Despite access to health care long being central in health services research and policy, we still seek answers to fundamental questions. Access theory has also been criticized for being unsuccessful at predicting and explaining health care use, for being inapplicable to disadvantaged populations, and for treating access as a static phenomenon. I argue that we need a better understanding of the mechanisms and context of access and must pay attention to theory development. I designed this study to address these criticisms and better understand access to care. Using grounded theory, I examined the contextual and holistic nature of access by conducting an inductive investigation of disadvantaged individual's experiences in four rural communities. I conducted 42 individual and two-person in-depth, unstructured interviews on getting and using health care. Individuals in this study consisted of persons most likely to experience trouble using the health care system and to have the most need for care. The communities used in this study illustrated a variety of approaches to and problems with rural health care delivery in North Carolina and Ontario. Participants' access narratives described dealing with and struggling with competing needs and demands to achieve or maintain a state of balance in having their needs met. Achieving and maintaining balance is part of a dynamic process with four stages in the balance process: seeking balance, achieving balance, maintaining balance, and balance upsets. This continual process requires tradeoffs and adaptation as circumstances change. Getting stuck or being unable to achieve balance results in adverse consequences for the individual and the individual's relationship with the health care system. The balance process operates throughout an individual's life, reflecting careers with health needs and the health care system. This conceptualization of access as a balance process shares commonalities with existing access theories as well as contributing new concepts including the iterative nature of access and the importance of personal interactions and community context. Conceptualizing access as a staged process of achieving balance also provides multiple distinct policy intervention opportunities
