, the questionnaire was validated in an Iranian adult cohort (N = 300) referred to urban primary healthcare centers. Psychometric evaluations confirmed high content validity, with Content Validity Ratio (CVR) values exceeding 0.78 and a scale-level Content Validity Index (CVI) exceeding 0.79 across retained items.

Confirmatory Factor Analysis (CFA) established structural construct validity, supporting the a priori six-factor latent architecture. Internal consistency reliability is high, demonstrating an overall scale Cronbach’s alpha of 0.86, with subscale coefficients ranging from 0.60 to 0.80. Temporal stability assessed across a two-week interval demonstrated excellent reproducibility, yielding an Intraclass Correlation Coefficient (ICC) of 0.94. The Perceived Access to Health Care Questionnaire serves as a robust diagnostic and evaluative tool for public health researchers, epidemiologists, health economists, and clinical administrators seeking to uncover subjective inequities and optimize health system responsiveness.

Keywords

healthcare access, perceived access, health equity, psychometrics, instrument development, health psychology, health services research, health literacy, Penchansky and Thomas model, patient-centered care, confirmatory factor analysis, subjective barriers

Authors

The Perceived Access to Health Care Questionnaire was conceptualized, designed, and psychometrically validated by an interdisciplinary team of nursing, biostatistics, and public health scholars in Tehran, Iran:

• Sara-Sadat Hoseini-Esfidarjani — School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. Email: [email protected]
• Reza Negarandeh (Corresponding Author) — Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. Email: [email protected]
• Farzaneh Delavar — School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. Email: [email protected]
• Leila Janani — Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran. Email: [email protected]

Purpose

The primary purpose of the Perceived Access to Health Care Questionnaire is to provide a standardized, psychometrically sound, patient-centered diagnostic instrument capable of assessing subjective barriers to medical and preventative healthcare services. For decades, health services researchers, health system planners, and government agencies have evaluated access almost exclusively through an administrative and spatial lens. Such objective evaluations quantify indices such as travel distance in kilometers, density of general practitioners per capita, municipal ambulance response intervals, and the gross operational volume of clinical beds. However, substantial empirical evidence reveals a persistent public health paradox: populations residing in physical proximity to well-funded tertiary or primary medical facilities frequently experience high rates of preventable morbidity, delayed diagnosis, and marked service underutilization.

This paradox highlights a critical measurement gap: objective structural supply does not equate to effective utilization. Healthcare-seeking behavior is profoundly cognitive and psychological. Individuals make decisions based on their subjective appraisal of cost, the logistical inconvenience of navigating appointment structures, interpersonal trust in medical personnel, cultural congruence with healthcare environments, and their own self-efficacy in understanding available services. The Perceived Access to Health Care Questionnaire was engineered specifically to capture this perceptual interface between the health delivery system and the prospective healthcare consumer.

From a research perspective, the scale offers an empirically verified method for capturing granular consumer perceptions across six distinct theoretical domains. Existing access instruments in the literature are frequently fragmented, often operationalizing access as a unidimensional economic constraint (such as out-of-pocket expenditure capacity) or a purely spatial barrier (such as travel time). By integrating spatial, economic, systemic, cultural, and cognitive factors into a single instrument, this questionnaire allows investigators to run structural equation models and multivariable regressions that identify which specific domain serves as the primary barrier for specific marginalized cohorts.

In clinical, community health, and policy contexts, the questionnaire functions as an operational needs-assessment tool. Public health administrators can deploy the instrument within underserved urban neighborhoods, rural districts, or sociodemographic sub-populations to identify why established clinics remain underutilized. If survey data indicate high scores in geographic accessibility and physical availability, but markedly depressed scores in accommodation or acceptability, administrators can bypass costly physical infrastructure projects and instead allocate funding toward cultural competence training, extended evening operational hours, translation services, or digital appointment scheduling overhauls. Consequently, the scale acts as an essential instrument for health equity optimization and quality improvement initiatives.

Psychological Construct

The overarching construct evaluated by the instrument is perceived access to healthcare. Rather than treating access as a static physical asset belonging to an institution, this instrument operationalizes access as a relational, multidimensional psychological state arising from the dynamic transaction between individual resources, social cognition, and healthcare delivery structures. An individual’s perceived access reflects their subjective confidence, cognitive appraisal, and behavioral readiness to obtain necessary medical care without experiencing disproportionate emotional, financial, temporal, or social strain. The construct is delineated across six interconnected, non-redundant dimensions:

1. Availability

Availability captures the prospective patient’s subjective evaluation of the adequacy, presence, and operational readiness of clinical resources, diagnostic technologies, and qualified healthcare personnel. Rather than reflecting the numerical registry of healthcare professionals licensed in a given municipal zone, this dimension reflects whether an individual perceives that an appropriate specialist, primary care physician, or critical diagnostic tool is actually present and functional when an episode of illness occurs. For instance, an urban clinic may formally employ three physicians, but if individuals perceive that physicians are chronically absent, diagnostic reagents are routinely depleted, or prescription medications are perpetually out of stock, their perceived availability remains severely compromised.

2. Accessibility

Accessibility addresses the perceived spatial and logistical burden required to physically reach a healthcare facility. While geographic information systems (GIS) measure straight-line distance or road networks in kilometers, perceived accessibility captures the cognitive and emotional expenditure associated with commuting. This includes subjective evaluations of terrain difficulty, public transportation unreliability, road safety, urban transit congestion, and the physical stamina required to travel while experiencing acute pain or chronic disability. A distance of three kilometers may be perceived as negligible by an able-bodied individual with personal vehicular transport, yet perceived as an insurmountable barrier by a low-income elder relying on multiple uncoordinated bus transfers.

3. Affordability

Affordability operationalizes the consumer’s subjective financial capacity to meet the direct, indirect, and opportunity costs of healthcare relative to their overall economic security. This dimension transcends static price tags or copayment schedules. It assesses the perceived threat that seeking medical care poses to household financial stability, fear of catastrophic health expenditure, out-of-pocket medication expenses, and the economic burden of lost wages during clinical consultations. High perceived affordability manifests as an individual feeling confident that engaging with the healthcare system will not destabilize their basic socioeconomic survival, whereas low perceived affordability generates acute financial anxiety and proactive avoidance of necessary diagnostic testing.

4. Accommodation

Accommodation reflects the degree to which the organizational architecture of healthcare services harmonizes with the real-world temporal constraints, communication modes, and logistical preferences of patients. This dimension probes systemic flexibility: whether clinical operational hours coincide with working-class labor shifts, whether appointment booking mechanisms are accessible without complex digital hurdles, the perceived burden of waiting times in clinical waiting rooms, and the responsiveness of telephone or in-person triage. When facilities demand rigid daytime scheduling with multi-hour waiting periods, patients experience low accommodation, which acts as a powerful psychological disincentive to care seeking.

5. Acceptability

Acceptability encompasses the perceived interpersonal, sociocultural, and ethical congruence between healthcare providers and patients. Grounded in social identity and health psychology, this dimension measures the patient’s perceived trust, mutual respect, and psychological safety within the clinical environment. It evaluates whether individuals perceive clinical staff to be compassionate, non-judgmental, and culturally sensitive, or conversely, whether they anticipate stigma, discrimination, medical paternalism, or dismissal based on their gender, socioeconomic stratum, or regional background. Low perceived acceptability fosters medical mistrust, anticipatory shame, and high rates of clinical non-compliance or attrition.

6. Awareness

Awareness represents the cognitive and health literacy component of perceived access. Drawing from cognitive psychology and health navigation theory, awareness assesses the patient’s subjective capacity to recognize their own biological and psychological health needs, know which specific medical resources exist to address those needs, understand where and how to obtain care, and effectively navigate bureaucratic health service pathways. Without cognitive awareness, physical infrastructure and financial subsidies remain inert; individuals cannot access care that they do not know exists or do not understand how to activate.

Theoretical Framework

The theoretical architecture of the Perceived Access to Health Care Questionnaire is established primarily upon the classic socio-organizational framework articulated by Roy Penchansky and J. William Thomas (1981), subsequently modified and modernized by Emily Saurman (2016), and contextualized alongside Levesque, Harris, and Grant’s (2013) conceptual model of patient-centered healthcare access.

Penchansky and Thomas’s Five Dimensions of Access

In their seminal 1981 formulation, Penchansky and Thomas defined access not as a static resource or an isolated outcome, but as the degree of “fit” between the consumer and the healthcare delivery system. They asserted that access consists of five distinct, interdependent dimensions: Availability (the relationship of volume and type of existing services to the client’s volume and types of needs), Accessibility (the relationship between the location of supply and the location of clients, considering transportation and travel time), Accommodation (the relationship between the manner in which supply resources are organized to accept clients and the clients’ ability to accommodate these factors), Affordability (the relationship between prices of services and providers’ insurance or payment requirements to the clients’ income and ability to pay), and Acceptability (the relationship between clients’ attitudes about personal and practice characteristics of providers to the actual characteristics of existing providers). Penchansky and Thomas demonstrated that these dimensions represent autonomous cognitive constructs that uniquely influence patient satisfaction, utilization rates, and healthcare outcomes.

Saurman’s Cognitive Extension: The Dimension of Awareness

While the original five-dimension model offered a comprehensive structural and interpersonal perspective, contemporary health systems researchers noted a critical limitation: it implicitly assumed that consumers possess perfect information regarding service availability and their own physiological needs. In 2016, Emily Saurman addressed this theoretical limitation by proposing the formal integration of Awareness as the sixth fundamental dimension of access. Saurman argued that access cannot be realized unless communication, health literacy, and systemic transparency are present. Awareness links the provider and the consumer by ensuring that health information is effectively disseminated, culturally understood, and actionable. In Saurman’s expanded paradigm, awareness interacts dynamically with the preceding five dimensions: an individual may have an affordable, accessible clinic nearby, but an absence of awareness regarding preventive screenings renders the entire clinical apparatus obsolete for that individual.

Synthesis with Levesque’s Patient-Centered Access Framework

The scale authors synthesized Penchansky, Thomas, and Saurman’s structural taxonomy with the conceptual advances of Levesque and colleagues (2013). Levesque posited that access must be understood as a dual-pathway continuum matching system dimensions (approachability, acceptability, availability and accommodation, affordability, appropriateness) with corresponding human abilities (ability to perceive, ability to seek, ability to reach, ability to pay, ability to engage). The development of the Perceived Access to Health Care Questionnaire translated these matching mechanisms into direct psychometric self-report items, prioritizing the patient’s subjective evaluation of this interaction. Consequently, the instrument operates on the cognitive-psychological assumption that an individual’s internal representation of access is the proximate determinant of healthcare-seeking behavior, mediating the relationship between structural health policy and population-level health equity.

Validity

The psychometric validation of the Perceived Access to Health Care Questionnaire was executed through an empirical validation protocol encompassing content validity, face validity, and construct validity testing within a representative adult population.

Content Validity

Initial item generation yielded an exploratory pool of 31 candidate items developed via a comprehensive systematic literature review and qualitative input from healthcare professionals. Content validity was evaluated using both qualitative assessment and quantitative indices evaluated by an expert multidisciplinary panel consisting of specialists in health services management, nursing, community medicine, and psychometric methodology:

• Content Validity Ratio (CVR): Evaluated against Lawshe’s criteria to ensure essentiality. Following panel review, items exhibiting CVR values below 0.78 were reviewed for deletion; one underperforming item failing to achieve consensus significance was eliminated, reducing the pool to 30 items.
• Content Validity Index (CVI): Evaluated for relevance, clarity, and simplicity. Both Item-level Content Validity Index (I-CVI) and Scale-level Content Validity Index (S-CVI) were calculated. Twenty-nine items demonstrated I-CVI values exceeding the strict 0.79 threshold, while one item demonstrating borderline validity underwent linguistic revision to enhance clarity, resulting in an acceptable overall scale content validity profile.

Face Validity

Face validity was confirmed through both qualitative interviews and quantitative item impact scoring. Ten target-population adults evaluated the items for wording ambiguity, contextual relevance, cognitive difficulty, and semantic comprehension. Quantitatively, an item impact score was derived using a 5-point importance scale (Impact Score = Frequency [%] × Importance). All 30 retained items achieved an impact score greater than 1.5, confirming that the questionnaire was readily comprehensible, culturally pertinent, and meaningful to community respondents.

Construct Validity: Confirmatory Factor Analysis

Construct validity was formally established via Confirmatory Factor Analysis (CFA) utilizing structural equation modeling in a cross-sectional sample of 300 Iranian adults (aged 20 to 60 years) recruited through multi-stage random sampling across health centers in southern Tehran. Given that the theoretical taxonomy of access was firmly established a priori via the six-dimension model of Penchansky, Thomas, and Saurman, an explicit six-factor CFA was specified rather than an exploratory model.

The empirical measurement model demonstrated excellent fit to the hypothesized six-dimensional latent structure. Standardized factor loadings across the 30 items mapped robustly onto their respective latent factors (Availability, Accessibility, Affordability, Accommodation, Acceptability, and Awareness). The empirical covariance matrix aligned closely with the theoretical model, demonstrating that each subscale uniquely contributed to the broader construct of perceived access without demonstrating pathological multicollinearity.

Reliability

The Perceived Access to Health Care Questionnaire exhibits solid internal consistency and temporal reproducibility across clinical and community populations.

Internal Consistency

Internal consistency was assessed using Cronbach’s alpha across the total scale and within each isolated subscale in the primary validation cohort (N = 300):

• Total Scale: The overall 30-item instrument yielded an aggregate Cronbach’s alpha of 0.86, denoting high global internal consistency well above the conventional 0.70 benchmark for research instrumentation.
• Acceptability Subscale: Demonstrated strong internal consistency with a Cronbach’s alpha of 0.80.
• Accessibility Subscale: Demonstrated good internal reliability with a Cronbach’s alpha of 0.76.
• Awareness Subscale: Exhibited an identical, robust alpha coefficient of 0.76.
• Affordability Subscale: Demonstrated acceptable internal reliability with a Cronbach’s alpha of 0.66.
• Availability Subscale: Yielded an acceptable alpha coefficient of 0.61.
• Accommodation Subscale: Exhibited an alpha coefficient of 0.60.

While the internal consistency metrics for Accommodation (0.60), Availability (0.61), and Affordability (0.66) are modest, psychometric literature indicates that for multidimensional constructs containing a relatively small number of items per latent factor (typically 4 to 6 items), alpha values within the 0.60 to 0.70 range remain methodologically acceptable and reflect breadth of construct domain rather than measurement noise.

Temporal Stability (Test-Retest Reliability)

To examine the stability of the measurement tool over time, a test-retest protocol was conducted with a subsample of participants re-assessed after a two-week interval under standardized conditions. Reliability was quantified using the Intraclass Correlation Coefficient (ICC) applying a two-way mixed-effects model with absolute agreement. The analysis yielded an exceptional overall ICC of 0.94 (95% CI: 0.91–0.96). This high level of temporal stability indicates that the questionnaire is highly robust against random temporal fluctuations, ensuring that observed longitudinal score alterations in intervention trials reflect authentic shifts in consumer perceptions rather than administrative or situational error.

Factor Analysis

The underlying latent architecture of the Perceived Access to Health Care Questionnaire was empirically evaluated through Confirmatory Factor Analysis (CFA) executed in R using the lavaan (Latent Variable Analysis) structural equation modeling package. A confirmatory approach was selected deliberately over exploratory factor analysis (EFA) due to the presence of a mature, well-operationalized theoretical foundation derived from Penchansky and Thomas (1981) and Saurman (2016).

Model Specification and Estimation

The measurement model specified six correlated latent variables corresponding to the theoretical domains: Availability ($\eta_1$), Accessibility ($\eta_2$), Affordability ($\eta_3$), Accommodation ($\eta_4$), Acceptability ($\eta_5$), and Awareness ($\eta_6$). Each of the 30 manifest items was constrained to load exclusively onto its corresponding a priori latent factor, with cross-loadings fixed to zero. Covariances between unique errors (residuals) were set to zero, and the latent factor variances were fixed to 1.0 to establish scale metric identification. Parameters were estimated using robust maximum likelihood estimation methods capable of handling potential multivariate non-normality in ordinal survey data.

Goodness-of-Fit Criteria and Findings

The fit of the empirical data to the proposed structural model was evaluated against established psychometric criteria: Tucker-Lewis Index (TLI) $\ge 0.95$, Comparative Fit Index (CFI) $\ge 0.95$, Goodness-of-Fit Index (GFI) $\ge 0.95$, and Root Mean Square Error of Approximation (RMSEA) $\le 0.05$ (with an upper 90% confidence interval bound below 0.08).

The confirmatory factor model converged successfully, yielding fit parameters that conformed to a priori structural thresholds. The items demonstrated statistically significant standardized factor loadings ($p < .001$) on their respective latent dimensions, confirming that the empirical data fit the hypothesized six-dimensional model of perceived healthcare access. The empirical confirmation of the Awareness factor was particularly critical, as it validated Saurman’s conceptual postulation that cognitive navigation and health literacy function as an autonomous empirical dimension distinct from physical availability or financial affordability.

Instrument / Measurement Tool

The technical, structural, and administrative parameters of the Perceived Access to Health Care Questionnaire are outlined below:

• Test Type: Psychometric self-report questionnaire / standardized patient-reported experience measure (PREM).
• Theoretical Basis: Penchansky and Thomas’s 5-dimension model of access (1981) integrated with Saurman’s 6-dimension cognitive framework (2016).
• Item Count: 30 items.
• Subscale Breakdown:
  • Availability: Perceptions of physical infrastructure, clinical equipment, medical supplies, and personnel adequacy.
  • Accessibility: Perceived travel burden, geographic proximity, and transportation convenience.
  • Affordability: Subjective economic strain, out-of-pocket costs, and health insurance adequacy.
  • Accommodation: Organizational scheduling, appointment mechanics, clinical waiting periods, and operational flexibility.
  • Acceptability: Patient-provider interpersonal dynamics, cultural safety, trust, and perceived respect.
  • Awareness: Health literacy, knowledge of existing clinical services, and navigation capacity.
• Target Population: Adult community members and clinical patients aged 20 to 60 years.
• Original Language: Persian (Farsi).
• Administration Mode: Interview-administered (recommended for community samples with varying literacy levels) or self-administered paper-and-pencil / digital format.
• Completion Time: Approximately 10 to 15 minutes.
• Authentic Response Scale: 30 items, 5-point Likert scale (strongly agree to strongly disagree).
• Scoring Protocols: Items are scored along a standardized numerical spectrum from 1 to 5. After reversing negatively worded items, subscale scores are computed by summing or averaging item values within each domain. Higher scores reflect greater perceived access and lower subjective barriers to care. An aggregate global perceived access score can be derived by summing all 30 items (yielding a potential raw score range of 30 to 150).

Permissions & Fee and Test Year

The Perceived Access to Health Care Questionnaire was published in 2021 following validation research conducted at the Tehran University of Medical Sciences in Tehran, Iran. The scale was formally reported in the peer-reviewed literature in BMC Health Services Research (Hoseini-Esfidarjani et al., 2021).

The validation study was published as an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0). However, the complete individual survey items were not reproduced in the body or supplementary appendices of the original open-access publication. The questionnaire itself remains the intellectual property of the primary investigators (Sara-Sadat Hoseini-Esfidarjani, Reza Negarandeh, Farzaneh Delavar, and Leila Janani). Researchers and clinical organizations interested in utilizing the scale, translating the instrument into other languages, or obtaining the validated Persian item inventory must contact the corresponding author, Dr. Reza Negarandeh (School of Nursing and Midwifery, Tehran University of Medical Sciences), directly via email ([email protected]). Non-commercial academic research usage is typically granted upon written request without licensing fees.

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Items of the Scale