Spatial Disparities in Access and Use of Rehabilitation Services in Northern Greece: a GIS-based Study

International Journal of Scientific and Research Publications, Volume 8, Issue 5, May 2018 167
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http://dx.doi.org/10.29322/IJSRP.8.5.2018.p7727 www.ijsrp.org
Spatial Disparities in Access and Use of Rehabilitation
Services in Northern Greece: a GIS-based Study
Christos V. Gogos*
, Eleni Papadopoulou*
, Ioannis D. Doukas **
, Magda Tsolaki ***
*
School of Spatial Planning and Development, Faculty of Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
**
School of Civil Engineering, Faculty of Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
***
School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
DOI: 10.29322/IJSRP.8.5.2018.p7727
http://dx.doi.org/10.29322/IJSRP.8.5.2018.p7727
Abstract- Access to health care is considered to be of great importance for a person’s right to health. This paper attempts to highlight
the spatial disparities in access to and use of rehabilitation services across Imathia’s area in Northern Greece. Our study is being
focused on one defined geographical area, Imathia, in Macedonia in northern Greece. We defined a public general hospital as a local
National Health System institution providing health services for the purpose of rehabilitation concerning patients with musculoskeletal
disorders. The implementation of data included descriptive and concluding statistical processing. The spatial data was visualized in
points and polygons. Most patients (60.5%) are from areas near to the hospital which means that there, is more concentration. The
research focuses on spatial disparities and does not deal with their causes. As a consequence these findings raise important research
questions for future investigation.
Index Terms- health care access, rehabilitation services, spatial accessibility, rural, geographical information system
I. INTRODUCTION
Musculoskeletal disorders (MSDs) are often the cause of dysfunction and disability, with a significant impact on economic and
social resources (Carmona et al. 2001). Thousands of people worldwide suffer from dozens of MSDs, while some of them are
presented as a result of injuries and degrade the level of health and the quality of peoples’ lives. The management of musculoskeletal
conditions is multidisciplinary and requires a wide range of therapeutic interventions, from simple guidance or recommendations to
specialized surgical treatments. Despite the fact that in some regions excellent care is provided, some others are characterized by low
availability of healthcare resources and barriers to health care access (UKDH, 2006).
Definition of access
According to the FRA (2008) “access to health care is a basic human right and one of the fundamental principles of European health
systems, together with safety, quality, and equity”. Inequitable access to rehabilitation services is a critical gap in health care in many
regions. Even though health is a public good, health care, like many public services, is not equally accessible to all individuals
(Powell, 2016). The distribution of people is uneven in the different geographical areas as well as their individual characteristics
(demographic characteristics, income etc). All these affect their health status and their ability to overcome the obstacles to health care
access (Aday and Andersen, 1974; Mc Lafferty, 2003).
According to Penchansky and Thomas (1981) access consists of five aspects: Adequate, Accessible, Affordable, Appropriate, and
Available. Accessibility represents the geographic dimension of access and it was classified (Abdullah, 1992; Shah et al., 2016) into
spatial component. Accessibility is spatial in nature as the location of healthcare units and health professionals plays a principal role in
providing healthcare services (Shah et al., 2016).
Over the last years (Sasaki et al., 2010; Russell et al., 2013; McGrail and Humphreys, 2015; Ward et al., 2015; Dohyeong et al.,
2016; Gao et al., 2016) researchers and health policy planners have been addressing the access’ spatial feature. In any case, the
conclusion is that the involvement of spatial planning in the development and application of health policies is nowadays an
incontestable necessity.
The WHO (1998) defines accessibility as “a measure of the proportion of the population that reaches appropriate health services”.
The inadequacy of the position of a healthcare organization is often responsible for limiting the access of the population.
However, literature indicates that access to health services is not the same thing as the adequacy of health resources in a
geographical area (Gulliford et al., 2000). Since the beginning of ’70s (Elesh and Schollaert, 1972; Wennberg and Gittelsohn, 1973;
Shannon and Dever, 1974) has been an interest in measuring spatial access to identify the social barriers that restrict the delivery of
health care in both urban and rural areas of the USA. The issue of social inequality (in health and health determinants) is related to
changes in health of the population. It is a fact that has been pointed out with the publication of the Black Report (Gray, 1982).

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Nevertheless, even though the EU is aiming at reducing social inequalities in health, there is little evidence concerning the impact of
intersectional grounds on limiting of the access to health care (FRA, 2012).
Access to health services is directly related to the issue of responding health systems to the needs of the population. In particular, the
issue of spatial access to healthcare facilities is related to equality of health and health-related quality of life (Delamater et al., 2012).
Geographical Information Systems (GIS) emphasize the spatial dimensions of access, giving information on available health facilities,
the network of healthcare providers and underserved geographical areas (Mc Lafferty, 2003).
Use of GIS in health care
GIS are computer-based tools for mapping and examining the changes on earth. These are spatial data management systems and
associated data properties. They are designed to gather, organize and classify data in order to specify the spatial properties of a
phenomenon or object. Thus, it is easier to monitor not only the phenomena but also the space they are evolving. GIS are also used in
public health, as a decision supporting tool to deal with health problems in different geographical areas (Kostantinidis, 2002).
GIS have a wide range of tools for the spatial structure of healthcare facilities and the monitoring of access to health services (Mc
Lafferty, 2003; Fradelos et al., 2014). The use of GIS is useful for understanding health problems in diverse geographical areas (dos
Anjos and Cabral, 2016). GIS technologies can contribute to the research and development of health policies through rational decision
making, since they allow for the spatial linking of different types of entities such as physical objects, regional units, demographic
information, geographical distribution of economic resources, population, and other relevant factors (Bellander et al., 2001; Mennecke
and Lawrence, 2001; Tanser and le Sueur, 2002).
This paper attempts to highlight the spatial disparities in access to and use of rehabilitation services across Imathia’s area. This study
hypothesizes that geographic accessibility to rehabilitation services will vary considerably across the specific geographical area. The
research focuses on spatial disparities, namely whether the access differs from municipality to municipality and the extent to which it
differs. It focuses on identifying disparities and it does not address their causes.
II. METHODOLOGY
Our study focused on one defined geographical area, Imathia, in Macedonia in northern Greece (Figure 1).
Figure 1. Location of Imathia / Greece.
Source: Gogos et al., 2018.
We defined a public general hospital as a local National Health System institution providing health services for the purpose of
rehabilitation for patients with MSDs. We studied retrospectively all patients' folders (N = 1005) in which rehabilitation services
rendered during the two-year period 2014 - 2015.
Initially, the Administrative division of the country was decided to be followed for obvious reasons, which were related to the
possibility of using existing data. With this approach, the adaptation and the data’s analysis was facilitated, as well as their

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cartographic depiction, as the homogenization of information was complete, while there were direct references to the same
geographical level.
The regional unit Imathia is divided into three municipalities. These are Alexandreia, Naousa and Veroia respectively. The
municipalities were reorganized, according to the table 1.
Table 1: Municipalities of Imathia
Municipal Units Municipalities
Alexandreia
Antigonides
Meliki
Platy
Alexandreia
Naousa
Anthemia
Eirinoupoli
Naousa
Veroia
Apostolos Pavlos
Vergina
Dovras
Makedonidos
Veroia
Source: Kallikratis reform law text, 2010
Data
The collected data can be divided into primary and secondary, as well as into geographical and descriptive. The descriptive, primary
elements concerned data related to sex, age, place of residence, occupation, income and ailing physical area.
The secondary elements come from the procession of primary descriptive elements, so as their use to be compatible on the one hand
during their statistical process and on the other hand their depiction to be understood.
The grouping of occupations happened according to the International Standard Classification of Occupations – 08 (ILO, 2010). The
classification of the income happened in accordance with the HSA (2011).
The coding of diseases happened initially, analytically to each one of the sample, according to the full list of the International
Statistical Classification of Diseases and Related Health Problems 10th Revision, (ICD-10) (WHO, 2011). The current project didn’t
have as its main purpose the clinical study of MSDs, so in retrospect a generalization as to the main category of the disease was
chosen to take place, which guaranteed – in always permissible limits – the same diagnosis of the diseases and allowed the frequencies
of each specific type to be calculated (Table 2). The implementation of this data included descriptive and concluding statistical
processing.
Table 2: Classification of Diseases
code Diseases of the musculoskeletal system
M16 Coxarthrosis [arthrosis of hip]
M17 Gonarthrosis [arthrosis of knee
M22 Disorders of patella
M23 Internal derangement of knee
M24 Other specific joint derangements
S42 Fracture of shoulder and upper arm
S43 Dislocation, sprain and strain of joints and ligaments of shoulder girdle
M50 Cervical disc disorders
S52 Fracture of forearm
S53 Dislocation, sprain and strain of joints and ligaments of elbow
M54 Dorsalgia
S62 Fracture at wrist and hand level
S63 Dislocation, sprain and strain of joints and ligaments at wrist and hand level
S72 Fracture of femur
S82 Fracture of lower leg, including ankle
S83 Dislocation, sprain and strain of joints and ligaments of knee
S92 Fracture of foot, except ankle
S93 Dislocation, sprain and strain of joints and ligaments at ankle and foot level
M99 Biomechanical lesions

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Source: ICD-10, 10th Revision
Transformation of spatial data was held in the system GGRS87 and based on creation of the Digital Elevation Models of Greece
(DEM), specifically for the county of Imathia. The creation of the DEM was deemed necessary, as it helps in gaining a global view of
the distinction of the information’s levels of the space. The spatial data was visualized into points and polygons.
Subjects were integrated in a GIS. Geocoding was done with the declaration of residential place. For the subjects’ geocoding, we used
cartographic data provided by the GIS. The addresses geocoding techniques were provided by ArcMap 9.3.
III. RESULTS AND DISCUSSION
Regarding the gender of the statistical population it has been observed uneven distribution in view of the fact that the percentage of
women (69.3%) was higher of the percentage of men (30.7%). In the map of figure 2, red dots represent women with MSDs and blue
dots represent men with MSDs.
Figure 2. Location of the population sample and of MSDs sufferers.
The map clearly shows areas with high and low rates of access. The maps in figure 3 and 4 are accessibility maps according to
gender (men and women with MSDs who received healthcare services). This visually confirms spatial inequalities in accessibility,
even among people in neighbouring locations.
As for the age, the statistics show that the sample mainly comprises a middle-aged or older while the smallest percentage belonged
to those from 18 to 40 years of age (n=128).

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Figure 3. Accessibility map of men who received healthcare services.
Figure 4. Accessibility map of women who received healthcare services.
Of the total sample of the population (N=1005), the majority involved farmers (48.7%), while the smallest proportion was
unemployed (3.3%). As for the educational level of the population, the highest rate (68.5%) was elementary graduates and few (15%)
are presented as university graduates. The declared income showed larger variations among the population of the study with the
majority to present a monthly income 301 – 630 €, while few (17.5%) declared a monthly income >801 €. The features of this sample
are imprinted on table 3.

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Table 3: Features of sample (N=1005)
Features Frequency
N
Percent
%
Gender men 308 30,7
women 697 69,3
Age group 18-40 128 12.7
41-60 350 34.8
60+ 527 52.4
Occupation Skilled Agricultural 489 48.7
Clerical Support Workers 176 17.5
Services and Sales Workers 144 14.3
Professionals 84 8.3
Other 79 7.9
Unemployed 33 3.3
Educational level Illiterate 14 1.4
elementary graduates 689 68.5
Graduates of Secondary-High School 148 14.7
University graduates 143 14.0
MSc/PhD 11 1.0
Monthly income <300 41 4.0
301-630 493 49.0
631-800 294 29.5
801-1,100 101 10.0
1,101-1,220 58 5.7
1,221-1,500 18 1.8
Source: Gogos et al., 2018
A “body map” was used in order to identify nine (9) body areas suffering by musculoskeletal problems: neck, shoulders,
elbows, hands, back, waist, hips, knees and ankles joints (Gogos and Papadopoulou, 2015). Based on the statistical analysis of the
data, MSDs occurs mainly in women (N=697). The most frequently reported MSDs of study population were located in knee joint
(22.78%) (Table 4).
Table 4: Allocation of MSDs per physical area
Physical area N Men
(N)
% Women
(N)
%
Neck 148 39 26.35 109 73.64
Shoulder 180 66 36.66 114 63.33
Elbow 40 34 85 6 15
Wrists/Hands 118 85 72.03 33 27.96
Upper back 60 6 10 54 90
Low back 190 22 11.57 168 88.42
Hips 22 8 36.36 14 63.63
Knees 229 40 17.46 189 82.53
Ankles/Feet 18 8 44.44 10 55.55
total 1,005 308 697
Source: Gogos et al., 2018
In map of figure 5, the entire population of the study that received health services during the aforementioned period from the
General Hospital that is based on the capital of the county is showed. The areas close to the hospital from where most of the patients
come from, like for example the municipal units of Veria’s Municipality, where a greater assembly is observed (60.5%), are obvious.
In contrast, the smaller rate of patients who visited the hospital (3.6%) comes from Naousa’s municipality.

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Figure 5. Study population that received health services.
Moreover there are substantial variations in geographical accessibility to health's rehabilitation services not only among but also
within Imathia’s areas. There was a fluctuation in access among the municipal units of Veria’s municipality with the most limited
access to be cartographically imprinted in the Municipal Unit of Makedonidos (0.8%). The study on the health access of a random
population sample of people residing in Imathia has shown spatial inequalities in accessibility to health's rehabilitation services.
Municipal units of Veria’s municipality show higher rates of accessibility to the specific health services in connection with the
municipal sections of Naousa’s Municipality.
Veria is the capital city and the commercial center of Imathia region. The secondary level general hospital of Imathia is situated in
the center of Veria’s city. Obviously, the proximity of Veria’s city and municipal units of Veria’s municipality in general to the base
of the general hospital has a positive impact on the access of the population to the services it offers. One the other hand, Naousa is a
rural area with population density below 150 inhabitants/ Km2 (ENRD, 2011). It has an average altitude 330m and average distance
20km from the hospital. As a consequence the rural dwellers are forced to travel farther to contact health facilities than their urban
center counterparts. Moreover rural residents without private vehicle depend on a poor public transportation. Consequently their
accessibility to health facilities is minimized even more.
In urban areas people with health problems more easily seek medical attention. There is evidence that people living far away from
healthcare facilities and those living in rural areas are less likely to see a health professional than those living closer or in urban areas
(Lankila et al., 2016).
At the same time, the cartography of the spatial distribution of the access within the Municipality of Veria presents fluctuations with
imprinted the limited access of the population from the municipal unit of Makedonidos (0.8 %), in the southern part of the county with
middle altitude 500m and middle distance 40km from the hospital.
In recent years, the region’s road network has improved significantly but still cannot be considered satisfactory. The transport
isolation of the specific disadvantaged area has not yet been lifted. In comparison with the population of the urban center, those
residing in the particular underprivileged, rural area encounter dual problems of the poor organizational structures, on one hand the
low quality of roads and on the other the lack of public transportation options. In addition, the large number of rural roads creates a
maximum traffic safety problem. The required low speed of the vehicles increases the travel time to healthcare services.
Municipal unit of Makedonidos is a rural and remote area, which leads to isolation as that transportation network is less available.
Remoteness creates difficulties for rural people resulting in obstruction to the use of secondary healthcare services. This condition is a
challenge in terms of health care access for its remote communities and it should give cause for concern.
People tend to use health services close to their home and work (Mizen et al., 2015; Aggarwal et al., 2017) because the distance is
often a barrier to health care use, reducing health facilities’ utilization. Distance-related inequity in health service use is potentially a
major public health issue, as it may increase actual health differences. In the Behavioral Model of Health Services Use, distance is
regarded as an enabling characteristic which makes health service resources available to the individual (Andersen and Newman,
2005).

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This has, however, never been examined in Greece. The dimension of accessibility could be more reliable in the case of Greece due
to the mountainous and insular relief of the country. Maybe the dimension of accessibility has to be re-examined by introducing time
as a crucial ingredient, given that distance is a relative factor.
The results of the study show that areas in Imathia are outside of a 30 minute travel time from hospital and thus have limited
geographic accessibility. For some types of health organizations, distance or travel time for the patients is a significant burden as they
have no easy access to them - evidence for experiencing low opportunities and great difficulties to use them (Comber et al., 2011).
Spatial accessibility as the distance or travel time to the healthcare facilities is one of the most important dimensions of quality care.
Spatial accessibility reflects to the equilibrium between the characteristics and the expectations of both the providers and clients, as the
distance or travel time for the patients is of utmost importance for appropriate health care (Levesque et al., 2013).
In general, the current study established a high prevalence of musculoskeletal conditions in farmers. People consider the work on the
farm as a healthy and idyllic occupation (Walker-Bone and Palmer, 2002). Nevertheless, farming has a wide range of threats to health
with a significant impact on farmer’s health status and health related quality of life (Xiao et al., 2013). Farmers and farm workers are
at risk of the prevalence of musculoskeletal disease due to their work, such as lift and carry heavy loads, are exposed to whole-body
vibration from powerful motor vehicle, walk on slippery and uneven walkways (Osborne et al., 2010). The prevalence of
musculoskeletal problem was observed higher in women and chronic pain is often observed in females (Nidhi and Vandana, 2001;
Myers et al, 2003; Arendt-Nielsen et al., 2004).
Limitations
Some specific limitations to this study need to be pointed out. It is well known that researchers need high-quality data, which can
contribute to more accurate results. However, in reality, the collected data is never perfect. Under this scope, we are considering this
earlier step of our research as a “kick off research”, which is looking forward to a larger volume (and better quality) of data.
Additionally, other factors that affect accessibility to healthcare services, such as the perceived quality of services provided (dos
Anjos and Cabral, 2016) are not addressed in this paper. Τhe presented results come from an exploratory spatial analysis of the
accessibility level in the population sample and they cannot be generalized to the whole population of specific geographical area
because the sample is not necessarily representative.
Nonetheless, we try to highlight the importance of studying the spatial aspect of the phenomenon, so that accessibility to healthcare
services can be linked to socio-economic factors that may influence their unequal spatial distribution in the future.
IV. CONCLUSIONS
The results of this study show substantial variations in geographical accessibility to health's rehabilitation services both within and
among Imathia’s areas. Access to health care varies among the regions of Imathia, because access is influenced by both the uneven
distribution of population and the spatial structure of health facilities.
This involves, on the one hand, an evidence-based planning of rural settings and on the other hand the establishment of new
cooperation models and their instrumental implementation in political decision making and administrative acting within the context of
transformation processes.
The adoption of GIS by researchers and health policy planners depends on the use of spatial data in health services. Therefore, we
need to realise the behavior of health service users and how spatial entities influence their relationship with health services.
The cartography of morbidity and spatial deviations in the provision of health care can be seen as a modern viewpoint for the
handling of the information that links the area with human health. One parameter that was taken into serious consideration for the
construction of the maps was that the receivers of these cartographic diagrams wouldn’t be necessarily aware of the principles of the
thematic cartography. Therefore, the possible creation of difficulty for the comprehension of the produced effect, which, anyway, is a
necessary requirement in order for a thematic map to perform its communicative role, is examined (Katsios, 2005).
Although MSDs are prevalent in communities across the globe and their impact is pervasive (Woolf and Pfleger, 2003) the effect of
space on their prevalence and the spatial distribution of populations at high risk for these diseases had not been previously studied.
The present study attempted to highlight the spatial inequalities in accessibility to rehabilitation services because of MSDs. These
findings raise important research questions for future investigation. One of these is the effect of environmental or occupational factors
in the prevalence of MSDs. Moreover, future research could aim to investigate the influence of socio-demographic parameters on
accessibility to health rehabilitation services in urban areas.
Ethical approval
For the collection of data and the conduct of the survey, the required permission was obtained from the Hellenic Data Protection
Authority (reference number: 1595) and the hospital's Scientific Council.
Competing interests: None declared.

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ACKNOWLEDGMENT
This research uses data from the Physical Therapy Department at General Hospital of Imathia. We would like to acknowledge
hospital administration consent and permission to conduct this study at the specific institution. We are grateful for providing access to
use information from patients’ records.
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AUTHORS
First Author – Christos V. Gogos, PT, MSc, PhD (c) School of Spatial Planning and Development, Faculty of Engineering, Aristotle
University of Thessaloniki, Thessaloniki, Greece. E-mail: chrisgogos@plandevel.auth.gr.
Second Author – Eleni Papadopoulou, Associate Professor, Head, School of Spatial Planning and Development, Faculty of
Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece. E-mail: epapa@plandevel.auth.gr.
Third Author – Ioannis D. Doukas, Professor, School of Civil Engineering, Faculty of Engineering, Aristotle University of
Thessaloniki, Thessaloniki, Greece. E-mail: jdoukas@civil.auth.gr.
Fourth Author – Magda Tsolaki, Professor, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki,
Thessaloniki, Greece. E-mail: tsolakim@auth.gr.
Correspondence Author – Christos V. Gogos. E-mail:chrisgogos@plandevel.auth.gr. Contact number: +30 2331351123.

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