Table 3 Summary of barriers to access by dimension

Barriers to perceiving need (approachability)

» Low or limited health literacy affects patients’ perceptions of health needs, their ability to navigate the health system and follow appropriate treatment pathways as well as to accept and follow indicated therapy.

» Patterns of poor patient-provider communication or ineffective patient-centred care restrict the approachability of health services and information exchange, often leading to reduced quality of care.

» Lack of awareness of the patients’ social and family background prevents providers from identifying individual help-seeking behaviour and specific treatment needs.

Barriers to seeking care (acceptability)

» Fear of stigmatisation is prevalent and often accompanied by a rejection of the psychological component of the disease, resulting in individuals potentially avoiding and/or delaying seeking professional help for mental health problems.

» Limited consultation time constrains patient’s care-seeking behaviour and acceptability of services.

» Insufficient consideration of comprehensive therapy approaches including psychological and social treatments is a major hurdle to successful treatment.

Barriers to reaching health care (availability)

» Previous experiences of treatment can have a significant influence on the behaviour of those seeking help.

» Structural barriers such as a lack of infrastructure, inadequate transportation, or waiting times affect families and patients particularly when their socio-economic situation does not allow them to switch to the private sector.

» The urban-rural divide exacerbates barriers to accessing specialists accompanied by longer distances and travel times to reach (specialist) care.

» The limited (regional) availability of specialists with an SHI contract results in individuals delaying specialist examinations or consulting primary healthcare providers instead, who often have limited knowledge of or experience with a certain condition and its associated specific needs.

» The strict separation between social care and the healthcare system highlights the lack of structured cooperation and consistency throughout the system.

» Holistic therapy approaches (bio-psycho-social) such as multimodal pain therapy in primary care settings or outpatient rehabilitation options are lacking.

Barriers to utilising care and barriers to ability to pay (affordability)

» Co-payments (e.g., for psychotherapists, physiotherapists, etc.) or private practice consultations, as a result of limited public capacities or waiting times, are a financial burden especially for patients with limited economic resources.

» Waiting times are long for those patients who cannot afford (to switch to) elective private practice consultations.

» Language skills, level of education and health literacy can affect the understanding of and adherence to certain treatment measures thus resulting in different health outcomes.

» Limited consultation times reflect the lack of representation of doctor-patient time in the SHI reimbursement scheme.

Barriers to ability to engage (appropriateness)

» Inconsistent and uncoordinated care pathways lead to doctor hopping on the part of patients, self-medication, avoiding seeking care, decreasing trust, and inefficiencies within the care process.

» A lack of continuity in care especially in transition phases (e.g., paediatric to adult medicine) may lead to gaps in care or reduced adherence to therapy.

» Missing or insufficient (adherence to) treatment guidelines lead to incorrect recommendations or even to manifestation of the disease concerned.