Access of older people to primary healthcare services in low- and middle-income countries: a systematic scoping review protocol [version 1; peer review: awaiting peer review]

Background: People across the world are living longer. This advantageous trend is escorted by an increased prevalence of chronic diseases, making healthcare needs more complex. Noncommunicable diseases induce a sharply rising economic and societal cost, particularly in lowand middle-income countries (LMIC), where most older people reside. In this context, the access of older people to primary health care (PHC) is vital because it brings solutions to the aforementioned issues. Furthermore, evidence strongly suggests that this approach to health ensures universal health coverage and enables health systems to adapt to rapid economic, technologic, and demographic changes. PHC improves health outcomes, health system efficiency, and health equity. Given their distinctive needs, older people face financial, geographical, social, cultural, structural, and organisational barriers, affecting their equitable access to PHC services. Therefore, many interventions have been implemented to maximise their access to PHC. This paper outlines the protocol for a scoping review that addresses the central question: What is the scope and nature of available evidence on older peoples’ access to PHC in LMICs? This includes the experience of older people having access to PHC, enabling and hindering access, outcomes of the lack of access, interventions implemented to improve access, and related theoretical frameworks. Methods: This scoping review will follow the theoretical framework proposed by Arksey and O’Malley. The five databases that will be searched are CINAHL, PubMed, LILACS, Embase, and Cochrane Libraries. Studies will be selected according to a set of inclusion/exclusion criteria. Data will then be mapped, extracted, and presented graphically along with a narrative report. Conclusions: The scoping review is a first step to synthesise and disseminate the literature on older people’s access to PHC. This will provide information for researchers to reorient their studies, and intel for decision-makers, enabling them to enact policies that meet older Open Peer Review Reviewer Status AWAITING PEER REVIEW Any reports and responses or comments on the article can be found at the end of the article. HRB Open Research Page 1 of 9 HRB Open Research 2021, 4:57 Last updated: 21 MAY 2021


Ageing population
The ageing population trend is challenging the whole world. The United Nations [UN] stated that one in 11 people was aged over 65 years in 2019, whereas it is expected to reach one person in six aged above 65 by 2025 (UN, 2019). Globally, the number of people aged 80 years and above in 2050 will be triple the number in 2017 (UN, 2017). Similarly, the World Health Organization (WHO) has anticipated that the number of people aged above 60 years will reach 20% of the total population in 2025, versus 11% in 2007, with 75% of them living in developing countries (WHO, 2011). The increase in numbers is estimated to be more than 250% in developing countries compared with 71 % in developed countries (WHO, 2011).

Ageing population challenge
The UN has projected that in 2050, eight out of 10 of the world's aged people will be residing in developing regions (UN, 2017). The challenge related to the growing older generation would be exacerbated by a significant shortage of resources and services. This will substantially impact not merely the health sector but social and economic ones as well.
Demographic, epidemiologic, and social transitions Increased life expectancy and decreased fertility rates are important demographic drivers. As individuals age, they develop a high need for health care services. The demographic population changes are accompanied by epidemiologic transitions marked by the increased prevalence of chronic non-communicable diseases (WHO, 2008). An analysis carried out by the WHO in 23 developing countries showed that chronic non-communicable diseases induce a sharp rise in economic and societal costs. Alleviating the disability related to those diseases is the key to limiting losses and reducing the impact on economic growth. This requires interventions at the individual, community and societal level to mitigate the social determinants of health (Andermann, 2016).
Moreover, population ageing takes place against the backdrop of many social developments with substantial implications for older people's lives. These include rapid technological development, unabated urbanisation, changing family structures due to migration, and global economic challenges. With less support from families, access to health care services, including primary care, is especially relevant to ensure the older adults' well-being and autonomy.
Universal health coverage Universal health coverage [UHC] is defined by WHO as "ensuring that all people and communities receive the quality services they need and are protected from health threats without financial hardship" (WHO, 2021, p. 1).
Despite broad international agreement on the Sustainable Development Goals (the 2030 Agenda for Sustainable Development & the Madrid International Plan of Action on Ageing MIPAA), older people still face significant challenges in achieving equitable access to primary health care [PHC] services (Lubenow et al., 2016). Especially, the inclusion of older people from low educational and socio-economic backgrounds is of vital importance. Primary health care model Primary health care is an approach to health that provides comprehensive lifetime care for the person, including health promotion, diseases prevention, treatment, rehabilitation and palliative care (WHO, 2019b). Nations are investing in PHC because it ensures universal health coverage and enables adaptation to rapid economic, technological, and demographic changes. The WHO conducted a scoping review within a technical series on PHC (WHO, 2018a). It brings strong evidence suggesting that PHC can improve health, health equity, and health system efficiency, leading to significant economic benefits. Mortality rate, hospital admissions, health expenditure, and return on investment in preventive care are considered outcomes delineating the economic value associated with PHC (WHO, 2018a).
This review suggests that more evidence is required to explore what specific aspects/facets of PHC contribute to maximising its economic worth. Moreover, identifying the barriers and enablers to implementing and optimising the economic value is highly needed. As the delivery of PHC is heterogeneous among countries, an international comparison would be useful to provide policymakers with a roadmap to prioritise the PHC systems and reorient investments (WHO, 2018a).

Access of older adults to healthcare
Having distinctive needs, older people face financial, geographical, ethnic, gender, social, cultural, and organisational barriers which make their access to adapted healthcare services difficult (Khanassov et al., 2016). In developing countries, added matters related to the infrastructure like public roads, common transportation, telehealth means, and physical structure of health settings are also of great importance (Lubenow et al., 2016).
The preliminary search conducted by the corresponding author (SD) on six databases (Cochrane libraries, CINAHL, Medline, Pubmed, Google Scholar, and Embase), revealed few studies had examined the factors that determine older people's access to health care in low and middle-income countries. These examined factors include characteristics of the PHC services, the perception, experience, and satisfaction of older persons regarding quality and efficacy (Lubenow et al., 2016).
A scoping review, looking at the organisational interventions that aim at improving the access of vulnerable populations to primary care services, highlighted approachability, availability, and affordability as most commonly evaluated access dimensions for aged, low-income and uninsured people suffering from chronic diseases (Khanassov et al., 2016). This review revealed that studies done in this area are of a limited breadth. Systematic reviews were rare. More evidence is needed to evaluate other access dimensions like acceptability and appropriateness, different outcomes like health status, and other types of interventions like multidisciplinary clinical teams, revision of professional roles, and institution incentives (Khanassov et al., 2016).
An integrative review summarising the evidence available on older adults' access to PHC in Brazil revealed that interventions are still falling short of older people's expectations and real needs. This review revealed the scarce number of studies examining the access issue and suggests conducting more on the same topic, primarily to evaluate interventions, thus supporting decision-makers in generating policies that meet older adults' needs (Flores da Silva et al., 2018).
In line with the ageing population trend, the WHO declared in 2019 a decade (2020-2030) of "Healthy Ageing". It invited governments, professionals, academics, members of the public, non-governmental and private sector organisations, and international agencies to collaborate to meet the emerging needs of the elderly and promote their wellbeing within their families and communities (WHO, 2019a). Moreover, through Alliance, WHO set a new research agenda to promote PHC in LMICs (WHO, 2018b) to ensure quality health services to all, including vulnerable groups.
To conclude, older adults are frequent users of health services. A three-way partnership between citizens, politicians, and experts, including researchers, is crucial to strengthening PHC systems (Ghaffar et al., 2019) and generating strategies inclusive of older people's needs.
The rationale for conducting the scoping review The proposed review is aligned with the WHO efforts to strengthen the PHC systems in LMICs and to ensure equitable access for older people aiming at healthy ageing. Moreover, older people's access to PHC in LMICs has not yet been comprehensively examined and synthesised. Available evidence comes from studies conducted in high-income countries like Canada, Australia, UK, and New Zealand, among others. Other studies from LMICs were conducted mainly in Brazil and their findings need to be updated. Understanding the peculiarities of healthcare systems available in LMICs and exploring whether healthcare services are meeting the older people's needs are highly needed.

Design
This scoping review will follow the five stages of the theoretical framework proposed by Arksey and O'Malley, along with the optional consultation exercise (Arksey & O'Malley, 2005): (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarising, and reporting the results; and (6) consultation with relevant stakeholders. The advancements to this framework, proposed by Levac et al. (Levac et al., 2010), will also be considered.
The protocol follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018) to ensure rigour in reporting.

Stage 1: Identifying the research question
This first aim of this review is to map and summarise the nature, features, and breadth of the available evidence related to older people's access to primary health care in LMICs, and to identify gaps in the existing literature.
The review will address other secondary questions: -How is 'access' conceptually defined, described or measured?
-What are the experiences with PHC access?
-What services are provided in PHC?
-What hinders and enables PHC access?
-Are there interventions to optimize PHC access?
In scoping reviews, questions are broad to map the existing data and examine its volume and nature (Levac et al., 2010). However, participants, concept, and context will be defined as per the PCC mnemonic, suggested by the Joanna briggs institute (JBI, 2020), to clarify the focus of this review and establish an effective search strategy (Levac et al., 2010).
Participants. This review will consider studies that include older adults aged 60 years and above, as per the UN definition of older people (UN, 2019), living in LMICs irrespective of health condition.
Concept. The phenomena of interest for this review is access to PHC. The concept of access is complex and has been defined differently in the existing literature (Levesque et al., 2013). Levesque et al. (2013) summarized the published literature on the conceptualization of access in the context of healthcare and suggested a revised conceptual framework delineating the broad dimensions of access and the determinants that affect the whole process of attaining services. Besides conceptualizing the five dimensions of access and the corresponding abilities of populations to interact with them, this revised framework, highlights the multifaceted perspectives to access. Factors related to the individual or to the population are deliberated along with factors related to health systems, institutions, and providers (Levesque et al., 2013). Levesque et al. (2013) explained the patient-centered access to healthcare conceptual framework as follows: the process of access starts with perceiving the health care needs, and progresses through seeking, reaching and utilizing the care, which leads to healthcare consequences.
This process is influenced by the five dimensions of access to health care that are approachability, acceptability, availability and accommodation, affordability, and appropriateness. Factors related to the individual or the population, that affect also the process are the ability to perceive, the ability to seek, the ability to reach, the ability to pay, and the ability to engage.
People wanting to get services can be challenged due to various financial, organisational, social, and cultural barriers (Gulliford et al., 2002).
This review will look at the conceptualisation of access in previous studies.
Context. This review will consider PHC services delivered in different LMICs, either virtually (telehealth), at clients' homes, or within PHC centres.
The World Bank classifies the countries as low-or middleincome ones based on the gross national income (GNI) per capita calculation. Every year, in July, the World Bank revises the classification of the world's economies based on estimates of the GNI for the previous year.
Economies are classified in general into four categories, listed below, as per the current 2021 fiscal year definition (WorldBank, 2021): -Low-income economies: with a GNI per capita of $1,035 or less in 2019.
-Lower middle-income economies: with a GNI per capita between $1,036 and $4,045.
-Upper middle-income economies: with a GNI per capita between $4,046 and $12,535.
-High-income economies: with a GNI per capita of $12, 365 or more.
In 2021, 135 countries are classified as LIMCs and 83 as high-income.
Stage 2: Identifying relevant studies Five databases will be searched: CINAHL, PubMed, Cochrane library, and Embase, which are resources for health-related studies and LILACS to access evidence from published studies based in LMICs. An inital search for scoping and systematic reviews revealed that relevant studies are available.
A three-step search strategy will be implemented (Peters et al., 2015): 1. Scanning the results of an initial search on PubMed and analysing keywords, index and MeSH terms found in titles and abstracts.
2. Informed by the first step, and by information specialists, formulating a comprehensive search strategy to be used on PubMed (Table 1). This strategy will be modified as necessary across the five databases.
3. Searching in the reference list of included studies for additional sources.
As for grey literature, governmental reports and publications issued by UN, WHO, and HelpAge will be included.

Stage 3: Study selection
EndNote X9 will be used to manage all identified citations. After eliminating duplicates, two reviewers (SD and TK) will independently assess the titles and abstract of retrieved studies against the inclusion/exclusion criteria detailed in Table 2.
Before screening all search results, a calibration exercise will be implemented; reviewers will screen 10 studies chosen randomly. They will then meet to ensure reliability in correctly screening according to inclusion and exclusion criteria. The need to update the set inclusion and exclusion criteria can be discussed in case of low agreement.
Disagreements will be resolved through discussion between the two reviewers. If consensus is not reached, the opinion of a third reviewer (KF) would be sought.
Excluded articles will be recorded along with the justification for exclusion in the review report. A PRISMA flow chart diagram will be used to detail the selection process.
Stage 4: Charting the data The two reviewers will independently extract data using the Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia) and a standardised form. Reviewers will pilot the form on a random sample of retrieved studies. In case of disagreement, the extraction form will be revised and retested accordingly.
Extracted data will be filled in an Excel sheet (version 16.48) according to the below themes ( Figure 1): Stage 5: Collating, summarizing, and reporting the results The extracted data will be represented in a tabular and descriptive format that aligns with the objectives of the review.
PRISMA-ScR guidelines (Tricco et al., 2018) will be followed. Results will be discussed, and limitations of the sources will be stated. Therefore, a narrative summary will accompany the data presented graphically and will relate the results to

Inclusion criteria Rationale
Primary studies adopting any study design and all types of published reviews.
Mapping available published evidence and examining its nature, characteristics and volume.
Governmental reports and publications issued by UN, WHO, and HelpAge (reports, policies, guidelines, manuals).
Mapping relevant grey literature issued by organizations that study issues related to older adults.
Dating 2000 and above.
In 2002 two important events took place and lead to the emergence of relevant research on ageing: a) second UN assembly on ageing that resulted in the Madrid International Plan of Action on Ageing and b) Launching of the WHO policy framework on active ageing.
Articles in all languages that include an abstract in English or French language.
Include as much as possible relevant studies from different LMICs that might not be published in English. Relevant articles could be converted to Word documents and translated through the DeepL translator program.

Exclusion criteria Rationale
Studies conducted in high-income countries. As mentioned above, the majority of older people reside in developing countries that are understudied.
Articles that do not include an abstract in English or French language.
For practicality purposes and time limitation, especially when screening titles and abstracts.
Grey literature other than Governmental reports and publications issued by UN, WHO, and HelpAge. Thesis, dissertations and conference posters will not be included.
For practical purposes and due to time limits.
Literature reviews and full articles that did not present the theme in the results.
To make sure that results answer to the proposed scoping review.
WHO=World Health Organization; UN=United Nations; LMICs=low-and middle-income countries the review objectives and questions. Any needed amendments to the protocol will be reported and justified. Description of gaps and suggestions for future research will also be reported.
Stage 6: Consultation with relevant stakeholders The consultation exercise presented as an optional stage in the scoping review framework proposed by Arksey & O'Malley will be implemented (Arksey & O'Malley, 2005).
Therefore, the corresponding author (SD) based in Lebanon will organise a meeting involving key stakeholders like older people, national representatives, experts, managers and practitioners representing non-profit organisations providing PHC services in Lebanon.
Lebanon is a Middle Eastern country, chosen for convenience to apply the consultation exercise. It is also classified as middle-income country (WorldBank, 2021).
The meeting will be organised in collaboration with Hel-pAge, an international non-governmental organisation [NGO], working in Lebanon to promote older people's wellbeing (HelpAge, 2021). HelpAge works in partnership with local NGO's that provide PHC services and old age-specific programs. The corresponding author will send an email to HelpAge officers in Lebanon to share details about the review, the purpose of the meeting, and the stakeholders who should be invited. This will help reach PHC professionals and older people who have access to PHC and others who don't. Emails will be sent also to local experts in the field and national representatives of the Lebanese ministries of public health and social affairs. Other logistic details related to the meeting will be discussed timely, based on the coronavirus disease 2019 (COVID-19) pandemic situation in the country. This exercise will allow the corresponding author to present the preliminary findings to the group of stakeholders so they can provide their first-hand feedback on them. The results of the discussion will be also reported in addition to the review findings. This exercise will also help authors develop an effective dissemination strategy.

Study status
At the time of publication of this protocol, the five databases' search terms must have been finalised.

Discussion
In light of the global trend of ageing, endeavours must be employed to meet older people's emerging needs, especially in terms of healthcare. Issues related to their access to PHC have not been comprehensively identified and synthesised for older people in LMIC. Mapping the available evidence will help identify knowledge gaps, orient future research, and guide policymakers to tailor policies that are responsive to older people's needs. Results will be published in an open-access scientific journal and disseminated to policymakers and organizations advocating for healthy ageing.

Data availability
No data are associated with this article.