# Systemic and dynamic analysis of access to health care: the example of haematological cancer in France

Milhan Chazeª, Laurent Mériadeª*, Corinne Rochetteª, Stephanie Malartre-Sapienzaᵇ, Anne Sophie Michalletᵇ

ªResearch chair "health and territories"
IAE School of Management
Clermont Auvergne University
11, boulevard Charles de Gaulle
63 000 Clermont-Ferrand – France

ᵇCLCC Léon Bérard
Medical Oncology Department
in charge of hematological tumors
28 rue Laennec
69008 Lyon - France

*Corresponding Author
laurent.meriade@uca.fr
0033 473-177-730

## Abstract

**Objective:** Access to health care aims to improve people's health and reduce inequalities. This is a fundamental health policy concern. Over the past 40 years, research has identified several dimensions of access to health care, but has often overlooked their interconnections. Based on a mixed geographical and relational method, our article aims to propose a systemic and dynamic analysis of the main dimensions of access to care.

**Methods:** The population studied in this work consists of all 364 haematological cancer patients. In the first step, we map the movements of these patients in order to categorize them according to their ease of access to care. In the second step, we conduct semi-structured interviews to identify non-spatial dimensions of access to care.

**Results:** Our theoretical results focus on identifying the main links and articulations between dimensions of access to care. They confirm the importance of geographical accessibility in access to care, but, in a more original way, they show the central role of acceptability (confidence in health care professionals), itself determined by awareness.

**Conclusion:** This study suggests that policies to improve access to care should be accompanied by the development of patient awareness and acceptability. In practice, this can be achieved by combining tools such as cooperation between hospitals and health care professionals, professional networks, telemedicine and local hospital accreditation.

**Keywords.** Accessibility; health care; dimensions; geographic map; cancer; France
# 1. Introduction

Access to health care is a health, social, societal, environmental, economic and political concern, designed to improve people's health and reduce health inequalities [1]. Generally speaking, access reflects the match between the characteristics and expectations of service providers and customers [2,3,4]. More specifically, access to health care is defined as the possibility of reaching and obtaining appropriate health care services in situations where there is a perceived need for care [5]. Thus, access to health care services is not just about going to a medical provider [6] but refers to the ability to access the right services at the right time to improve health outcomes for individuals [7].

The literature shows that access to healthcare depends both on the structural dimensions of access to healthcare related to healthcare systems (availability, affordability, adequacy, geographical accessibility, etc.) and on individual socio-economic determinants related to patients (gender, level of education, income level, nationality). The structural dimensions of access to care are factors internal to the health system and managed by its administrators. The socio-economic determinants are factors external to the health system, specific to each patient [8].

Firstly, the structural dimensions of access to care make it possible to represent the main factors determining patients' accessibility to the health services available in their region. Secondly, the individual socio-economic determinants describe the capacity of each patient to access these health services according to their capacity to respond to the structural dimensions of access to care. Consequently, the identification of these structural dimensions of access to care is a priority and has been the subject of a significant body of literature aimed at precisely characterizing these dimensions [5,9,10,11,12,13,14].

To date, these main studies have focused on the rather static study of the dimensions of the health care resources available and their adequacy with the demand for care [15]. However, in order to achieve the political objective of equal, equitable or efficient access to care, it seems important to attach prime importance to the articulation of these dimensions in access to health care [16]. Indeed, access to health care is not just an individual problem, it is also a systemic one encompassing a set of individual and collective dimensions [17]. Yet most interventions to strengthen access to health care ignore the interconnections between the dimensions of the health care access system [18].

Indeed, in traditional approaches of access to health care, political decisions are supposed to influence the level of available medical resources, whereas in reality they also influence the interconnections between the dimensions of access to care and its complexity [19]. Also, there is a lack of research to analyze the dynamics of health care access systems. This is reflected in a failure to take into account the multiple and processual relationships between all the dimensions that make up health care delivery systems [20,21].

This work aims to fill this gap. To do this, our research objective is to analyze, using a systemic and dynamic approach, the different ways in which the main dimensions of patient access to healthcare are connected to each other. To meet this objective, the systems approach reflects the complexity of health care systems and patient access to care [18,19]. This approach can more easily account for the way in which the different resources in a process of access to care are dynamically articulated.

To achieve a systematic approach specific to the issue of access to health care, we are developing a geographical and relational methodology [22]. This combines a geographic map analysis of patients' care pathways with a qualitative study using individual interviews to gather information on how patients perceive their care pathway [23,24]. The combination of these two methods (geographical and narrative) should enable us to apply a dynamic reading of the main dimensions of patients' access to health care. To do this, we propose to mobilize the conceptual
framework for analyzing access to care proposed by Penchansky and Thomas [2] and updated
by Saurman [12] (the 6As model).

The literature offers us numerous conceptual frameworks identifying the dimensions of access to health care [5,9,10,13]. One of the most widely used access frameworks is Andersen et al.'s [9] behavioral model of health service utilization. It views access as a function of predispositions to health service utilization, health care needs, and factors favorable and unfavorable to utilization [9]. Frenk's framework [10] is another commonly cited framework that defines access as the ability of the population to seek and then obtain care [10]. This framework further identifies resource availability, utilization power and resilience as dimensions of access and assesses the performance of health care systems [10]. Levesque et al.'s conceptual framework [5] for access to health care defines access as the ability to identify, seek, attain, obtain or use health care and to ensure the satisfaction of needs for these services [13]. The 6As model is the one that has gone furthest in identifying six dimensions of this access to health care which are the most observed and analyzed in theory and practice alike [16]: Acceptability refers to whether the customer is comfortable with the more immutable characteristics of the provider, and vice versa (age, gender, social class, ethnic origin of provider and patient, diagnosis, type of customer coverage) [2]; Availability estimates the extent to which the provider has the necessary resources, such as personnel and technology, to meet the customer's needs [2] ; Adequacy refers to the way in which the provider organizes itself in order to meet the customer's constraints and preferences (opening hours, management of telephone communications, ability of the customer to receive care without prior appointment) [2]; Affordability is determined by the ratio of the provider's costs to the customer's ability and willingness to pay for the services [2]; Accessibility in the geographical sense is determined by the ease with which the customer can physically reach the service provider's location [2]. Recently, Saurman [12] has proposed a sixth dimension Awareness which refers to effective communication and information strategies mobilizing relevant users (clinicians, patients, community).

We apply this 6As model to a cohort of patients from a French cancer center (CLCC -
in french, *Centre de Lutte Contre le Cancer*), one of whose specialties is the treatment of
hematological cancers.

**2. Materials and methods**

**2.1. Case study**

Blood cancer, also known as hematological cancer, is a complex disease that affects the
blood, bone marrow and lymphatic system. In France, this family of cancers affects almost
35,000 people every year, particularly children, young adults and the elderly. The CLCC under
study is a center of excellence for the diagnosis and management of hematological cancers,
located in France's second-largest metropolis in terms of population. Every year, more than
11,000 hematology consultations are carried out at the CLCC. In 2016, an Ambulatory Medical
Assistance (AMA) [25] program was set up in the hematology department of the CLCC. The
aim of the AMA program is to reduce patient visits to hospital and to develop very close follow-
up by specialized nurses (AMA nurses). This program is a relatively new monitoring practice,
initially for patients treated with conventional (intravenous) chemotherapy, which was
subsequently extended to patients receiving targeted (oral) therapies. This monitoring is similar
to a remote monitoring system [26] and takes the form of scheduled and regular outgoing calls
according to a protocol and carried out by dedicated nurses. This program, developed in 2018
at the CLCC by the hematology department, is in line with the hospital's policy of providing
care outside its walls and offering personalized follow-up to patients to promote their
progressive empowerment and a successful transition to post-treatment care. It is based on the
development and promotion of new nursing expertise. The evaluations carried out have shown
the relevance of this system, which, following its trial period, was maintained and is now being
rolled out on a larger scale. The 364 patients included in this study represent the entire active
patient file of the AMA program over the last three years.

**2.2. Research design**

**2.2.1. Research design and analytical process of the 1st step**

Based on a geographical and relational approach [22,23], the first step aims to spatially map the criteria representative of patients' care pathways and then try to distinguish patients according to these criteria by categorizing them.

For each of the 364 patients included in the study, we first had data on the location of their home, their General Practitioner (GP) and their pharmacy. Thanks to the AMA program, we also had data on the precise accounting of appointments (consultations, examinations, chemotherapy), the number of prescriptions and journeys made by patients.

Then, in order to determine patient types according to their accessibility to medical
services integrated into their care pathways, we used the hierarchical ascending classification
method based on travel times calculated between each patient's home and the location of their
GP, pharmacy, nearest hospital and the CLCC Léon Bérard. The choice of these four medical
services is explained by their integration in patients' care pathways. This method enabled us to
define and map four types of patient according to their accessibility to the medical services
included in their care pathway.

**2.2.2. Research method and analytical process of the 2nd step**

The second step aims to embody the situations observed on the maps, to see how access
to care is experienced by patients. For this second step, from among the 364 patients in our
study, we selected a sample of patients (table 1) representative of each of the patient categories
identified in the first step of this study. The interview guide was based on how patients
experienced their care at the CLCC in relation to the 6As (theme 1), what this meant for them
in terms of personal organization and adaptation of their daily life (theme 2), as well as
appreciated dimensions of care and more critical points still in relation to the 6As (theme 3).
Furthermore, in order to enhance the depth of our analysis, we complemented the spatial
classification of patients with a categorization based on gender and indicative socio-
professional status. This additional classification was inferred from participants' reported
occupations and references made during interviews to their financial situation or family
responsibilities. This multidimensional perspective allowed us to highlight variations in patient
experiences, particularly in how trust in healthcare providers (acceptability) was expressed, and
in the challenges some patients (especially working women) faced in balancing treatment with
professional commitments.
<table><caption>Table 1. sample of interviewed patients</caption><thead><tr><td>Patients</td><td>Start of medical treatment (month and year)</td><td>Age range (years old)</td><td>Geographical location distance from the CCU</td><td>Marital Status</td><td>Socio-professional Status</td><td>Duration of the interview in minutes</td></tr></thead><tbody><tr><td>Patient 1</td><td>April 2016</td><td>61-80 yo</td><td>20-25 min</td><td>widow</td><td>Unknown</td><td>29</td></tr><tr><td>Patient 2</td><td>August 2018</td><td>26-45 yo</td><td>10 min</td><td>married</td><td>Unknown</td><td>20</td></tr><tr><td>Patient 3</td><td>April 2018</td><td>26-45 yo</td><td>10 min</td><td>single</td><td>Unknown</td><td>39</td></tr><tr><td>Patient 4</td><td>July 2018</td><td>26-45 yo</td><td>40 min</td><td>co-habiting</td><td>Unknown</td><td>21</td></tr><tr><td>Patient 5</td><td>December 2017</td><td>26-45 yo</td><td>10 min</td><td>married</td><td>Unknown</td><td>51</td></tr><tr><td>Patient 6</td><td>January 2018</td><td>26-45 yo</td><td>10-15 min</td><td>single</td><td>Unknown</td><td>34</td></tr><tr><td>Patient 7</td><td>March 2018</td><td>61-80 yo</td><td>20-25 min</td><td>married</td><td>Unknown</td><td>25</td></tr><tr><td>Patient 8</td><td>December 2017</td><td>46-60 yo</td><td>30 min (rural area)</td><td>married</td><td>Unknown</td><td>22</td></tr><tr><td>Patient 9</td><td>April 2016</td><td>26-45 yo</td><td>>2h road (150 kms)</td><td>single</td><td>Unknown</td><td>25</td></tr><tr><td>Patient 10</td><td>April 2018</td><td>61-80 yo</td><td>20 min</td><td>married</td><td>Unknown</td><td>16</td></tr><tr><td>Patient 11</td><td>May 2017</td><td>81-100 yo</td><td>20-25 min</td><td>married</td><td>Unknown</td><td>38</td></tr><tr><td>Patient 12</td><td>July 2018</td><td>81-100 yo</td><td>10 min</td><td>married</td><td>Unknown</td><td>18</td></tr><tr><td>Patient 13</td><td>October 2017</td><td>81-100 yo</td><td>10-15 min</td><td>widow</td><td>Unknown</td><td>23</td></tr><tr><td>Patient 14</td><td>March 2018</td><td>46-60 yo</td><td>30-35 min (rural area)</td><td>married</td><td>Active</td><td>41</td></tr><tr><td>Patient 15</td><td>February 2018</td><td>46-60 yo</td><td>1h</td><td>divorced</td><td>Retired</td><td>22</td></tr><tr><td>Patient 16</td><td>September 2018</td><td>46-60 yo</td><td>35-40 min</td><td>married</td><td>Unknown</td><td>27</td></tr><tr><td>Patient 17</td><td>August 2018</td><td>61-80 yo</td><td>25-30 min</td><td>married</td><td>Unknown</td><td>30</td></tr><tr><td>Patient 18</td><td>April 2018</td><td>46-60 yo</td><td>25-30 min</td><td>divorced</td><td>Unknown</td><td>12</td></tr><tr><td>Patient 19</td><td>September 2018</td><td>18-25 yo</td><td>10-15 min</td><td>co-habiting</td><td>Unknown</td><td>34</td></tr><tr><td>Patient 20</td><td>June 2018</td><td>26-45 yo</td><td>1h28 min</td><td>married</td><td>Active</td><td>40</td></tr><tr><td>Patient 21</td><td>June 2018</td><td>46-60 yo</td><td>1h59 min</td><td>co-habiting</td><td>Retired</td><td>35</td></tr><tr><td>Patient 22</td><td>February 2019</td><td>46-60 yo</td><td>2h08</td><td>divorced</td><td>Retired</td><td>23</td></tr><tr><td>Patient 23</td><td>March 2019</td><td>61-80 yo</td><td>22 min</td><td>divorced</td><td>Active</td><td>94</td></tr><tr><td>Patient 24</td><td>January 2019</td><td>18-25 yo</td><td>8 min</td><td>married</td><td>Unknown</td><td>44</td></tr></tbody></table>
Once all the interviews had been transcribed, a detailed thematic and lexical content analysis was carried out on all the verbatim using the predefined grid base on the 6As model [15] (table 2). To support a more nuanced interpretation of patient experiences, Table 1 was extended to include gender and indicative socio-professional characteristics (employment status, retirement, student). This multidimensional classification allowed for cross-analysis and a better understanding of the diversity of patient trajectories and lived experiences.

<table><caption>**Table 2. Coding grid**</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td>Acceptability</td><td>Acceptability of the exchange with healthcare professionals and/or the healthcare facility, acceptability of the diagnosis (trust)</td></tr><tr><td>Awareness</td><td>Access to information and understanding for action (literacy)</td></tr><tr><td>Availability</td><td>Adequate human and technical resources available at the point of delivery of the care service.</td></tr><tr><td>Adequacy</td><td>Convenient opening hours, quick and easy contact (by phone or on site)</td></tr><tr><td>Affordability</td><td>Financial resources for travel, childcare, appointments for parents, paid supportive care to relieve symptoms...</td></tr><tr><td>Geographical accessibility</td><td>Ease of travel / territorial configuration and topography: distance to travel, easy travel infrastructure (public transport access), easy parking, etc.</td></tr></tbody></table>

The combination of geographic map analysis (1st step) and relational analysis (2nd step) should enable us to gain a better understanding of the choices made by patients in terms of access to care, by applying a dynamic reading of their dimensions (6As).

## 3. Results

In the following, we present the results of the two successive study steps.

### 3.1. Map analysis results

As explained in the methodology section, in a first step, to summarize patients' accessibility to health care services, we performed a hierarchical ascending classification based on the distances separating patients' homes from the nearest health care services (figure 1).

The first category corresponds to category 1 patients (figure 1) who are located close to the CLCC (12.4 km on average). These patients are also close to other health care facilities and services (on average 2.4 km from a local hospital, 0.3 km from a GP and 0.4 km from a pharmacy). These are the patients for whom access to health care services is easiest.

A second category of patients (category 2) have good access to local health services (on average 0.8 km from a GP and 0.9 km from a pharmacy), as well as to local and regional hospitals (on average 4.5 km away), but are very far from the CLCC (on average 104 km). For these patients, the only accessibility issue is their distance from the CLCC, so the support of local hospitals in the care process can be particularly useful.

The third category of patients (category 3) lives the furthest away from local hospitals (12.5 km on average), but has good access to the CLCC (47.8 km on average), and good access to local health care services (0.7 km on average to a GP, and 0.9 km on average to a pharmacy), similar to category 2. In this case, it is difficult to rely on local hospitals as intermediaries, and the CLCC's capacity to receive patients is key.

Finally, the last category (category 4) includes patients whose access to all health care structures and services is the most difficult. Access to the CLCC is remote (79 km on average). Access to local hospitals is good (8.9 km on average), while access to local health care is relatively poor (3.6 km on average to a GP, and 4 km on average to a pharmacy) (figure 1).
In a second step, we construct a sample of patients representative of each of these
categories (24 patients) and interview them (see Appendix 1 for extracts of coded verbatims -
v1, v2, etc.- for each patient - P1, P2, ..,P24, etc.).

<figure><img src="image_1.png" /><figcaption>**Figure 1 - Classification of patients according to accessibility to care services**</figcaption></figure>
## 3.2. Identify the dimensions of access to care and their links in patient discourse.

In a second step, the interviews we conducted enabled us to analyze patients' perceptions of the six dimensions of access to care in the 6As model (appendix 1) and their systemic articulations.

- **Acceptability**

Acceptability refers to confidence in patients' exchanges with health care professionals and their diagnoses. The patients we interviewed emphasize the strong confidence they have developed in their haematologist and their nurse. Nurses are part of patients' lives, and every week patients look forward to their calls as a beneficial appointment (P1-v5; P5-v2). Similarly, the regular exchanges between nurses and patients create a special kind of knowledge: the nurses' ability to understand patients' reactions, both psychological and physiological (E10-v1).

Perhaps surprisingly, GPs are rarely involved in care pathways of the patients surveyed. This loose link does not help to build a relationship of trust with the GP. However, this relative lack of trust in the GP mainly concerns patients who are closest to the CLCC (P2-v1; P19-v3; P19-v4). Those who live further away don't mention it, and have to trust their GP, who remains the most accessible medical professional. So, for all patients, the adequacy of resources is conditioned by acceptability.

In any case, in the discourse of those interviewed, acceptability is above all personal and social (P7-v4; P14-v3). Thus, acceptability is often linked to the hope that the patient places in the health care system to provide a solution to his condition (P14-v4; P16-v2). Additional nuances emerged regarding gender and socio-economic background. Some female patients found it difficult to discuss intimate issues with physicians and preferred the empathetic, confidential relationship developed with specialist nurses (P5-v2). Socio-economically, a few patients with greater financial means (e.g., P23) reported using complementary therapies such as osteopathy or acupuncture, suggesting disparities in access to non-reimbursed supportive care. If, in his imagination, his treatment is in vain, he will not seek access to care. This is particularly true for patients who are farthest from the CLCC and from specialty care (category 3). So, to understand acceptability, we need to look at its links with the availability and adequacy of resources, as well as awareness.

- **Awareness (Access to information and understanding)**

Access to information (awareness) is particularly important, and involves several aspects: knowledge of care structures, acquisition of knowledge about the disease and treatments. The results of our interviews show that, whatever the patient category, patients do not have much information on the management of this type of illness. Indeed, the GP seems to play a relatively minor role in providing information and guidance to patients (P7-v1; P14-v1; P4-v1). Paradoxically, however, patients are very receptive to advice and need to have a clear idea (P17-v1). Irrespective of the category to which they belong, the patients interviewed recognize that the introduction of the AMA system makes a significant contribution to patient literacy (P1-v1; P7-v2; P19-v1; P22-v1). Patients particularly appreciate exchanges with the nurse specialist (AMA) because she uses a language they understand, which is not always the case with exchanges with the haematologist (P5-v1; P13-v1). This makes awareness very closely linked to acceptability, as it determines to a very large extent the trust that patients can place in health care professionals and their diagnoses.
- Availability

Availability refers to two dimensions: attention paid to the patient (cognitive availability) and the right size of the resource to avoid waiting. The AMA system relies on a high level of availability of resources, particularly nurses. Whatever the category of patients concerned, this availability generates a certainty in them that they will be effectively monitored, which brings them psychological comfort (P1-v2; P8-v1; P4-v2; P13-v1; P18-v1). The cognitive availability and resources offered by this system more than compensate for the lack of awareness deplored by all categories of patients. This proves, for all patient categories, the strong link between the "availability" and "awareness" dimensions of the 6A models.

This remote availability of AMA nurses limits the need for other forms of health care that are more difficult to set up, such as recourse to emergency services, particularly for patients with remote access to care (categories 3 and 4) (P14-v2; P21-v1; P9-v1; P20-v1). However, this system also has its limitations in terms of access to resources. The main one is that it does not operate at weekends or in the evenings. At these times, while some patients are able to manage the effects of their treatment, others have had to contact the CLCC switchboard, or even the local emergency services. In such cases, some patients cite a human resource less suited to their needs (P1-v3; P19-v2).

- Adequacy

Adequacy concerns the ability of care providers to respond to the constraints and preferences of users (opening hours, management of phone communications, customer's ability to receive care without prior appointment). Surprisingly, the adequacy of the CLCC's resources is generally perceived as better than adequacy of a nearby GP. Indeed, the CLCC system is seen as an opportunity for patients treated at the CLCC. Patients appreciate having a single point of entry to deal with their questions, rather than multiple contacts. This single point of entry is an important element of accessibility, especially for patients who are not far from the CLCC (P1-v4; P3-v1; P4-v3) (categories 1 and 2). For these patients, it appears that perceptions of the adequacy of the care on offer are highly dependent on perceptions of the availability of resources.

On the other hand, for patients further away from the CLCC (categories 3 and 4), optimal disease management can also go hand in hand with the provision of supportive care such as adapted sports, nutrition, sophrology, etc., but these services are only available at the CLCC (P7-v1; P15-v1; P16-v1). For these patients, it appears that their perceptions of the adequacy of the care on offer, over and above a sufficient volume of services, is strongly correlated with the question of geographical accessibility.

- Affordability

This aspect of accessibility was rarely mentioned directly. Just one patient (P23) out of 24 mentioned the use of an osteopath, fasciatherapist and acupuncturist because she could afford them (P23-v1; P23-v2). But overall, affordability seems to have little to do with the other dimensions of the 6As model. In particular, it has not been demonstrated here that affordability is intertwined with geographic accessibility.

- Geographical accessibility

Finally, in virtually every interview, geographical accessibility was spontaneously mentioned. Distance is a real difficulty, requiring patients to have the organizational and financial resources to get to the CLCC. The difficulties of geographical accessibility are compounded by the fact that patients may live far from their place of work. Travel is a source of fatigue, in addition to that caused by illness and treatment (P1-v6; P9-v2; P7-v5). Unsurprisingly, these difficulties of geographical accessibility are mainly mentioned by the
most distant patients, located more than 20 minutes from the CLCC (categories 2, 3 and 4). In case of emergency, these patients prefer to be hospitalized in a local hospital, and only on a scheduled basis at the CLCC (P15-v2; P16-v3; P22-v2).

For patients whose access to care is generally good (categories 1 and 2), the fact that they have different contacts (replacements for their GP) reinforces the difficulty of trust, which also ties in with the question of acceptability (P13-v2; P17-v2; P5-v3). In contrast, for patients who are the most distant from care (categories 3 and 4) make greater use of the GP (P9-v4; P15-v3; P20-v3; E22-v3). These patients are also more willing to undergo part of their treatment in local hospitals, whose spatial access is better than that of the CLCC (P14-v5; P14-v6). This demonstrates the strong link between the geographical accessibility of care and its acceptability to patients.

In some cases, difficulties of geographical access have been compensated for by what amounts to "telediagnosis" (P9-v3; P20-v2). The availability of telemedicine is particularly sought after by patients with difficult access to care (category 4), as it helps to compensate for geographical remoteness. This finding also demonstrates the connections between the dimension of resource availability and that of geographical accessibility.

# 4. Discussion

## 4.1. Theoretical implications: Enriching the reading of the 6As model

Access to health care is multi-faceted [26] and requires a systemic understanding of its dimensions. The results of our geographical and relational study of access to care make a significant contribution to the literature, by explicitly highlighting the links between the six dimensions of the 6As model, while specifying how these links are constructed for each category of patient (table 3).

First and foremost, as these results underline, acceptability appears a central dimension in this accessibility. Acceptability is dependent on the information available to patients (awareness). In the case of hematological cancer, acceptability also means putting one's health in the hands of trusted professionals. The presence of a nurse simultaneously increases the availability and adequacy of resources, confirming the need for systemic thinking on access-to-care [18,19] (table 3).

Secondly, the results of this study show that awareness is an essential dimension of acceptability. Official texts mention the obligation to inform patients as precisely as possible [28]. The nurses make a major contribution to reducing any information asymmetries. They contribute to educating patients about their illness and treatments (health literacy) [29], well beyond the simple awareness-raising recommended by Saurman [12]. The CLCC's AMA system facilitates patient navigation [25].

Thirdly, the centrality of acceptability in the construction of access to care is reinforced by its strong links with the availability of resources (table 3) - patients appreciate being able to have contact with nurses when they feel the need. This result highlights the acquisition of experience in interacting with the health care system [18]. It shows that availability cannot be disconnected from the trust they place in health care professionals and their diagnoses [30] nor from adequacy to demand.

In fact, and fourthly, in our study, adequacy is emphasized from two angles: from the point of view of the competence of the interlocutors, i.e. AMA nurses, specialist doctors, GPs and even pharmacists (1), but also from the point of view of capacity in terms of the quantity of resources present or absent (2). However, this recourse to resources such as the skills of health care professionals is strongly linked to acceptability. Two aspects that had not yet been mentioned in work involving the 6As.
Finally, in the context of our study, affordability was rarely mentioned spontaneously, probably due in part to the fact that French social insurance organizations cover 100% of health care expenses throughout the course of the disease for the patients included in our study. In contrast, for the patients interviewed in our study, geographical accessibility also appears to be a central variable. Geographical distance is a real difficulty for patients. As demonstrated by major previous studies [14,24,31,32], our study identifies geographical access as an essential variable for improving access to care. Nevertheless, we also demonstrate that, in the construction of access to care for the patients in our study, this geographical accessibility is strongly linked to acceptability (itself linked to awareness), but also to the availability of resources and their adequacy (table 3).

The combination of these last five major dimensions of access to health care for the patients in our study begins to outline the first contours of the systemic functioning of patients' access to care (table 3). This systemic access-to-care network is based on a first part of articulations between awareness, acceptability and adequacy, which concern all patients (table 3). This first part of the network shows the importance of awareness, which relies above all on trust in health care professionals and their diagnoses (acceptability), but also helps to reinforce it. This patient confidence (acceptability) authorizes all patients to use the medical resources available and benefit from their adequacy, which is largely reinforced in our study by the AMA system (table 3).

This first part of the access-to-care network seems to play a decisive role in improving patients' access to care. Synchronously and almost simultaneously, this first part of the access-to-care network links up with geographical accessibility and the availability of resources, enabling all patients, according to their greater or lesser ease of spatial access to care (categories 1 to 4), either to access the medical resources that are most accessible to them (table 3).

<table><caption>Table 3. Systemic analysis of links between dimensions of access to care</caption><thead><tr><th>Systemic links</th><th>Awareness</th><th>Acceptability</th><th>Adequacy</th><th>Geographical accessibility</th><th>Availability</th><th>Affordability</th></tr></thead><tbody><tr><th>Awareness</th><td></td><td>All types of patients</td><td></td><td></td><td></td><td></td></tr><tr><th>Acceptability</th><td>All types of patients</td><td></td><td>All types of patients</td><td>Close patients (categories 1 and 2)</td><td>Patients far from specialized medicine (category 3)</td><td></td></tr><tr><th>Adequacy</th><td>All types of patients</td><td></td><td></td><td>All types of patients</td><td>Close patients (categories 1 and 2)</td><td></td></tr><tr><th>Geographical Accessibility</th><td>Close patients (categories 1 and 2)</td><td>All types of patients</td><td>Close patients (categories 1 and 2)</td><td>Very distant patients (category 4)</td><td></td><td></td></tr><tr><th>Availability</th><td>Patients far from specialized medicine (category 3)</td><td></td><td>Close patients (categories 1 and 2)</td><td>Very distant patients (category 4)</td><td></td><td></td></tr><tr><th>Affordability</th><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

systemic access-to-care network

## 4.2. Managerial implications: rethinking access to complex care

From a managerial point of view, our study shows that better access to care requires reinvestment in several dimensions (acceptability and awareness in particular) in order to attenuate certain spatial inequalities [33]. Improving geographical access to care [2,5,10,12]
seems to be strongly linked to the other dimensions of access to care (acceptability, awareness, availability, adequacy). Implementing policies to improve access to health care therefore requires systemic management, which, as demonstrated by the network of links highlighted by our study (table 3), could be based on developing confidence (acceptability) and information (awareness).

In practice, to support the implementation of policies to improve access to care, this systemic access-to-care network could be developed, for example, through cooperation between centers of expertise and local hospitals. This could take the form of opening local haematology units to manage certain situations, provide certain treatments and offer support care as close as possible to the patient. This could also lead, for example, to the labeling of local hospitals developing this expertise. The creation of local haematology networks involving GPs, pharmacists and local hospitals, to support the work of centers of expertise, is one way of improving access to care for patients, based on organizational configurations that have yet to be devised (mobile units or digital access, for example) [34].

**5. Conclusion**

The aim of this article was to analyze the different ways in which the main dimensions of patient access to healthcare are connected to each other, based on the study of a complete cohort of patients managed for haematological cancer. Our results present several important contributions.

On a theoretical level, by describing in detail the links between the determinants of the 6As, this study highlights, for the first time, the importance of these links in the construction of patients' access to care. In addition, still on a theoretical level, but without claiming to generalize this result for the moment, our results show, in an original way, the central place occupied by acceptability in the construction of access to care and indirectly that of awareness. This is an original contribution of our study, which shows that alongside geographical accessibility to care and the availability and adequacy of resources, confidence in health care professionals (acceptability) is a determining factor in the construction of links between the different determinants of access to care. This contribution therefore enables us to begin to sketch the first outlines of a network of 6As articulations in which these last two determinants occupy an essential place.

Methodologically, our work demonstrates the relevance of combining spatial and non-spatial approaches to analyze the determinants of access to care. Combining a geographic map approach with a qualitative one enables us to identify the systemic relationships and articulations between the determinants of access to care, and, in practical terms, to encourage innovative approaches to care, while thinking about cooperation between health care professionals in the area where the patient lives. Finally, in terms of organizational and managerial recommendations, this work highlights the need for collaboration between the CLCC and local hospitals, in order to improve the match between supply and demand, as well as the acceptability of local resources.

However, despite their novelty, these contributions have several limitations. The first is the non-exhaustiveness of our unique and specific case study. The large amount of data collected in this study was made possible by the AMA system implemented in this case. Other situations of access to care do not have such a system. So, in the future, to improve the exhaustiveness of our results, the application of our 6As systemic analysis, based on a geographic and relational methodology, should be replicated on other cases to collect equivalent data. The second significant limitation of our work stems from our approach to access to care, which remains very hospital-centric. Another limitation concerns the uniqueness of the study setting and its hospital-focused perspective on access to care. Data were drawn from a specialized cancer center with an innovative follow-up system (AMA), making the context both
relevant and atypical. Future research could build on this framework to explore access to care
in relation to other chronic conditions, in rural or overseas territories. Nevertheless, the
geographic map analysis carried out here identifies several categories of access to patient care
and opens up prospects for applying our methodological approach to other regions and health
care interventions (town medicine, isolated or disadvantaged areas, medico-social care, etc.).

**Supplementary Material**

Appendix 1. Presentation of all verbatim quotations cited in the manuscript

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