Download Equity in Primary Health Care use among vulnerable

“Softly, one can shake the world”
Mahatma Gandhi
Aan mijn ouders
aan Wouter
Equity in Primary Health Care use among vulnerable populations in Belgium:
an exploration
PhD-Thesis, Department of Family Medicine and Primary Health Care
Ghent University, Belgium
Please cite as:
Evelyn Verlinde. (2012). Primary health care use among vulnerable populations in
Belgium: an exploration. Thesis submitted in fulfilment of the requirements for the
degree of Doctor in Medical Sciences.
Ghent University
ISBN: 9789491125034
NUR: 882
Copyright © Evelyn Verlinde 2012
All rights reserved. No part of this publication may be reproduced in any form, by print,
photocopying, recording or otherwise, without prior written permission of the author.
Layout: Anja Peleman
Equity in Primary Health Care use
among vulnerable populations in
Belgium: an exploration
Evelyn Verlinde
2012
Promotor:
Prof. Dr. Sara Willems, Department of Family Medicine and
Primary Health Care, Ghent University
Co-promotor:
Prof. Dr. Jan De Maeseneer, Department of Family Medicine
and Primary Health Care, Ghent University
Supervisors
Prof. Dr. Sara Willems, supervisor, Ghent University
Prof. Dr. Jan De Maeseneer, co-supervisor, Ghent University
Head of examination board
Prof. Dr. Marleen Temmerman, Ghent University
Examination board
Prof. Dr. Peter De Paepe, Ghent University
Prof. Dr. Koen Van Herck, Ghent University
Prof. Dr. Peter Groenewegen, Nivel
Prof. Dr. Kristin Hendrickx, Antwerp University
Prof. Dr. Lea Maes, Ghent University
Prof. Dr. Dirk Avonts, Ghent University
Table of Content
Summary/Samenvatting
4
List of abbreviations
8
Preface
9
Chapter 1: Introduction
11
1.Background
12
2.Determinants of health inequities
18
3. Tackling health inequities
20
3.1. European policy actions
20
3.2. Proportionate universalism
22
4. The importance of primary care in tackling health inequities
24
4.1 Defining primary health care
24
4.2. Defining (in)equity in (primary) health care
25
4.3. A role for primary health care in tackling health inequities
31
Chapter 2: Research aim
43
Chapter 3: Research papers
51
Chapter 4: Discussion
131
4.1. What this thesis adds: summary of the results
132
4.2. Conclusion
137
4.3. What this thesis could not add: suggestions for future research
140
4.4. Policy and practice implications
142
Chapter 5: Dankwoord
173
Chapter 6: CurrisulumVitae
177
5
6
Summary
There is extensive literature and evidence on the existing inequities in health.
These health inequities are a result of social inequities. It takes a wide range of
interventions to tackle these social inequities. One of the interventions is building a sustainable, strong Primary Health Care system in order to contribute to
more health equity.
The aim of this doctoral thesis is to focus on the equity in primary health care in
Belgium in terms of equal access, equal treatment and equal outcomes for vulnerable
population groups in equal need. To do so, five studies were set up: one qualitative
study, one literature review and three quantitative studies.
Five hypotheses were formulated, each described in a paper:
Hypothesis 1: The specialist is the doctor of the higher-income people and
the GP is the doctor of the lower-income people (paper 1).
Hypothesis 2: Homeless people have a higher likelihood to consult the emergency department than the general population. A universal primary health
care system with active guidance for homeless people towards this system
might counter this (paper 2).
Hypothesis 3: People who are not able to cope with their available income
have a higher likelihood to postpone a visit to a GP (paper 3).
Hypothesis 4: The social gradient in doctor-patient communication persists
over time, where patients from lower socio-economic classes are less involved
during the consultation, receive less control and a more paternalistic consultation style (paper 4).
Hypothesis 5: Physicians have a negative attitude towards patients with a low
SES and as a result make changes in their clinical decision which do not favor
the outcomes for the patient (paper 5).
This thesis shows us that:
The specialist is not the doctor of the higher-income people but the doctor of the
higher educated people. While the GP is not the doctor of the lower-income people, but the doctor of the lower-educated people. These findings indicate that the
7
Belgian health care system is financially accessible, but still has other access issues
related to the educational level of the patient.
Low-income people suffering from bad health, those suffering from a severe depression and those without complete trust in their GP have a higher risk of postponing
a visit to a GP. People not able to cope with their monthly income do not have a
higher risk of postponing a visit to a GP.
A universal health care approach for homeless people, with active guidance by social
workers seems to be far more effective than a selective setting focusing solely on
that specific population. This universal approach leads to less stigmatization and
labeling than a selective approach, leading to a higher use of these services.
The social gradient in doctor-patient communication persists over time, where
patients from lower social classes receive less socio-emotional talk, a more directive and less participatory consultation style characterized by less involvement in
treatment decisions, lower patient control over communication, less diagnostic and
treatment information and more physical examinations.
8
The attitude and decisions of GPs toward patients from lower social classes depend
on the number of contacts physicians have with this population group. GPs with
occasional contact with patients from low SES take more time for these patients,
invest more energy and see it as a positive challenge. They make changes in their
clinical decisions, but these changes are made in order to enhance the patients
outcomes. However, when the number of low SES patients is too large, GPs seem
not always capable to keep providing good qualitative care. The changes they make
in their decisions are not always in favor of the outcomes for the patient.
It seems that the Belgian primary health care system does not create huge financial barriers, however, there still seems to be some inequity in the other aspects of
access to health care (e.g. cultural, geographical) as well as in the treatment and
outcomes patients in equal need perceive. Therefore, action is needed on practice
level (e.g. intersectoral approach) as well as on policy level (e.g. additional resources
for practices working with low SES patients).
Samenvatting
Er bestaat reeds een uitgebreide hoeveelheid aan literatuur omtrent de bestaande
ongelijkheden in gezondheid. Deze ongelijkheden zijn het resultaat van sociale
ongelijkheden. Om deze sociale ongelijkheden aan te pakken, is een breed spectrum
aan interventies noodzakelijk. Een mogelijke interventie is het uitbouwen van een
goed georganiseerd eerstelijnsgezondheidszorg systeem.
Het doel van deze doctoraatsthesis is het onderzoeken van de ongelijkheden in het
gebruik van de eerstelijnsgezondheidszorg in België in termen van gelijke toegang,
gelijke behandeling en gelijke gezondheidsuitkomsten voor kwetsbare groepen met
gelijke noden. Hiertoe werden vijf studies opgezet: een kwalitatieve studie, een
literatuur-review en drie kwantitatieve studies.
Vijf hypotheses werden geformuleerd, die elk behandeld worden in een paper:
Hypothese 1: De specialist is de arts van de ‘rijkere’ mensen, de huisarts is de
arts van de ‘armere’ mensen’ (paper 1).
Hypothese 2: Daklozen zijn vaker geneigd om de spoeddienst te raadplegen
dan de gemiddelde niet-dakloze populatie. Een universeel eerstelijnsgezondheidszorgsysteem met actieve toeleiding voor daklozen kan dit fenomeen
tegen gaan (paper 2).
Hypothese 3: Personen die niet in staat zijn rond te komen met hun maandelijks inkomen stellen vaker een bezoek aan de huisarts uit (paper 3).
Hypothese 4: De sociale gradiënt in arts-patiënt communicatie blijft bestaan
doorheen de tijd. Hierbij worden patiënten met een lage sociale status minder
betrokken tijdens de consultatie, hebben minder controle en ontvangen een
paternalistische communicatiestijl (paper 4).
Hypothese 5: Artsen hebben een negatieve attitude tegenover patiënten met
een lage sociale status. Als gevolg van deze attitude maken ze wijzigingen
in hun klinische beslissingen. De uitkomsten van deze beslissingen zijn niet
steeds in het voordeel van de patiënt (paper 5).
De resultaten van deze thesis tonen aan dat:
De specialist niet de arts is van de ‘rijkere’ mensen, maar de arts van de hoger
opgeleiden. De huisarts is eveneens niet de arts van de ‘armere’ mensen, maar de
9
arts van de lager opgeleiden. Deze resultaten tonen aan dat het Belgische gezondheidszorgsysteem financieel toegankelijk is, maar toch nog barrières vertoont die
gerelateerd zijn aan het opleidingsniveau van de patiënt.
Mensen met een laag inkomen die een slechte gezondheid hebben, een zware depressie of zij zonder volledig vertrouwen in hun huisarts hebben een hoger risico
om een bezoek aan de huisarts uit te stellen. Mensen die niet in staat zijn rond te
komen met hun maandelijks inkomen daarentegen stellen niet vaker een bezoek
aan de huisarts uit.
Een universeel eerstelijnsgezondheidszorg systeem met actieve toeleiding door
maatschappelijk werkers voor daklozen draagt bij tot toegankelijkere vorm van
zorg voor daklozen. Deze aanpak leidt tevens tot minder stigmatisatie dan een
selectieve aanpak.
10
De sociale gradiënt in arts-patiënt communicatie blijft bestaan doorheen de tijd.
Hierbij ontvangen patiënten van een lagere sociale klasse minder socio-emotionele
gesprekken, een directieve consultatie-stijl, ervaren ze minder controle over de
consultatie, worden ze minder betrokken en ontvangen ze minder behandelingsinformatie en meer fysieke onderzoeken dan patiënten met een hogere sociale status.
De attitude van artsen ten opzichte van patiënten met een lage SES varieert naargelang het aantal contacten artsen hebben met deze patiëntengroep. Artsen die
slechts zorgen voor een relatief kleine hoeveelheid patiënten met een lage sociale
status investeren meer tijd en energie in deze patiënten en zien het werken met
hen als een positieve uitdaging. Deze artsen wijzigen hun beslissingsproces, maar
deze wijzigingen worden gemaakt in het voordeel van de patiënt. Echter, wanneer
het aantal patiënten met een lage SES te groot wordt in een praktijk, zijn artsen
niet meer in staat om dezelfde kwalitatieve zorg te garanderen. De wijzingen in
hun klinische beslissingen zijn daardoor niet altijd in het voordeel van de patiënt.
De resultaten van deze thesis tonen aan dat het eerstelijnsgezondheidszorgsysteem in
België geen al te grote financiële barrières creëert. Toch blijken er nog ongelijkheden
te bestaan in de andere facetten van de toegang tot zorg (waaronder culturele en
geografische toegang). Ook in de behandeling en de uitkomsten van zorg blijken
er enkele ongelijkheden te zijn. Om deze ongelijkheden aan te pakken is er zowel
actie nodig op het niveau van de praktijk (vb intersectorale samenwerking) als op
beleidsniveau (vb extra steun voor praktijken die werken met een grote hoeveelheid
lage SES patiënten).
List of abbreviations
SES
Socio-economic Status
WHO
World Health Organization
EFTA European Free Trade Association
EU
European Union
PHC
Primary Health Care
AML
Acute Myeloid Leukemia
PCI
Percutaneous Coronary Intervention
OECD
Organization for Economic Cooperation and Development
CI
Confidence Interval
HIS
Health Interview Survey
ED
Emergency Department
GP
General Practitioner
FP
Family Physician
CRC
ColoRectal Cancer
CSDH Commission on Social Determinants of Health
US
United States
UK
United Kingdom
DES
Drug Electing Stents
COPC
Community Orientated Primary Care
DWA
Data Warehouse Arbeidsmarkt
IMA InterMutualistisch Agentschap
11
Preface
The Department of Family Medicine and Primary Health Care of Ghent University
supports, respects and is guided by the overall mission statement of the Faculty of
Medicine and Health Sciences. The department aims to contribute to the development of teaching, research and health policy development. It wants to promote and
provide opportunities for participation in research and development of new forms
of primary health care delivery in the city of Ghent, in the country of Belgium, in
Europe and in developing countries.
12
Within the Department of Family Medicine and Primary Health Care, the research
group “Health Equity” focuses its research activities on the (in)equity in health care.
Within the scope of this commitment, the research group participated in the ‘Focal
point on Welfare, Public Health and Family’ (Steunpunt Welzijn, Volksgezondheid
en Gezin), a policy related research consortium funded by the Flemish Minister of
Welfare, Public Health and Family (2007-2011). The research group in health equity
was, in cooperation with LUCAS (KULeuven), responsible for a research project
on the utilization of health care and welfare services of socially vulnerable people.
The foundation of this thesis was laid in this Steunpunt and one of the papers included in this thesis uses data from the work of this project. It formed the basis of
further research on (in)equity in health care use, reported in the additional papers.
In concordance with the mission statement of the faculty, this doctoral thesis wants
to give a better understanding on inequities in health care in Belgium and aims to
identify key concepts for actions to reduce inequities in health care use.
Ghent, 03.10.2012
Chapter 1
Introduction
13
14
Chapter 1: Introduction
1. Background
Increase in life expectancy…
Over the last centuries there is a marked improvement in life expectancy across
countries. In 1843, a man living in Belgium had a life expectancy of 39.06 years, a
woman of 39.59 years. In 2009, Belgian men had a life expectancy of 77.15 years
and women of 82.43 years [1, 2]. Figure 1 illustrates that the life expectancy in
Belgium has nearly doubled during the past century. Drops in life expectancy can be
noticed in 1866 and 1871, due to the cholera- and smallpox-epidemics, and during
the two World Wars. Between 1880 and 1940, life expectancy increased with two
or three years per decade. In the last decade there is still a rise in life expectancy,
however less steeply (table 1). Compared to 1998, in 2009 men lived nearly three
years longer and women nearly two years longer [1].
15
Source: Devos I. De evolutie van de levensverwachting in België, 18de-20ste eeuw. Gent: Academia Press; 2006
Figure 1: the evolution of life expectancy at birth in Belgium (1843-1996)
Chapter 1: Introduction
Figure 1 and table 1 show that women live longer than men. It is assumed that
biological and sociological factors are important determinants [1]. Yet, in the last 10
years this gap in life expectancy between men and women seems to narrow (table 1).
Source: FPS economie: http://statbel.fgov.be/nl/statistieken/cijfers/bevolking/sterfte_leven/tafels/
Table 1: the evolution of life expectancy at birth in Belgium: 1998-2009
… but not for all to the same extent
16
Despite this marked improvement in life expectancy, not all population groups
enjoy this to the same extent. For example in Belgium, a 25 year old man with a
higher educational level has on average another 55.03 years to live, a man with a
higher secondary education degree has on average another 52.52 years to live, a
man with a lower secondary education degree 51.33 years, a man with a primary
school degree 49.29 years and one without any degree 47.56 years. For women, a
similar gradient can be noticed (figure 2) [3].
70
60
50
number of years
to live
40
30
Men
Women
20
10
0
Higher
education
Higher
secondary
education
Lower
secondary
education
Primary school
degree
No degree
Educational level
Source: Van oyen et al, 2010
Figure 2: life expectancy for men and women aged 25 in Belgium according to education
Chapter 1: Introduction
Also healthy life expectancy – the number of years a person can expect to live in
good health- shows a similar pattern. A 25 year old Belgian woman without a diploma can expect to live another 29 years in good health, a woman with a primary
school degree 32 years, a woman with lower secondary education degree 42 years, a
woman with higher secondary education degree 41 years and a woman with a higher
educational level 47 years [3]. Identical patterns are found in most industrialized
countries. For example, in England, people living in the poorest neighborhoods
(based on income level), will on average die seven years earlier than people living
in the richest neighborhoods [4]. Even more striking is the difference in disability
free life expectancy, which is in England 17 years between people in the richest and
poorest neighborhood. This means that people living in the poorest neighborhoods
not only die younger, they also spend more of their shorter lives with a disability [4].
Lower socio-economic status (SES) is not only associated with lower (healthy)
life expectancy, and higher mortality rates, but with all kinds of health problems
including psychological and mental disorders. For example in Europe, smoking
and obesity are more common among people with a lower educational level [5].
In Belgium, lower educated persons suffer more often of chronic diseases such as
diabetes, asthma, arthrosis, etc. than higher educated persons. Lower educated persons also suffer more from functional diseases such as migraine and irritable bowel
syndrome and perceive higher levels of pain than higher educated persons [5-7].
These differences in health follow a social gradient. The social differences are not
only between the rich and the poor, but there is a stepwise or linear decrease in
health expectancy with decreasing social position [4, 8, 9] (see figure 2).
Social justice
Not all differences between population groups can be considered as inequities.
Sometimes genetic and constitutional variations can be responsible for differences
in health between population groups. For example the difference in health between
younger and older people and some differences between ethnic groups (e.g. higher
prevalence of sickle cell anemia in a black population) are purely the effect of genetics
or natural aging. Next to these genetic and constitutional variations, there is also
the factor chance or luck in people’s lives. (e.g. a car accident, having an infectious
disease,…). For these unavoidable differences in health, usually the term “health
inequalities” is used. The term “health inequities” is used to refer to systematic dif-
17
Chapter 1: Introduction
ferences in health between social groups which are socially produced and therefore
considered as unfair [4, 10, 11], preventable, avoidable and unjustifiable [12].
The concept of health inequity fits in the broader context of social justice. This refers
to the organization of society in which a common good, to which all are expected
to contribute in different ways, is available to all its members. To promote and
respect social justice means to be part of a society where all members, regardless of
their background, have basic human rights and equal access to their community’s
wealth and resources [13]. Creating a social democracy comprises two normative
ideas: personal accountability for personal choice and a sense of social commitment
in economic behavior. These ideas should shape society’s institutions and the way
economic agents behave within those institutions. It calls upon the talented and
the powerful, as much as it calls upon the poor and the powerless [14].
A universal phenomenon
18
Variations in health according to social status is a global phenomenon, seen in
low, middle and high income countries [9]. For example: in Bolivia, babies born
to women without any education have an infant mortality greater than 10 per 100
live births, while the infant mortality rate - the risk of a baby dying between birth
and one year of age- of babies born to mothers with at least secondary education is
under 4 per 100 births [9]. Life expectancy at birth among indigenous Australians is
substantially lower (59.4 for males and 64.8 for females) than that of non-indigenous
Australians (76.6 and 82.0 respectively) [9]. The prevalence of long-term disabilities
among European men aged 80+ is 58.8% among the lower educated versus 40.2%
among the higher educated [9].
Yet, the extent of health inequities tends to vary importantly between countries.
According to differences in mortality regarding to educational level, Mackenbach
et al. systematically compared gradients in mortality inequity among men and
women according to educational level by using individual information obtained
by the Eurothine project from studies in 16 countries in the EU and European
Free Trade Association (EFTA). The results of this project indicate that there is a
great variation among these countries in levels of inequity in mortality, based on
the length of education (figure 3). Inequity was greatest in the countries in central
and eastern Europe, and least in Italy, Spain and Sweden [11].
Chapter 1: Introduction
19
Source: Mackenbach et al.
Figure 3: absolute inequity (slope index of inequality) in male death rate by level of edu-
cation in selected EU and EFTA countries
The importance of equality in the distribution of income
Important is that, when comparing countries, not the level of welfare but the extent of income inequality tends to associate with health inequity. Wilkinson states
that in countries which reached a certain level of welfare, a smaller gap between
rich and poor means a happier, healthier, and more successful population. Figure
4 shows that countries as the US, the UK, Portugal and New Zealand in the top
right of the graph (being countries with greater income inequality) do much worse
than Japan, Sweden or Norway in the bottom left. Countries with more equitable
societies have among others better child well-being, higher levels of trust, lower
levels of mental illness, longer life-expectancy, lower infant mortality rates and
lower levels of obesity [15].
Chapter 1: Introduction
20
Source: Wilkinson & Pickett, The Spirit Level (2010)
Figure 4: health and social problems are worse in more unequal countries
Social determinants of health
To understand what causes health inequity and how the phenomenon can be tackled,
understanding what determines health is an important prerequisite. Many models
have been developed to explain the processes and elements that contribute to the
health of our populations. The model developed by Dahlgren and Whitehead is
one of the most frequently used models to explain the determinants of health and
is recognized by the WHO [16]. Based on a social ecological theory to map the
relationship between the individual, their environment and disease, Dahlgren and
Whitehead created a conceptual framework of the most important determinants
of health (figure 5).
Chapter 1: Introduction
Source: Dahlgren and Whitehead, 1993
Figure 5: the determinants of health
The centre of the figure comprises the fixed factors that influence a person’s health
such as age, sex and constitutional characteristics. Surrounding them are the influences that are theoretically modifiable: the individual lifestyle factors such as
smoking, physical activity, diet, and the social and community networks such as the
interactions with peers and community members. The living and working conditions
include aspects such as food supply, access to essential goods and services, housing,
education,… Finally, general socio-economic, cultural and environmental conditions
mediate population health. A strength of this model is that it emphasizes interactions: individual lifestyles are embedded in social norms and networks, and in living
and working conditions, which in turn are related to the wider socioeconomic and
cultural environment. These determinants can be positive health factors, protective
factors or risk factors [16].
21
Chapter 1: Introduction
2. Determinants of health inequities
Knowledge of the social determinants of health is necessary but not sufficiently
for identifying, analyzing and tackling the social inequities in health. One way to
understand the determinants of health inequities is to focus on the distinct pathways
and mechanisms by which the known health risk factors and risk conditions bring
about the social gradients in health that are observed within different countries [17].
Five mechanisms or pathways are generally recognized to explain social inequities
in health [16].
1. Different levels of power and resources
22
A person’s social position in society has a powerful influence on the health risks
experienced within different socio-economic groups. The better-off have more
power and opportunities to live a healthy life than their worse-off counterparts.
This implicates that social position itself is an important determinant of social
inequities in health [16, 18]. People in a low socio-economic position experience
more psychosocial stress, high job demands with low control, dire housing, financial difficulties,… These factors can lead to multiple disease outcomes by multiple
risk-factor mechanisms. As an example, stressful life events have been linked to
higher ratios of heart disease, stroke, diabetes, cancer, depression, fetal death, and
low birth-weight in offspring [7, 16, 18, 19].
Also the psychosocial determinants of health such as lack of control in the workplace, low social capital and social exclusion are related to social position: these are
more common among people from lower social classes compared to people from
the higher social classes. Low social status is stressful because it reduces people’s
control over their lives and work. As Wilkinson states “ It has a huge impact on
health whether people feel valued, appreciated and needed or on the other hand
looked down on, treated as insignificant, disrespected, stigmatized and humiliated”
[16, 19, 20]. These forms of psychosocial stress can in their turn lead to ill health
either through biological pathways (eg. affecting the immune system) or through
behavioral pathways (eg. risk behavior) [16, 21].
2. Different levels of exposure to health hazards
Different exposure to risk factors can lead to the observed differences for most major
diseases among socio-economic groups. Studies show that, for almost all risk factors,
Chapter 1: Introduction
exposure is inversely related to social position. The lower a person’s social position,
the greater the exposure to different health hazards. People with most access to
important social and economic resources are best able to avoid risks, diseases and the
consequences of ill health [16]. As time changed, risk factors such as bad sanitation
and infectious diseases were eradicated, but instead they were replaced by factors
that include smoking, low exercise and poor diet. People of higher socio-economic
status are less likely to start smoking and more likely to quit when they smoke
[18]. Additionally, as the risk factors tend to increase with decreasing social class,
healthy behaviors (such as breast-feeding, exercise, healthy diet…) tend to decrease
with lower social class. Also environmental conditions have their impact. A report
on environmental pollution in England and Wales showed that people living in
deprived neighborhoods (based on income) are more often exposed to air pollution
due to the higher number of polluting factories in their neighborhood [16, 22].
3. The same level of exposure leading to differential impacts
The same level of exposure to a certain risk factor may have different effects on
different socio-economic groups. A Swedish study showed that similar levels of
alcohol misuse cause two to three times more alcohol-related diseases and problems
(such as psychological problems, divorce, low emotional control, contact with police
and injuries) among lower social classes than among the higher social classes. One
of the explanations is the difference in drinking patterns between the different
groups, but also the level of social support people perceive -which functions as a
protective factor-, was important [16, 23]. A 2002 study from Pope et al. showed
increased risk for both cardiopulmonary and lung cancer mortality with less educated participants at the same level of air pollution [24]. The differences in impact
of risk factors could be due to the fact that low socio-economic groups are more
likely to be exposed simultaneously to several risk factors that reinforce each other.
For example, smoking, bad housing, air pollution, suppressed immune system due
to prolonged stress,…[19].
4. Life-course effects
The life-course effects include the accumulation of all the above mentioned pathways
over a person’s life-time. Many life-events generate poor health later on, and material
circumstances in early life are stronger predictors of health status in later life than
social position during adulthood [16, 25, 26]. Life-course effects may be passed from
generation to generation as they are closely related to social position. For example,
23
Chapter 1: Introduction
the social position of parents has an influence on the education children receive,
which in turn influences their job opportunities, working condition, and the salary
of the children when they are grown [16, 26].
These life-course effects start from the womb on. A Belgian consumer organization
studied the smoking behavior of 22.000 pregnant women. Smoking during the
pregnancy can lead to a lower birth weight and a higher risk for chronic conditions
(such as heart conditions) during adult life. Despite this fact 18% of the women kept
smoking. There was a clear social gradient noticeable: 35% of lower socio-economic
groups kept smoking compared to 7% of the women of higher social groups [25].
5. Different social and economic effects of being sick
24
Poor health may have many adverse consequences for the life of individuals: job
loss, loss of income, restrictions, social isolation,… At the same time, people with ill
health often face additional financial problems due to high out of pocket payments
for health care, medication, household help,… [16]. A Swedish survey shows that
people from higher socio-economic groups with a limiting longstanding illness
have better chances keeping their job than those from the lower socio-economic
group with the same health problems [27].
The impact of this pathway depends partly on the health care system and welfare
regime (e.g. social security) within a country [16]. For example, when a person in
Belgium gets sick, he/she does not automatically lose his/her income thanks to the
social security system in Belgium.
Chapter 1: Introduction
3. Tackling health inequities
As stated above, health inequities are a result of social inequities. Action on health
inequities requires action across all the social determinants of health. Also, focusing solely on the most disadvantaged population groups will not reduce health
inequities. To tackle these inequities, universal strategies for the entire population
are needed, as well as strategies targeting certain subgroups [28]. This is known as
proportionate universalism [4, 29].
3.1 European policy actions
Several important organizations addressed the importance of taking action across all
the social determinants of health. The actions are global as well as within countries
and between countries.
In 2005, in the spirit of social justice, the Commission on Social Determinants of
Health (CSDH) was set up by the World Health Organization (WHO) to marshal
the evidence on what can be done to promote health equity and to foster a global
movement to achieve it. The commission aims at supporting health policy changes
by assembling effective practices that address the social determinants of health,
making health equity a shared goal and building a sustainable global movement
for action on health equity and social determinants.
The Commission on Social Determinants of Health’s report, Closing the Gap in a
Generation, published in August 2008, identified three main principles to reduce
health inequalities: improve daily living conditions; tackle the unequal distribution
of power, money, and resources; and measure and understand the problem and assess the results of action [13].
Professor Sir Michael Marmot was challenged to convert these three principles
into practical policies that are appropriate for England and the UK in general. The
report was published in 2010 as Fair society healthy lives, also known as the Marmot
review, and emphasizes the importance of inequalities in daily life conditions and the
fundamental drivers that give rise to them: inequities in power, money and resources
[13]. The review states that health equity can become reality but only when health
equity becomes a fundamental principle underlying national and local policies for
health delivery. Six main policy objectives are outlined in the Marmot Review as
crucial to achieving health equity: give every child the best start in life; enable all
children, young people, and adults to maximise their capabilities and have control
25
Chapter 1: Introduction
over their lives; create fair employment and good work for all; ensure a healthy
standard of living for all; create and develop healthy and sustainable places and
communities; and strengthen the role and impact of ill-health prevention [4] [30].
Although this report was written from a UK context, its message inspired many
European policy makers.
Based on this work and other work of the Commission on Social Determinants
of Health, the WHO Regional Office for Europe commissioned a review for the
European Region (review of the health divide and inequality in health in the
WHO European Region) [31].
In the light of this review, Health 2020 was introduced as a collaborative initiative
between EU Member States and their health-related institutions to strengthen
existing evidence, expertise and support for action on achieving better health for
the European Region at the year 2020 [11].
26
The goals of Health 2020 are: to achieve better health for the European Region and
its people; to increase equity in health and accelerate progress on achieving the right
to health; to make health an endeavor for all in society; to enhance regional and
global awareness of and action for health and the determinants of health; to develop
suggested solutions, tools, evidence, guidance and partnerships that support health
ministries, together with other stakeholders, in putting in place national policies,
services and governance arrangements that realize their societies’ health potential
on an equal basis [11]. Each EU member state must produce a National Reform
Program each year in April, explaining what they are doing to move closer to the
Europe 2020 targets. Flanders also produced its own Flemish Reform Program.
Flanders in Action, the Flemish long term strategy and the Pact 2020, served as a
broader policy framework. Furthermore, the Strategic Advisory Board on Welfare,
Health and Family created in the light of 2020 a report on socially accountable
care. Important concepts are the quality, performance, justice, relevance and access
of the delivered care [32].
Chapter 1: Introduction
Box 1: Health 2020 in Flanders
The Flanders’ health care 2020 objectives are:
•
In 2020, Flanders will be able to boast of an adapted, accessible, affordable,
and high-quality aid and care system.
•
Efficacy, efficiency, and quality of care from the perspective of the patient
are the central points.
•
Primary health care and homecare are improved in 2020.
•
Establishing group-practices is being promoted.
•
Child care is available for minimum half of the children aged 3 years or
younger.
•
There is a sufficient supply of care for the disabled, the elderly and people
with mental health problems.
In 2011 there was the first follow up measurement on some of these objec-
tives. There was a decline in the accessibility and affordability of the medical
and social care: data from the HIS 2008 showed that 11% of the households
postponed a medical care visit due to financial reasons. This number has dou-
bled since the HIS 2004. The percentage of group-practices in Flanders is stable: 33% of all practices in Flanders are group-practices. No statement can be
made on the evolution of this number [33].
3.2 Proportionate universalism
To reduce the steepness of the social gradient in health, actions must be universal,
but with a scale and intensity that is proportionate to the level of disadvantage.
This is called proportionate universalism. Where policies have been designed with
a focus on health inequities, they are often aimed at the lower end of the social
gradient. Even if they are effective, these policies fail to tackle all the inequalities
that exist for other socio-economic groups and even create “new vulnerable groups”
[4]. Figure 6 shows that interventions focused on the lower social groups can reduce
the differences between the lower and higher social groups. However, when these
27
Chapter 1: Introduction
actions are not focused on all social groups in society, a new vulnerable population
group is created.
I
II
III
IV
V
Figure 6: action is needed on all levels of society
28
Many of the key health behaviours significant to the development of chronic diseases follow a social gradient: smoking, obesity, lack of physical activity, unhealthy
nutrition. Reducing health inequalities requires an amplified focus on these health
behaviours in a way that ensures proportional universalism is being achieved. What
will be required are population-wide interventions on smoking, alcohol and obesity
to reduce the social gradient but targeted interventions may be needed to target
particular groups. Often, the most advantaged groups are often better resourced
to take advantage of population-wide interventions. Indeed, without attention to
distributional impact and the underlying causes of behaviours, interventions to
improve health may increase inequities. Wherever ill health prevention and health
promotion take place, whether in primary care, a school or in a leisure centre,
evaluations need to assess effectiveness across the social gradient. The impact of
interventions need to be assessed by measurable indicators of reductions in health
inequalities and separately assessed for cost-efficiency [34].
Chapter 1: Introduction
4. The importance of equitable primary health care
This thesis focuses on equity in health care and was written with a special interest
for primary health care. Therefore, in this part of the intro, we will emphasize on
primary health care.
4.1 Defining primary health care
Primary Health Care as defined by the World Health Organization on the Alma
Ata declaration in 1978 is:
“Essential health care; based on practical, scientifically sound, and socially acceptable
method and technology; universally accessible to all in the community through
their full participation; at an affordable cost; and geared toward self-reliance and
self-determination. It forms an integral part both of the country’s health system, of
which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals,
the family and community with the national health system bringing health care as
close as possible to where people live and work, and constitutes the first element
of a continuing health care process” [35, 36].
Primary care addresses the most common problems in the community by providing
preventive, curative and rehabilitative services to maximize health and well-being.
It integrates care when more than one health problem exists, deals with the context
in which illness exists and influences people’s responses to their health problems.
It is care that organizes and rationalizes the deployment of basic and specialized
resources directed at promoting, maintaining and improving health [37].
These definitions have been used to identify the four main features of primary care
services: first-contact access for each new need; long-term person- (not disease)
focused care; comprehensive care for most health needs; and coordinated care when
it must be sought elsewhere [38].
29
Chapter 1: Introduction
Box 2: Primary care in Belgium
In Belgium, GPs do not serve a gatekeeping role. Patients have free choice
concerning the first physician to contact, can change physician at any time,
get a second opinion, or even consult several physicians at a time. Moreover,
they can directly access specialists or enter hospitals. The free choice of phy-
sician is an important right granted to patients. Nevertheless, a large number
of patients have a regular GP. The average number of physician contacts per
person in Belgium is in line with the EU27 average (6.9 outpatient contacts
per person in 2008, compared to the average of 6.86 in the EU27 [39, 40]. In
Flanders 97.1% declares to have a regular GP, in the Walloon region this percentage is decreasing from 96% in 2004 to 94.4% in 2008 [41].
Physicians operate in solo- or group-practices. Apart from these solo- or
group- practices there are integrated primary health care centers, such as me30
dical houses (maison médicale or Community Health Centres), which operate
a multidisciplinary team, including several GPs, administrative and reception
staff and nurses and sometimes also a physiotherapist and psychotherapists,
social workers,…. The number of such practices is growing, although there is
still only a small minority of people affiliated to them [39, 40].
According to the satisfaction with the delivered care, 96% of the patients in
Flanders is satisfied with the delivered primary care of the GP, in the Walloon
region, 92% is satisfied with the delivered primary care and in the Brussels
region 91% is satisfied [41].
4.2 Defining (in)equity in (primary) health care
“No one should be denied access to life-saving or health-promoting interventions for
unfair reasons, including those with economic or social causes”
Margaret Chan, WHO Director-General [42].
There is a higher prevalence of chronic diseases such as diabetes, asthma, chronic
obstructive pulmonary disease, heart disease,… among persons from lower socioeconomic groups, leading to higher health care need [43-45]. Tudor Hart captured
Chapter 1: Introduction
the idea of inequity in health care use in the Inverse Care Law, stating that “the
availability of good medical (primary and specialist) care tends to vary inversely
with the need for it in the population served”. So those with the greatest need for
care, often have the poorest access [46, 47].
Sometimes this inequity in health care is very clear (e.g. low social status is associated with worse quality of diabetes care) [48], but in other cases, it can be very
complex. For example, when health status is taken into account, the utilization of
GP is equitable (does not vary across income or socio-economic groups) or propoor (favoring the lower socio-economic groups), whereas specialist care tends to
favor the better off (higher income and better educated groups) [44, 49, 50]. This
phenomenon appears to be universal, but is reinforced when private insurance or
private care options are offered [44, 49].
Also social differences in postponing health care have been described. Studies suggest that disadvantaged people are at a higher risk for delaying care for medical
conditions. These untreated conditions may eventually lead to hospitalization or
emergency department use [51].
4.2.1 Equity in health care
Striving for equity in health care is one of the primary goals of the WHO [52].
Equity in health care means that patients who are alike should be treated in the
same way (horizontal equity) and that patients who are unlike, should be treated in
the same unlike way (vertical equity) [53-56]. Health care systems contribute most
to improving health and equity when the institutions and services are organized
around the principle of universal coverage (extending the same scope of quality
services to the whole population, according to needs and preferences, regardless of
ability to pay) [13].
Essential in an equitable health care system are: (1) equal access for equal need,
(2) equal treatment for equal need and (3) equal outcomes for equal need [10].
4.2.2. Equal access for equal need
It is a human right to have access to effective health care. But around the world,
access is inadequate for some groups or may even be unattainable for all practical
purposes [10, 51]. According to Goddard et al. (2001), ‘access’ refers –at the most
general level- to “the ability to secure a specified range of services, at a specified
31
Chapter 1: Introduction
level of quality, subject to a specified maximum level of personal inconvenience and
costs, whilst in the possession of a specified level of information” [56]. This definition indicates that access to health services has many aspects. Based on literature
we can distinguish geographical access, cultural access and economic access to care.
Geographical access
Geographical accessibility enholds the availability and distance to health care
providers (in terms of distance and time). The location of the GP to the place of
residence has a major influence on the accessibility to the doctor for the patient,
both directly (e.g. time to get to the doctor) and indirectly (by affecting travel mode
and through interactions with factors such as family and work commitments). Aside
from the distance to the doctor, also personal mobility such as car ownership, access
to a car and use of alternative methods of transport (e.g. public transportation) is
important. Non-car owners more often make use of home visits, the same results
appear for not having access to a car [57, 58].
32
The study of Hart in the coal-mining valleys of Wales is a good illustration of geographic access. The miners suffered from occupational disabilities (such as pulmonary
diseases). However, the health care facilities and the quality of the provided care
were much worse in the areas where these miners lived compared to other regions
with lower morbidity rates [46].
But then there is also the doctor’s side. Doctors in deprived areas, where there are
higher sickness and death rates have to work harder: more out-of-hour contacts
and more same day consultation with less support (hospitals far away, transportation problems…) and a higher load of longer-distance house-visits [46, 47, 57-59].
Cultural access
Cultural access relates to acceptability and respect. Language barriers, miscommunication between health care provider and patient due to different priorities,
receiving an unequal amount of attention or differences in treatment outcomes are
often the result of cultural access [10]. Physicians may have a harder time understanding symptoms or they might even misunderstand the symptoms of vulnerable
patients due to language barriers or miscommunication. Sometimes physicians
may hold unconscious racial or ethnic biases that influence their interactions with
minority patients [10, 60-63]. Studies have shown that minority patients often
benefit less from treatment and as a result may demand less care [64-66]. A study
Chapter 1: Introduction
by Campbell et al. reported that non-white-ethnic minority respondents reported
less favorable assessments on almost all of the 13 dimensions of care examined.
Differences were highest in the performance of the reception staff, accessibility of
care and trust in the GP [67].
Shortcomings in respect and dignity to certain groups is another example of cultural access. Several studies showed that homeless people often postpone health
care because they feel labeled, stigmatized or considered as “problem patients” [68,
69]. But this is not only the case for homeless people. Van Ryn et al. found that
physicians tend to perceive members of low and middle SES groups more negatively
on personality characteristics (lack of self-control, irrationality) and level of intelligence. They also perceive low SES patients as people with little compliance, less
commitment, no career demands and no desire for a physically active lifestyle [61].
A common issue in these patient groups are the competing priorities. Homeless
people postpone more often their health care because of these competing priorities:
e.g. finding housing or employment, getting through the day, feeding their children
etc. is more important than caring about their own health [70-72].
Furthermore, there is a gap of awareness and understanding of the day-to-day restrictions of low-income or homeless people by health care workers [10, 65]. People
from deprived areas in Scotland prefer holistic GPs who understand the realities of
life in such areas and whom they can trust as both competent and genuinely caring.
Without this, they may judge their GP as socially distant and emotionally detached
[73]. Also, there may be differences in the attention that patients from less advantaged backgrounds receive. This can lead to differences in the quality of care [74].
Economic access
What use is there in having health care services on your doorstep when you cannot
afford to use them? The strongest example of the problem of economic access is
when people in need of emergency care are turned away from a clinic or hospital
and left to die because they cannot afford to pay [10]. Although this extreme practice is very rare in Europe, there are an increasing number of people postponing
medical care due to financial reasons [10, 75]. In Europe, 4.5% of the low income
people cannot afford medical care compared to 0.5% of the high income people. In
Belgium, for 2008, 1.5% of the 20% low income people cannot afford medical care,
compared to 0.1% of the 20% high income people [76]. Data from the Belgian
Health survey show that in 2008, 13.7% of the households postponed medical care
33
Chapter 1: Introduction
due to financial reasons. There is a clear social gradient: 18.1% of the households
with a low educational level postponed care, compared to 17.6% of those with a
lower secondary school education, 13.4% of those with a higher secondary education
and 9.4% with a high educational level [6]. In Belgium, 7% of the total monthly
household income is spent on medical care. As a consequence, 35% of the Belgian
households report that health care costs are a large burden on their income [6, 77].
Another aspect of economic access is, when people have to pay the out-of-pocket
fees, and get into financial troubles or debts as a result of it. Whitehead and Dahlgren
call this the medical poverty trap: impoverishment caused by paying for medical
care. This is most frequent in the developing world, but the medical poverty trap is
also present in Eastern Europe and the United States [10, 78].
Box 3: Financing of the Belgian health care system
Belgium has a nearly universal health care system. Patients can choose their
physicians freely and have direct access to any GP or specialist at any time, for
34
any problem. Almost 99% of the Belgian population is covered by the compulsory health insurance [39]. The main payment system used in Belgium is
the fee-for-service system. In this system, payment is made for units of service:
physicians are paid an amount of money for each type of service they provide.
This payment system has the intention to allow physicians to respond in a
flexible way to their patient’s needs and demands [79, 80]. The patient pays
the set fee for the consultation directly to the GP, and patients are then partly
reimbursed by their sickness funds. Co-payments vary from service to service.
Co-payments rates are about 25% for GP consultations, 35% for GP home visits and 40% for specialist consultations. For certain groups of patients, among
the lower socio-economic groups, there is a reduced co-payment of about 10%
for the GP consultation and about 15% for specialist consultation [39]. The
total amount of co-payment per year is limited by an income-related thres-
hold called the maximum billing: as soon as expenses reach the set ceiling, any
further health care costs are fully covered by the health insurance fund for the
remaining part of the year [39]. Furthermore, for people with financial dif-
ficulties, there is the third-party system. Physicians using the third-party sys-
tem, get paid by the sickness fund and the patient only has to pay user charges
Chapter 1: Introduction
(co-payments) to the physician [39].
Since 1982, the legal possibility to work in a capitation system in Belgium
was put into practice. The patient has to be registered with a GP or a group
of primary care providers and does not have to pay for a consultation. This
method of payment is also meant to eliminate the financial barrier in visiting
primary care [79]. Currently 2% of the Belgian population is cared for in the
capitation system [39]. In the capitation system, the unit that is paid for is the
patient. The health care provider is paid a specified sum of money by the insurance companies for the ongoing care of a patient for a particular period over
time no matter how often this patient uses this service [79]. The total number
of group practices using a capitation system increased from 53 in 2003 to 99
in 2009 [39, 40]. A Belgian cohort study showed that patients visiting group
practices working with capitation system are generally more vulnerable (low
income, low social class). Patients visiting these group practices have lower
specialist referrals and therefore lower expenses for specialist care and received
a better follow up on preventive interventions. The quality of care delivered
from practices working with capitation compared to practices working on a
fee-for-service base was the same [81].
4.2.3. Equal treatment for equal need
In an equitable health care system, patients should receive the same health care
treatment independent from their age, sex, income,.. [54, 82]. However evidence
shows that higher-income groups receive higher quality-services than lower-income
people [5, 50, 83]. A systematic literature review found that low socio-economic
position, measured by income or education, is associated with receiving fewer childhood and influenza immunizations and diabetic eye examinations, later enrollment
in prenatal care, lower quality ambulatory and hospital care and fewer cervical smear
tests, mammograms [84] For example, in the US, almost 80% of women below
the poverty level never had a mammogram, compared with 50% of women in the
highest income category. For ever having had a Pap smear, the percentage varies
from less than 1% in well-served groups to more than 40% in very poorly served
groups [85]. A US study found that low income people received less chronic and
preventive care than their more-affluent counterparts, however they did not find
35
Chapter 1: Introduction
differences in treatment according to educational level [86]. Le et al found that
patients from lower social class, suffering from colorectal cancer (CRC) were more
often refused surgery than patients from higher social classes [87].
‘Treatment’ is not only about the medical procedures followed but also the attitude and the interaction with the health care provider is essential in giving equal
treatment. A systematic review of literature found that patients from lower social
class received less socio-emotional talk, a more directive and a less participatory
consulting style characterized by for example less involvement in treatment decisions, lower patient control over communication, not explaining things in a way
patients understand, less diagnostic and treatment information and more physical
examination [88, 89]. Bernheim et al. found, by means of qualitative research that
physicians undertook changes in their management decisions (for example, referral
to hospitals, additional tests,…) depending on the social class of the patient [74].
4.2.4. Equal outcomes for equal need
36
When people receive the same access and same treatment in health care, they should
have the same outcomes when they are in similar needs. However, differences in
treatment outcomes between different socio-economic groups may be observed
despite the fact that the same treatment was given [8, 10, 90]. A Norwegian study
found an overall negative socio-economic gradient in cancer survival [91]. A UK
population based study found differences in incidence and mortality from Acute Myeloid Leukemia (AML): poorer survival in AML patients from low socio-economic
classes despite the same treatment as patients from higher socio-economic classes
[92]. Shimony et al investigated the impact of SES on the outcomes following
percutaneous coronary intervention (PCI). Previous studies found no association
between SES and cardiovascular outcomes [93] or found that unemployment and
a deprived status were associated with poorer quality of life indices one year after
PCI, however, clinical outcomes were not taken into account [94]. In their study
they found that low SES was associated with less use of drug eluting stents (DES),
lower adherence to aspirin and to clopidogrel and higher rates of repeat revascularization and recurrent myocardial infarction [95]. A US study on the health (care)
outcomes of epilepsy patients of different socio-economic populations found that
low SES patients had a greater likelihood of having uncontrolled seizures, drugrelated side effects, to be stigmatized and have a lower overall quality of life [96].
Chapter 1: Introduction
4.3 A role for Primary Health Care in tackling health inequities
While equity marks one of PHC’s boldest features, it is one of the areas where
results have been most uneven and where the premium for more effective reforms
is perhaps the greatest. Out-of-pocket payments for health care are but one of the
sources of health inequity. Deeply unequal opportunities for health combined with
endemic inequalities in health care provision lead to pervasive inequities in health
outcomes [52]. It takes a wide range of interventions to tackle the social determinants
of health and make health systems contribute to more health equity. One of the
interventions is building a sustainable strong Primary Health Care system [38, 97].
Improving population health
International studies show that the strength of a country’s primary care system
is associated with improved population health outcomes for all-cause mortality,
all-cause premature mortality and cause-specific premature mortality from major
respiratory and cardiovascular diseases [98]. This relationship is significant after
controlling for determinants of population health at the macro-level (GDP per
capita, total physicians per one thousand population, percentage of elderly) and
micro-level (average number of ambulatory care visits, per capita income, alcohol
and tobacco consumption) [36, 98].
Furthermore, PHC characteristics such as geographic regulation, longitudinality,
coordination and community orientation were associated with improved population
health. This reinforces findings of an earlier international comparison involving 11
developed countries which demonstrated that a higher primary care orientation of
a health system was more likely to produce better population health outcomes, at
lower cost, and with greater user satisfaction [36-38] .
But also the relationship between a primary care provider and a patient has an
impact on the health outcomes. People who identify a primary care physician as
their usual source of care are healthier, regardless of their initial health or various
demographic characteristic [38, 99].
Disparities in health outcomes
When reviewing the impact of primary care on reducing the inequities in health,
Starfield et al. found that higher ratios of primary care physicians to population are
associated with relatively greater effects on various aspect of health in more socially
37
Chapter 1: Introduction
deprived areas (measured by high levels of income inequity). In the United States a
study on county level showed that the adverse impact of income inequity on all-cause
mortality, heart disease mortality and cancer mortality was considerably diminished
in counties where the number of primary care physicians in county-level analyses
was high [100]. The equity-related effect of having a good primary care source was
also found in a study that examined the degree of primary care-oriented services
that people received. Good primary care experiences were associated with reductions in the adverse effects of income inequality on health, with fewer differences in
self-rated health between higher and lower income-inequality areas where primary
care experiences were stronger [101].
Cost-effectiveness
38
Health systems dominated by specialists, such as that of the United States, have
higher total costs and reduced access to health care by vulnerable populations [36,
102, 103]. The high cost is attributed to proportionately low number of primary
care physicians and consequent impairment of the gate-keeping function [104,
105]. Shifting care across specialist-general practice and secondary-primary care
boundaries is possible and has been shown to be cost effective without an adverse
effect on outcomes. For example: GP-led hospitals in Norway provided health
care at lower cost compared to alternative modes of care, due to averted hospital
costs [106]. Several studies show that care delivered by GPs, compared to hospital
specialists, in hospital-based accident and emergency departments is more cost effective with lower use of diagnostic investigations, lower referral rates to secondary
services, lower prescription levels and no significant difference in patient satisfaction
or health outcomes [107-109].
Quality, efficiency and satisfaction of care
Primary care physicians are more likely than specialists to provide continuity and
comprehensive care resulting in improved health outcomes [110]. Better access to
primary care physicians leads to less hospitalization, less utilization of specialist
and emergency centres and less chance of being subjected to inappropriate health
interventions [36]. In contrast, when direct access to specialists is possible without a
controlling mechanism by primary care physicians, the quality of care, as measured
by appropriateness, worsens and health care costs increase [111].
Chapter 1: Introduction
However, it is also important to consider the possible adverse effects of a strong
primary health care system.
First of all, the expansion of primary health care services may not always reduce
costs because it may end up identifying previously unmet needs, improves access,
and tends to expand service utilization [36]. In a complex healthcare system, every
organizational structure, like gatekeeping, may have unwanted effects [112]. One
of the adverse effects of the gatekeeping system are the long waiting times. For
the UK, it has been stated that 500-10.000 patients with cancer die each year due
to delays in diagnosis resulting from the long waiting times [113]. Further, a gatekeeper system may delay advanced diagnostic tests. GPs are often not licensed
to refer patients to the appropriate diagnostic tests, so the patients first need to
be referred to a specialist before receiving the appropriate tests (such as imaging
technologies) [112].
Finally it is important not to define the role of primary care in isolation but in
relation to the other aspects of the health care system. Primary and secondary care
all have important roles in the health system. They are not mutually exclusive, but
rather necessary ingredients for a good working system [36].
4.3.1 The mechanisms through which primary care can tackle the inequities
in health
We have described above that people from lower socio-economic groups are disproportionately affected by many of the various barriers that may hinder health
service access, treatment and outcomes. A lot of health may be gained by tackling
these inequities. Health professionals are well placed as health advocates to influence
social determinants of health and to tackle health inequalities: yet their role is often
under-utilised. They are involved in direct patient care, are in contact with people
over longer periods in their life- e.g. general practitioners and dentists-, at key points
across their life course- e.g. midwives, health visitors, school nurses, nursing home
staff-, or at times of illness- primary, secondary or even tertiary care teams [97].
In primary care, shifting service provision away from vertical, disease oriented
programs towards horizontal community-oriented programs promises to yield
results. There is also great potential for healthcare professionals to support and
empower communities and individuals taking more control over their health and
well-being, especially when they join forces with local health trainers, community
health champions and community development work [97].
39
Chapter 1: Introduction
Literature shows that people from lower social classes receive lower levels of qualitative health care, fewer preventive tests and tend to postpone health care [19, 84,
114]. Primary health care can help to tackle these problems. Based on the available
evidence, Starfield et al. proposed several mechanisms that may account for the
beneficial impact of primary care on tackling the health inequities.
•
•
40
•
Primary care adds to a better quality of care
Primary care physicians do at least as well as specialists in caring
for common diseases, and they do better overall when the measures
of quality are generic (e.g. not focused on specific diseases). For less
common conditions, the care provided by primary care physicians
with appropriate backup from specialists may be the best; for rare
conditions, appropriate specialist care is needed because primary
care physicians do not see these conditions frequently enough [38].
Primary care has a greater focus on prevention
Evidence shows that “generic” preventive interventions – these are
preventions not related to a disease or an organic system- are best
implemented in primary care. Interventions on breast-feeding,
smoking cessation, diet, physical exercise,…seem to have the best
impact when they are implemented in primary care [38, 115].
Furthermore a greater supply of family physicians is associated with
an earlier detection of breast cancer, colon cancer, cervical cancer
and melanoma [38, 116-118].
Primary care adds to the early management of health problems
Primary care is able to manage health problems before they become
too serious and require hospitalization or emergency services [38].
In the UK, each 15-20% increase in the supply of primary care physicians was associated with a decrease in hospital admission rate of
about 14 per 100.000 for acute illnesses and about 11 per 100.000
for chronic illnesses, even after controlling for the degree of social
deprivation, ethnicity and limiting long-term illness [38, 119].
Furthermore, low social groups have a higher tendency to visit the emergency
department and perceive several barriers towards the health care system [50, 120].
Also here, primary care can make a contribution:
•
Primary care increases access to health services for relatively deprived population groups
Chapter 1: Introduction
•
Primary care functions as the point of first contact with health services and facilitates the entry to the rest of the system. With the
exception of the United States, most industrialized countries have
achieved universal and equitable access to primary health services
[121]. As a results, in the United States, socially deprived population subgroups are more likely than more advantaged people to lack
a regular source of care [38].
Primary care reduces unnecessary and potentially harmful specialist care
Studies from the United States show that increasing the supply
of specialist care either has no effect or an adverse effect on major
health outcomes. The adverse effects of seeking specialist care as a
point of first contact can be explained by a strong theoretical basis.
Specialists are trained in a hospital setting and the patients they see
are not representative for patients in community settings. Patients
consulting a specialist often have a more specific and more serious
disease that needs additional diagnostic tests. The result is that specialist practices as a point of first contact overestimate the likelihood
of illness in the patients they see, with the consequently inappropriate use of diagnostic and therapeutic modalities, both of which raise
the likelihood of adverse effects [38].
Finally, there is a positive effect of the accumulation of the main primary care
characteristics.
The beneficial effects of primary care on mortality and morbidity can be attributed, at least in part, to the person-focused aspect of primary care rather than on
the management of particular diseases. Primary care focuses on achieving better
outcomes for health in all of its aspects rather than on the procedures directed at
improving the processes or outcomes of care for a particular condition or disease.
Another important characteristic of primary care is its role as the first contact for
patients when a problem develops. Having a relationship with a GP who can function as an initial point of contact is strongly associated with less use of specialists
and emergency rooms. Furthermore, continuity of care, which means that a person
uses his/her GP as a source of care over time for most of his/her health care needs,
is associated with greater satisfaction, better compliance and lower hospitalization
and use of emergency department. On the other hand, very short-term relationships
with physicians are associated with poor health outcomes [38].
41
Chapter 1: Introduction
References
1.
Devos I: De evolutie van de levensverwachting in België, 18de-20ste eeuw.
Gent: Academia Press; 2006.
2.
Levensverwachting Belg bedraagt net geen 80 jaar [http://www.belgium.
be/nl/nieuws/2011/news_levensverwachting-belg.jsp]
3.
Van Oyen H, Deboosere P, Lorant V, Charafeddine R, Demarest S, Portet
F: Programma Samenleving en Toekomst. Eindverslag- deel “Synthese van
het onderzoek”. In. Brussel: Federaal Wetenschapsbeleid; 2010.
4.
Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, Geddes I:
Fair Society, Healthy lives. The Marmot review. Executive Sumary; 2010.
5.
Mackenbach JP, Stirbu I, Roskam AJ, Schaap MM, Menvielle G, Leinsalu
M, Kunst AE: Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008, 358(23):2468-2481.
6.
Drieskens S, Van der Heyden J, Hesse E, Gisle L, Demarest S, Tafforeau J:
Gezondheidsenquête België, 2008. Rapport V - Sociaal-economische ongelijkheden in gezondheid. In.; 2010.
7.
Link BG, Phelan J: Social conditions as fundamental causes of disease. J
Health Soc Behav 1995, Spec No:80-94.
8.
Whitehead M, Dahlgren G: Concepts and principles for tackling social
inequities in health: Levelling up Part 1. 2006.
9.
Social determinants of health. Key Concepts. [http://www.who.int/social_
determinants/thecommission/finalreport/key_concepts/en/index.html]
42
10. Whitehead M, Dahlgren G: Levelling up (part 1): a discussion paper on
concepts and principles for tackling social inequities in health. In.: WHO
collaborating Centre for Policy Research on Social Determinants of Health,
University of Liverpool; 2006.
11. Interim second report on social determinants of health and the health divide in the WHO European Region. In.: Regional Committee for Europe;
2011.
12. Chang WC: The meaning and goals of equity in health. J Epidemiol Community Health 2002, 56(7):488-491.
13. CSDH: Closing the gap in a generation: health equity through action on
the social determinants of health. Final Report of the Commission on Social Determinants of Health. In. Geneva: World Health Organisation; 2008.
Chapter 1: Introduction
14. Vandenbroucke F: Social Justice and Individual Ethics in an Open Society.
Equity, Responsibility and Incentives.: Springer; 2001.
15. Wilkinson RG, Pickett KE: The Spirit level. Why Equality is better for
everyone: Penguin Books; 2010.
16. Dahlgren G, Whitehead M: Levelling up (part 2): a discussion paper on
European strategies for tackling social inequities in health; 2006.
17. Diderichsen F, Evans DB, Whitehead M: The social basis of disparities in
health. In: Challenging inequities in health - from ethics to action. edn.
New York: Oxford University Press; 2001.
18. Link BG, Phelan JC: Understanding sociodemographic differences in
health--the role of fundamental social causes. Am J Public Health 1996,
86(4):471-473.
19. Wilkinson RG, Pickett KE: Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 2006, 62(7):1768-1784.
20. Wilkinson RG: the impact of inequality: how to make sick societies healthier. London: Routledge; 2005.
21. Health inequalities: Europe in profile. An independent expert report commissioned by and published under the auspices of the United Kingom
Presidency of the European Union [http://ec.europa.eu/health/ph_determinants/socio_economics/documents/ev_060302_rd06_en.pdf ]
22. McLaren D, Cottray O, Taylor M, Pipes S, Bullock S: The geographic relation between household income and polluting factories. In. Edited by Earth
Fot; 1999.
23. Hemmingsson T, Lundberg I, Diderichsen F, Allebeck P: Explanations of
social class differences in alcoholism among young men. Soc Sci Med 1998,
47(10):1399-1405.
24. Pope CA, 3rd, Burnett RT, Thun MJ, Calle EE, Krewski D, Ito K, Thurston
GD: Lung cancer, cardiopulmonary mortality, and long-term exposure to
fine particulate air pollution. JAMA 2002, 287(9):1132-1141.
25. Eriksson JG, Forsen T, Tuomilehto J, Winter PD, Osmond C, Barker DJ:
Catch-up growth in childhood and death from coronary heart disease: longitudinal study. BMJ 1999, 318(7181):427-431.
26. Power C, Matthews S: Origins of health inequalities in a national population sample. Lancet 1997, 350(9091):1584-1589.
27. Lindholm C, Burstrom B, Diderichsen F: Class differences in the social
consequences of illness? J Epidemiol Community Health 2002, 56(3):188192.
43
Chapter 1: Introduction
28. Baum F: Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health. Promot Educ 2007,
14(2):90-95.
29. Marmot M: Status Syndrome. How your social standing directly affects
your health and life expectancy: Bloomsbury; 2004.
30. Health equity - an election manifesto? The Lancet 2010, 375(9714):525.
31. Marmot M: Interim first report on social determinants of health and the
health divide in the WHO European Region. In: European Social Determinants and Health Divide Review. World Health Organization Regional
office for Europe; 2010.
32. SARWGG: Visienota Maatschappelijk Verantwoorde zorg. In. Brussels;
2011.
33. Vlaanderen in actie. PACT 2020. Levenskwaliteit [http://vlaandereninactie.
be/actie/pact-2020/levenskwaliteit/]
34. Annual report 2010/11. In. Edited by Health SDoP; 2010.
44
35. Declaration of Alma-Ata. In: International Conference on Primary Health
Care. USSR; 1978.
36. What are the advantages and disadvantages of restructuring a health care
system to be more focused on primary care services? In. Edited by (HEN)
WROfEsHEN: World Health Organization Europe; 2004.
37. Starfield B: Primary Care. Concept, evaluation and policy. New York: Oxford University Press; 1992.
38. Starfield B: Contribution of Primary Care to Health Systems and Health.
The Milbank Quarterly 2005, 83(3):457-502.
39. Gerkens S, Farfan M, Desomer A, Stordeur S, De Waroux M, Van de Voorde C, Van de Sande S, Leonard C: Het Belgische Gezondheidssysteem in
2010. In. Edited by research HS. Brussel: Federaal Kenniscentrum voor de
Gezondheidszorg (KCE); 2010.
40. Gerkens S, Merkur S: Belgium. Health System Review, vol. 12; 2010.
41. Van Der Heyden J: Patiënttevredenheid. Gezondheidsenquête, België 2008.
In. Brussel: Wetenschappelijk Instituut Volksgezondheid; 2010.
42. Speech to the International Federation of Red Cross and Red Crescent
Societies Global Health and Care Forum 2008: Primary care starts with
people [http://www.who.int/dg/speeches/2008/20080514/en/index.html]
Chapter 1: Introduction
43. Droomers M, Westert GP: Do lower socioeconomic groups use more
health services, because they suffer from more illnesses? Eur J Public Health
2004, 14(3):311-313.
44. Regidor E, Martinez D, Calle ME, Astasio P, Ortega P, Dominguez V:
Socioeconomic patterns in the use of public and private health services and
equity in health care. BMC Health Serv Res 2008, 8:183.
45. Westert GP, Satariano WA, Schellevis FG, van den Bos GA: Patterns of
comorbidity and the use of health services in the Dutch population. Eur J
Public Health 2001, 11(4):365-372.
46. Hart JT: The inverse care law. Lancet 1971, 1(7696):405-412.
47. Carlisle R, Avery AJ, Marsh P: Primary care teams work harder in deprived
areas. J Public Health Med 2002, 24(1):43-48.
48. Baz L, Muller N, Beluchin E, Kloos C, Lehmann T, Wolf G, Muller UA:
Differences in the quality of diabetes care caused by social inequalities disappear after treatment and education in a tertiary care centre. Diabetic medicine : a journal of the British Diabetic Association 2012, 29(5):640-645.
49. van Doorslaer E, Masseria C, Koolman X: Inequalities in access to medical
care by income in developed countries. CMAJ 2006, 174(2):177-183.
50. Van der Heyden JH, Demarest S, Tafforeau J, Van Oyen H: Socio-economic differences in the utilisation of health services in Belgium. Health Policy 2003, 65(2):153-165.
51. Weissman JS, Stern R, Fielding SL, Epstein AM: Delayed access to
health care: risk factors, reasons, and consequences. Ann Intern Med 1991,
114(4):325-331.
52. WHO report 2008: Primary health care now more than ever. In.; 2008.
53. Culyer AJ: Equity - some theory and its policy implications. Journal of medical ethics 2001, 27(4):275-283.
54. Bayoumi AM: Equity and health services. Journal of public health policy
2009, 30(2):176-182.
55. Hanafin S, Houston AM, Cowley S: Vertical equity in service provision:
a model for the Irish public health nursing service. J Adv Nurs 2002,
39(1):68-76.
56. Goddard M, Smith P: Equity of access to health care services: theory and
evidence from the UK. Soc Sci Med 2001, 53(9):1149-1162.
57. Knox PL: The accessibility of primary care to urban patients: a geographical
analysis. J R Coll Gen Pract 1979, 29(200):160-168.
45
Chapter 1: Introduction
58. Field KS, Briggs DJ: Socio-economic and locational determinants of accessibility and utilization of primary health-care. Health Soc Care Community
2001, 9(5):294-308.
59. Leira EC, Hess DC, Torner JC, Adams HP, Jr.: Rural-urban differences
in acute stroke management practices: a modifiable disparity. Arch Neurol
2008, 65(7):887-891.
60. van Ryn M, Burgess D, Malat J, Griffin J: Physicians’ perceptions of patients’ social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease. Am J Public
Health 2006, 96(2):351-357.
61. van Ryn M, Burke J: The effect of patient race and socio-economic status
on physicians’ perceptions of patients. Soc Sci Med 2000, 50(6):813-828.
62. Burgess DJ, van Ryn M, Crowley-Matoka M, Malat J: Understanding the
provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping. Pain Med 2006, 7(2):119134.
46
63. De Maesschalck S: Linguistic and cultural diversity in the consultation
room: a tango between physicians and their ethnic minority patients.
Ghent: Ghent University; 2012.
64. Balsa AI, McGuire TG: Statistical discrimination in health care. J Health
Econ 2001, 20(6):881-907.
65. Doescher MP, Saver BG, Franks P, Fiscella K: Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med 2000,
9(10):1156-1163.
66. Burgess DJ, Fu SS, van Ryn M: Why do providers contribute to disparities
and what can be done about it? J Gen Intern Med 2004, 19(11):1154-1159.
67. Campbell JL, Ramsay J, Green J: Age, gender, socioeconomic, and ethnic
differences in patients’ assessments of primary health care. Qual Health
Care 2001, 10(2):90-95.
68. Martins DC: Experiences of homeless people in the health care delivery
system: a descriptive phenomenological study. Public Health Nurs 2008,
25(5):420-430.
69. Riley AJ, Harding G, Underwood MR, Carter YH: Homelessness: a problem for primary care? Br J Gen Pract 2003, 53(491):473-479.
70. Kushel MB, Vittinghoff E, Haas JS: Factors associated with the health care
utilization of homeless persons. JAMA 2001, 285(2):200-206.
71. Hwang SW: Homelessness and health. CMAJ 2001, 164(2):229-233.
Chapter 1: Introduction
72. Gelberg L, Gallagher TC, Andersen RM, Koegel P: Competing priorities
as a barrier to medical care among homeless adults in Los Angeles. Am J
Public Health 1997, 87(2):217-220.
73. Mercer SW, Cawston PG, Bikker AP: Quality in general practice consultations; a qualitative study of the views of patients living in an area of high
socio-economic deprivation in Scotland. BMC Fam Pract 2007, 8:22.
74. Bernheim SM, Ross JS, Krumholz HM, Bradley EH: Influence of patients’
socioeconomic status on clinical management decisions: a qualitative study.
Ann Fam Med 2008, 6(1):53-59.
75. Ziglio E, Barbosa R, Charpak Y, Turner S: Health Systems confront poverty. Public Health Case Studies, no. 1. In. Edited by Organization WH.
76. Dierckx D, Van Herck N, Vranken J: Armoede en sociale uitsluiting in
Europa en België. In: Armoede in België. edn. Edited by OASeS. Leuven/
Den Haag: Acco; 2010: 37-60.
77. Drieskens S, Van der Heyden J, Hesse E, Gisle L, Demarest S, Tafforeau
J (eds.): Gezondheidsenquête België, 2008. Rapport IV - Gezondheid en
Samenleving; 2010.
78. Whitehead M, Dahlgren G, Evans T: Equity and health sector reforms:
can low-income countries escape the medical poverty trap? Lancet 2001,
358(9284):833-836.
79. Physicians funding and health care systems - an international perspective.
In: A summary of a conference hosted by the WHO, WONCA and RCPG
at St John’s College, Cambridge. Edited by Brown PS.
80. De Maeseneer J, Willems S, De Sutter A, Van de Geuchte M, Billings M:
Primary health care as a strategy for achieving equitable care: a literature review commissioned by the Health Systems Knowledge Network. In.; 2007.
81. Annemans L, Closon J, Heymans I, Lagasse R, Mendes Da Costa E, Moureaux C, Roch I: Vergelijking van kost en kwaliteit van twee financieringssystemen voor de eerstelijnsgezondheidszorg in België. KCE reports 85A.
In.; 2008.
82. Aday LA, Begley CE, Lairson DR, Slater CH, Richard AJ, Montoya ID:
A framework for assessing the effectiveness, efficiency, and equity of behavioral healthcare. The American journal of managed care 1999, 5 Spec
No:SP25-44.
83. van der Meer JB, van den Bos J, Mackenbach JP: Socioeconomic differences
in the utilization of health services in a Dutch population: the contribution
of health status. Health Policy 1996, 37(1):1-18.
47
Chapter 1: Introduction
84. Fiscella K, Franks P, Gold MR, Clancy CM: Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA
2000, 283(19):2579-2584.
85. Calle EE, Flanders WD, Thun MJ, Martin LM: Demographic predictors
of mammography and Pap smear screening in US women. Am J Public
Health 1993, 83(1):53-60.
86. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn
EA: Who is at greatest risk for receiving poor-quality health care? N Engl J
Med 2006, 354(11):1147-1156.
87. Le H, Ziogas A, Lipkin SM, Zell JA: Effects of socioeconomic status and
treatment disparities in colorectal cancer survival. Cancer Epidemiol Biomarkers Prev 2008, 17(8):1950-1962.
88. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J:
Socio-economic status of the patient and doctor-patient communication:
does it make a difference? Patient Educ Couns 2005, 56(2):139-146.
48
89. DeVoe JE, Wallace LS, Fryer GE, Jr.: Measuring patients’ perceptions of
communication with healthcare providers: do differences in demographic
and socioeconomic characteristics matter? Health Expect 2009, 12(1):7080.
90. Alter DA, Naylor CD, Austin P, Tu JV: Effects of socioeconomic status on
access to invasive cardiac procedures and on mortality after acute myocardial infarction. N Engl J Med 1999, 341(18):1359-1367.
91. Braaten T, Weiderpass E, Lund E: Socioeconomic differences in cancer survival: the Norwegian Women and Cancer Study. BMC Public Health 2009,
9:178.
92. Bhayat F, Das-Gupta E, Smith C, McKeever T, Hubbard R: The incidence
of and mortality from leukaemias in the UK: a general population-based
study. BMC cancer 2009, 9:252.
93. Denvir MA, Lee AJ, Rysdale J, Walker A, Eteiba H, Starkey IR, Pell JP:
Influence of socioeconomic status on clinical outcomes and quality of life
after percutaneous coronary intervention. J Epidemiol Community Health
2006, 60(12):1085-1088.
94. Leslie SJ, Rysdale J, Lee AJ, Eteiba H, Starkey IR, Pell J, Denvir MA:
Unemployment and deprivation are associated with a poorer outcome following percutaneous coronary angioplasty. International journal of cardiology
2007, 122(2):168-169.
95. Shimony A, Zahger D, Ilia R, Shalev A, Cafri C: Impact of the community’s socioeconomic status on characteristics and outcomes of patients
Chapter 1: Introduction
undergoing percutaneous coronary intervention. International journal of
cardiology 2010, 144(3):379-382.
96. Begley C, Basu R, Lairson D, Reynolds T, Dubinsky S, Newmark M, Barnwell F, Hauser A, Hesdorffer D: Socioeconomic status, health care use, and
outcomes: persistence of disparities over time. Epilepsia 2011, 52(5):957964.
97. Re-orienting health systems: towards modern, responsive and sustainable
health promoting systems: draft. In. Edited by EuroHealthNet: EuroHealthNet; 2012.
98. Macinko J, Starfield B, Shi L: The contribution of primary care systems
to health outcomes within Organization for Economic Cooperation and
Development (OECD) countries, 1970-1998. Health Serv Res 2003,
38(3):831-865.
99. Franks P, Fiscella K: Primary care physicians and specialists as personal
physicians. Health care expenditures and mortality experience. J Fam Pract
1998, 47(2):105-109.
100. Shi L, Macinko J, Starfield B, Politzer R, Wulu J, Xu J: Primary care, social
inequalities and all-cause, heart disease and cancer mortality in US counties: a comparison between urban and non-urban areas. Public Health 2005,
119(8):699-710.
101. Shi L, Starfield B, Politzer R, Regan J: Primary care, self-rated health, and
reductions in social disparities in health. Health Serv Res 2002, 37(3):529550.
102. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE: Medicare
costs in urban areas and the supply of primary care physicians. J Fam Pract
1996, 43(1):33-39.
103. Rivo ML, Satcher D: Improving access to health care through physician workforce reform. Directions for the 21st century. JAMA 1993,
270(9):1074-1078.
104. Moore GT: The case of the disappearing generalist: does it need to be
solved? Milbank Q 1992, 70(2):361-379.
105. Franks P, Clancy CM, Nutting PA: Gatekeeping revisited--protecting patients from overtreatment. N Engl J Med 1992, 327(6):424-429.
106. Aaraas I, Sorasdekkan H, Kristiansen IS: Are general practitioner hospitals cost-saving? Evidence from a rural area of Norway. Fam Pract 1997,
14(5):397-402.
49
Chapter 1: Introduction
107. Dale J, Lang H, Roberts JA, Green J, Glucksman E: Cost effectiveness of
treating primary care patients in accident and emergency: a comparison
between general practitioners, senior house officers, and registrars. BMJ
1996, 312(7042):1340-1344.
108. Murphy AW, Bury G, Plunkett PK, Gibney D, Smith M, Mullan E, Johnson Z: Randomised controlled trial of general practitioner versus usual
medical care in an urban accident and emergency department: process, outcome, and comparative cost. BMJ 1996, 312(7039):1135-1142.
109. Ward P, Huddy J, Hargreaves S, Touquet R, Hurley J, Fothergill J: Primary
care in London: an evaluation of general practitioners working in an inner city accident and emergency department. J Accid Emerg Med 1996,
13(1):11-15.
110. Shear CL, Gipe BT, Mattheis JK, Levy MR: Provider continuity and quality of medical care. A retrospective analysis of prenatal and perinatal outcome. Med Care 1983, 21(12):1204-1210.
50
111. Leape LL, Park RE, Solomon DH, Chassin MR, Kosecoff J, Brook RH:
Does inappropriate use explain small-area variations in the use of health
care services? JAMA 1990, 263(5):669-672.
112. Vedsted P, Olesen F: Are the serious problems in cancer survival partly
rooted in gatekeeper principles? An ecologic study. Br J Gen Pract 2011,
61(589):e508-512.
113. Richards MA: The size of the prize for earlier diagnosis of cancer in England. British journal of cancer 2009, 101 Suppl 2:S125-129.
114. Whitehead M, Hanratty B: Health care for rich and poor alike. In: Accessing health care Responding to diversity. edn. Edited by Healy J, McKee M.
Oxford: Oxford University Press; 2004: 71-88.
115. Shi L: Primary care, specialty care, and life chances. Int J Health Serv 1994,
24(3):431-458.
116. Campbell RJ, Ramirez AM, Perez K, Roetzheim RG: Cervical cancer
rates and the supply of primary care physicians in Florida. Fam Med 2003,
35(1):60-64.
117. Ferrante JM, Gonzalez EC, Pal N, Roetzheim RG: Effects of physician
supply on early detection of breast cancer. The Journal of the American
Board of Family Practice / American Board of Family Practice 2000,
13(6):408-414.
118. Roetzheim RG, Pal N, van Durme DJ, Wathington D, Ferrante JM, Gonzalez EC, Krischer JP: Increasing supplies of dermatologists and family
Chapter 1: Introduction
physicians are associated with earlier stage of melanoma detection. Journal
of the American Academy of Dermatology 2000, 43(2 Pt 1):211-218.
119. Gulliford MC: Availability of primary care doctors and population health
in England: is there an association? J Public Health Med 2002, 24(4):252254.
120. Ahmed SM, Lemkau JP, Nealeigh N, Mann B: Barriers to healthcare access
in a non-elderly urban poor American population. Health Soc Care Community 2001, 9(6):445-453.
121. van Doorslaer E, Koolman X, Jones AM: Explaining income-related inequalities in doctor utilisation in Europe. Health Econ 2004, 13(7):629-647.
51
52
Chapter 2
Research aim
53
54
Chapter 2: Research aim
Research aim
In the previous chapter we introduced the concept of inequity in health and health
care and its determinants. Next, we focused on the role primary health care can play
in reducing inequities in health.
One of the actions in tackling health inequities is providing an equitable primary
health care system. The aim of this doctoral thesis is to focus on the equity in primary health care in Belgium in terms of equal access, equal treatment and equal
outcomes for vulnerable population groups. Part I of the thesis will focus on the
access to primary health care, where access is adressed by the definition of Goddard
et al (2001) “the ability to secure a specified range of services, at a specified level of
quality, subject to a specified maximum level of personal inconvenience and costs,
whilst in the possession of a specified level of information” [1]. In part II of the thesis
the emphasis is on the treatment and outcomes of primary care, more specifically
on the attitude of the doctor, doctor-patient communication and decision making.
In some of the studies, primary health care use is compared to other types of care
(e.g. specialist care) or is studied in specific settings (e.g. care for the homeless
people, low income people).
Figure 8 provides an overview of the main focus of the thesis and the hypotheses.
55
Chapter 2: Research aim
Equity in Health Care
Equal treatment for
patients in equal need
Equal access to care for
patients in equal need
e.g. communication, attitude, decision making
Equal outcomes for
patients in equal need
e.g. financial, cultural and
geographical access
Hypothesis 1
The specialist is the doctor of the high income
people and the GP is the doctor of the low to
middle income people (paper 1).
56
Hypothesis 2
Homeless people have a higher likelihood to
consult the emergency department than the
general population. A universal primary
health care system with active guidance for
homeless people towards this system might
counter this (paper 2).
Hypothesis 3
People who are not able to cope with their
available income have a higher likelihood to
postpone a visit to a GP (paper 3).
Hypothesis 4
The social gradient in doctor-patient communication persists, where patients from lower
socio-economic classes are less involved during
the consultation, receive less control and a
more paternalistic consultation style
(paper 4).
Hypothesis 5
Physicians have a negative attitude towards
patients with a low SES and as a result make
changes in their clinical decision which do not
favor the outcomes for the patient (paper 5).
Figure 8: an overview of the main focus of this thesis, the hypotheses and the research papers
Part I: Access to primary care for people with low SES in
Belgium
In the first part of this thesis we focus on access to care. Three hypotheses are
formulated:
•
Hypothesis 1: The specialist is the doctor of the higher-income people
and the GP is the doctor of the lower-income people.
•
Hypothesis 2: Homeless people have a higher likelihood to consult the
emergency department than the general population. A universal primary
health care system with active guidance for homeless people towards this
system might counter this.
•
Hypothesis 3: people who are not able to cope with their available income have a higher likelihood to postpone a visit to a GP.
Chapter 2: Research aim
Hypothesis 1: The specialist is the doctor of the higher-income people and the GP is the
doctor of the lower-income people.
International literature shows a social gradient in health care use, where people
from lower social classes tend to visit a GP more frequently than people from
middle or higher social classes, while people from higher social classes tend to
use more frequently specialist care than the less well-of. However, when taking
into account health care need, in some studies this gradient persists, in others this
gradient disappears [2-6]. Most of the studies describing the social variations in
health care utilization are based on data that are obtained from self-administered
questionnaires or interviews. We believe that analyzing health care use by means
of registered medical utilization data on the one hand and detailed self-reported
information on respondent’s health on the other hand, we can overcome the methodological restraints caused by the use of self-reported utilization data or the lack
of information about health status that many other studies are confronted with.
Paper 1 aims to describe the social gradient in the use of specialist care and primary
care in Belgium. Hereto data from the Belgian Health Interview are linked with
the corresponding registered medical utilization data delivered by the sickness
funds. The innovation of this study lays in the fact that this linked database allows
us to research the social gradient on actual registered health care utilization data
and not on reported data.
Hypothesis 2: Homeless people have a higher likelihood to consult the emergency department than the general population. A universal primary health care system with active
guidance for homeless people towards this system might counter this.
Literature shows that both homeless people and low-income people are vulnerable
population groups facing a higher disease burden leading to a higher health care
need [7-9]. Despite their higher health care need, these people do not always find
the way to the appropriate health care, or they might even postpone their needed
medical care [10-14].
Paper 2 presents the findings of a survey conducted in a sample of 122 homeless
people living in Ghent. Data collected by face-to-face interviews are compared with
comparable data from the Belgian Health Survey which gives information on the
general population. The health care use of the homeless people is compared to the
use of the non-homeless people living in Ghent, taking into account several health
indicators. The merits of this study lie in the fact that a relatively large sample of
57
Chapter 2: Research aim
the homeless population residing in Ghent, an area with a nearly universal health
care system and with active guidance towards that system, was questioned following
the research protocol and instruments of the Belgian Health Interview Survey.
Hypothesis 3: People who are not able to cope with their available income have a higher
likelihood to postpone a visit to a GP.
Paper 3 aims to identify which subgroups of low-income people are most at risk
for postponing a visit to a GP. Data are collected among 606 low-income people
living in Flanders. An important strength of this study is the success of questioning
606 low-income people about their health and healthcare use. In other studies this
population group is often under-represented, making it very difficult to formulate
strong conclusions.
Part II: Treatment and outcomes of care for vulnerable social
groups
58
Part two of this thesis focuses on equal treatment and outcomes in primary health
care. Two hypotheses are formulated:
•
•
Hypothesis 4: The social gradient in doctor-patient communication persists over time, where patients from lower socio-economic classes are less
involved during the consultation, receive less control and a more paternalistic consultation style.
Hypothesis 5: Physicians have a negative attitude towards patients with
a low SES and as a result make changes in their clinical decision which
do not favor the outcomes for the patient.
Hypothesis 4: The social gradient in doctor-patient communication persists, where patients
from lower socio-economic classes are less involved during the consultation, receive less
control and a more paternalistic consultation style.
Several studies on health care use have repeatedly shown the importance of a good
doctor-patient interaction [15, 16]. Good doctor-patient communication is associated with better patient health and outcomes [17, 18]. By communicating with a
patient, a physician gets to know the patient’s problems and creates a therapeutic
relationship necessary for its management and, if possible, its solution [19].
Chapter 2: Research aim
Nevertheless, qualitative studies show that patients from lower social classes are
often less involved in the decision making process or do not always understand
what the doctor says [20].
In Paper 4 we aimed, by means of a systematic review of the literature, to answer
the question whether the doctor-patient communication varies according to the
socio-economic status of the patient. And if so, which aspects of the consultation
are affected. The social gradient in doctor-patient communication is an emerging
topic in the research on health care use. The importance of this topic is made clear
by the large number of citations of the review on doctor-patient communication
by Willems et al. (2005) [21]. Therefore it is important to keep this information
up to date and address possible new issues.
Hypothesis 5: Physicians have a negative attitude towards patients with a low SES
and as a result make changes in their clinical decision which do not favor the outcomes
for the patient.
Physicians are expected not to judge patients on their social class, and not to treat
patients differently because of their social class. Qualitative studies have shown that
patients from lower social classes have the feeling that physicians have a different
attitude towards them. They have the feeling they are sometimes not respected by
the doctor, or the doctor does not take his/her time to understand the complex
situation of the patient [20].
In Paper 5 we aimed to explore the influence of the socio-economic status of the
patient on the clinical decision making of the general practitioner by means of a
qualitative study among 11 GP’s in Flanders. By means of face-to-face interviews,
physicians were asked to which extent they think their clinical decisions are influenced when working with low SES patients. There is only little evidence on the
influence of patient’s SES on the clinical decisions of the GP, and the evidence is
nearly almost restricted to the US. These results may be context-dependent and
cannot be generalized.
59
Chapter 2: Research aim
References
60
1.
Goddard M, Smith P. Equity of access to health care services: theory
and evidence from the UK. Soc Sci Med. 2001;53(9):1149-62. Epub
2001/09/15.
2.
Van der Heyden JH, Demarest S, Tafforeau J, Van Oyen H. Socio-economic
differences in the utilisation of health services in Belgium. Health Policy.
2003;65(2):153-65. Epub 2003/07/10.
3.
Bongers IM, van der Meer JB, van den Bos J, Mackenbach JP. Socio-economic differences in general practitioner and outpatient specialist care in The
Netherlands: a matter of health insurance? Soc Sci Med. 1997;44(8):11618. Epub 1997/04/01.
4.
Fernandez de la Hoz K, Leon DA. Self-perceived health status and inequalities in use of health services in Spain. Int J Epidemiol. 1996;25(3):593603. Epub 1996/06/01.
5.
van Doorslaer E, Masseria C, Koolman X. Inequalities in access to medical
care by income in developed countries. CMAJ. 2006;174(2):177-83. Epub
2006/01/18.
6.
van Doorslaer E, Koolman X, Jones AM. Explaining income-related inequalities in doctor utilisation in Europe. Health Econ. 2004;13(7):629-47.
Epub 2004/07/20.
7.
Droomers M, Westert GP. Do lower socioeconomic groups use more health
services, because they suffer from more illnesses? Eur J Public Health.
2004;14(3):311-3. Epub 2004/09/17.
8.
Hwang SW. Homelessness and health. CMAJ. 2001;164(2):229-33. Epub
2001/05/03.
9.
Morris DM, Gordon JA. The role of the emergency department in the care
of homeless and disadvantaged populations. Emerg Med Clin North Am.
2006;24(4):839-48. Epub 2006/09/20.
10. Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health
care utilization of homeless persons. JAMA. 2001;285(2):200-6. Epub
2001/02/15.
11. Power R, French R, Connelly J, George S, Hawes D, Hinton T, et al.
Health, health promotion, and homelessness. BMJ. 1999;318(7183):590-2.
Epub 1999/02/26.
Chapter 2: Research aim
12. Drieskens S VdHJ, Hesse E, Gisle L, Demarest S, Tafforeau J. Gezondheidsenquête België, 2008. Rapport V - Sociaal-economische ongelijkheden in
gezondheid. 2010 2032-9172.
13. Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities
as a barrier to medical care among homeless adults in Los Angeles. Am J
Public Health. 1997;87(2):217-20. Epub 1997/02/01.
14. Whitehead M, Hanratty B. Health care for rich and poor alike. In: Healy J,
McKee M, editors. Accessing health care Responding to diversity. Oxford:
Oxford University Press; 2004. p. 71-88.
15. Street RL, Jr., Millay B. Analyzing patient participation in medical encounters. Health Commun. 2001;13(1):61-73. Epub 2001/05/24.
16. Bensing J. Doctor-patient communication and the quality of care. Soc Sci
Med. 1991;32(11):1301-10. Epub 1991/01/01.
17. Duberstein P, Meldrum S, Fiscella K, Shields CG, Epstein RM. Influences
on patients’ ratings of physicians: Physicians demographics and personality.
Patient Educ Couns. 2007;65(2):270-4. Epub 2006/11/28.
18. Cheraghi-Sohi S, Bower P, Mead N, McDonald R, Whalley D, Roland M.
What are the key attributes of primary care for patients? Building a conceptual ‘map’ of patient preferences. Health Expect. 2006;9(3):275-84. Epub
2006/08/17.
19. Bensing J, Kerssens JJ, Vanderpasch M. Patient-directed gaze as a tool for
discovering and handling psychosocial problems in general practice. Journal
of Nonverbal Behavior. 1995;19:223-42.
20. Willems S. The socio-economic gradient in health: a never-ending story?
A descriptive and explorative study in Belgium. Ghent: Ghent University;
2005.
21. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J.
Socio-economic status of the patient and doctor-patient communication:
does it make a difference? Patient Educ Couns. 2005;56(2):139-46. Epub
2005/01/18.
61
62
Chapter 3
Research Papers
63
64
Chapter 3: Research papers
Paper 1:
Verlinde E., Pasteels I., De Maeseneer J., Willems S. Socio-economic differences
in the utilization of FP and specialist care: do patients form lower social class visit
more often a doctor when taking into account their higher health care need? Health
Policy. Submitted. IF: 1.383
SW contributed to the application for the National Privacy Commission to obtain permission to use and link the data. IP contributed to the data manipulation
and linkage of the data. EV, IP, and SW contributed to the analysis. EV and SW
contributed to the writing of the article. IP and JDM participated in the revision
of the manuscript.
Paper 2:
Verlinde E., Verdee T., Van de Walle M., Art B., De Maeseneer J, Willems S.
Unique health care utilization patterns in a homeless population in Ghent. BMC
Health Services Research. 2010; 10(242). IF:1.66
MVDW, TV, BA , SW and JDM contributed to the design of the study. MVDW
and TV contributed to the data retrieval. EV and SW contributed to the analysis
and the writing of the paper. BA, SW and JDM participated in the revision of the
manuscript.
Paper 3:
Verlinde E., Poppe A., DeSmet A., Hermans K., De Maeseneer J., Van Audenhove
C., Willems S. Social differences in postponing a GP visit: Which low-income
patients are most at risk? Health and Social Care in the Community. Under review.
IF: 1.008
EV, AP, AD, JDM, CVA, and SW contributed to the design of the study; EV, AP,
and SW contributed to the analysis and the writing of the article; and AD, KH,
JDM, CVA, and SW participated in the revision of the manuscript.
Paper 4:
Verlinde E., De Laender N., De Maesschalk S., Deveugele M., Willems S. The
social gradient in doctor-patient communication. Journal for equity in health. 2012,
11:12.IF:1.30
EV, NDL, SW and SDM equally contributed to the research and the report of the
study. EV, NDL and SW contributed to the writing of the paper. DM and SDM
contributed to the revision of the manuscript.
65
Chapter 3: Research papers
Paper 5:
Verlinde E., Bonte E., Willems S. Socio-economic status of the patient: does it
influence the decisions of the GP? Patient education and Counseling. Submitted.
IF: 2.237
EV and SW contributed to the design of the study. EB and EV contributed to the
data retrieval and the analysis. EV, and SW contributed to the writing of the paper.
66
Chapter 3: Research papers
Socio-economic differences in the utilization of FP and
specialist care.
Evelyn Verlinde, MA§
Phd Candidate
Department of Family Medicine and Primary Healthcare
Ghent University
De Pintelaan 185, 9000 Ghent
Belgium
Evelyn.Verlinde@UGent
Inge Pasteels, MA
Coordinator “Divorce in Flanders”
Research Center for Longitudinal and Life Course Studies (CELLO)
Antwerp University
Sint-Jacobstraat 2, 2000 Antwerp
Belgium
[email protected]
Jan De Maeseneer, MD PhD
Full Professor
Department of Family Medicine and Primary Healthcare
Ghent University
De Pintelaan 185, 9000 Ghent
Belgium
[email protected]
Sara Willems MD PhD
Professor
Department of Family Medicine and Primary Healthcare
Ghent University
De Pintelaan 185, 9000 Ghent
Belgium
[email protected]
§Corresponding author
Evelyn Verlinde
De Pintelaan 185 – 6K3
9000 Ghent
Phone: 0032 9 332 6082
Fax: 0032 9 332 4967
[email protected]
67
Chapter 3: Research papers
Abstract
International studies report higher primary care utilization rates for people with
a lower socio-economic status (SES) and higher specialist care utilization rates
for people high on the socio-economic ladder. These studies are often limited due
to the use of self-reported utilization data, or the lack of detailed information on
health status. In this paper, we describe the social variation in primary care and
specialist care use in Belgium based on registered medical utilization data, taking
into account health status.
Data from the Belgian Health Interview Survey are linked to registered medical
utilization data. SES was measured in terms of education and income.
Lower-educated and middle-educated people make greater use of FP than do
higher-educated, whereas higher-educated make greater use of specialist care, even
after controlling for health status.
68
Although the Belgian health care system covers almost 100% of the population,
this does not correspond with equity in health care use. This could be due to the
lack of a gatekeeper in primary care and free access to secondary care in the Belgian
health care system.
Keywords:
Primary care, social class, registered utilization data
Chapter 3: Research papers
Background
Equity in health can be defined as “the absence of systematic disparities in health
(or in major social determinants of health) between social groups who have different
levels on underlying social advantage”[1]. In order to obtain equity in health there
needs to be equity in health care. Equity in health care means that patients who
are alike should be treated in the same way (horizontal equity) and that patients
who are unlike, should be treated in the same unlike way (vertical equity) [2-5].
An important aspect of delivering equitable health care is providing equal care for
those in equal need [6].
In the light of providing equal care to people in equal need, it would be assumed
that in the absence of barriers to health care, the demand for health services is
similar across socioeconomic groups after controlling for their health status [6].
Nevertheless, across countries, higher utilization rates of primary care are reported
for people with a lower socio-economic status (SES) [7-10]. On the contrary, the
higher the SES, the higher the use of specialist care, physiotherapy, and dentistry
[7]. However, as low SES is known to be associated with poor health, adjustment
for health status is necessary for interpretation of social gradients in health care use
[11]. For example, the Belgian Health Interview Survey 2004 shows that the social
gradient found in the use of general practitioner care, nursing care at home, and
admissions to hospitals (all higher for patients with a lower educational attainment)
disappears when self-rated health status is taken into account [7]. Based on the
data from 21 OECD (Organization for Economic Cooperation and Development)
countries, the social gradient in specialist care seems to remain after controlling
for need differences: Higher-income people are still more likely to see a specialist
than lower-income people [10].
Prudence in the interpretation of these results is of utmost importance. Most of the
studies describing the social variations in health care utilization are based on data
that are obtained from self-administered questionnaires or interviews. This has some
implications. First of all, reliability studies show that self-reported use of health
services, in general, leads to an over-reporting of the number of visits to a health
care provider. In case of an actual high number of visits to a health care provider or
when the recall period lengthens (for example, in the question “how many times
did you visit your FP in the past 12 months” compared to “how many times did you
visit your FP in the past month” ), patients tend to under-report [12-14]. Secondly,
there could be a recall bias according to social class [12].
69
Chapter 3: Research papers
In order to overcome these problems, studies on the use of health care services can
make use of registered medical data. However, there are only a small number of
studies that analyse the social gradient in health care use based on registered data [11,
15-19]. All of them confirm the significance of primary care in the health care for
disadvantaged populations. For example, the Universal Health Insurance in Canada
successfully achieves equity in its access to primary care but not to specialist care
[11, 15]. The results of these studies are highly context-dependent, and so, the social
gradient in health care use might differ according to different health care systems.
70
Our objective is to examine equity in the use of primary care and specialist care
in Belgium, a country in which the health care system achieves almost universal
public coverage of the population for the majority of health care services with
direct access to any general practitioner and specialist at any time for any problem
[10]. In the Belgian fee-for-service system, patients pay about 30% co-payment
for primary health care and 40% for specialist care, with reduced co-payment rates
(8%) for lower socio-economic groups [10]. We hypothesize that, in Belgium, the
specialist is the doctor of the higher income people and the FP the doctor of the
lower income people.
By analyzing individuals’ registered medical utilization data on the one hand and
detailed self-reported information on their health on the other hand, this study
aims to overcome the methodological restraints caused by the use of self-reported
utilization data or the lack of information about health status that many other
studies in this research domain are confronted with.
Methods
In this study, data from the Belgian Health Interview Survey (BHIS) 1997 are
linked with the corresponding registered medical utilization data provided by the
Sickness Funds. The linkage between these databases is unique for Belgium and
has not been repeated in the case of more recent BHIS data.
The Belgian Health Interview Survey
The Belgian Health Interview Survey is a cross-sectional survey based on a representative sample of the non-institutionalized population residing in Belgium who are
aged 15 years or older. Sampling has been based on a combination of stratification,
multistage sampling, and clustering [7].
Chapter 3: Research papers
The first stage was a stratification by region (Flemish Region, Walloon Region,
and the Brussels Region) with a fixed sample size. The second stratification was
at the level of the provinces with the sample size defined proportional to the population size of the province. In the third step, the primary sampling unit (PSU)
was selected within each stratum by a weighted systematic sampling procedure.
In the fourth stage, a number of households were selected, called the secondary
sampling units (SSUs), by a clustered systematic sampling procedure after ranking
the household hierarchically by the statistical sector, household size, and age of the
reference person. This method allowed to minimise selection bias. In the last step,
the individual or the third sampling unit was selected within the household. Up to
a maximum of four persons could be interviewed within each household. The first
two subjects were selected by definition: the reference person and his/her partner.
The two other individuals were selected based on a birthday rule: the persons who
had their birthday coming up first after the interview [20].
Overall, 10.221 individuals, living in 4.664 households, were questioned, that is
0.1% of the Belgian population [7, 21].
The variables used in this study were collected by means of a face-to-face interview
carried out at home [7]. More detailed information on the methodology of the
Belgian Health Interview Survey has been published elsewhere [20].
Medical care utilization data registered by the Sickness Funds
In the Belgian fee-for-service system, patients advance the fee for ambulatory
medical care and get a refund from the Sickness Funds afterward. In this context,
the Sickness Funds registers all medical utilization data.
The database from the Sickness Funds analyzed in this study contains the medical
care use of almost all individuals included in the Belgian Health Interview Survey,
for the reference period of 1996 – 1997. It contains information on all medical care
subject to a refund by the Sickness Funds. This database contains no information on
medical care that is not refunded (such as supplements). However, these are scarce in
the Belgian primary care. In addition, the self-employed respondents were excluded,
as they are not covered by the public health insurance the same way as employees.
This implies that the data concerning the health care use of the self-employed is
registered in another way, making comparison of the datasets not possible.
71
Chapter 3: Research papers
Linking both databases
To protect the privacy of the participants, the linking of the two databases was carried out by the Crossroads Bank for Social Security, a governmental organization
in charge of promoting information security and privacy protection and delivering
integrated statistical information to politicians and researchers in order to support
the social policy [22].
The linked database contains information on 7.364 individuals who are aged 15 years
or older. The reduction compared with the 10.221 individuals in the HIS was due
to small loss of data at the different levels of the linking process, persons who died
during the reference period and the exclusion of the self-employed respondents. In
order to match the Belgian population, the weighing procedure was recalculated
according to the original weighing procedure applied but with taking into account
the drop-out of observations after linking both datasets, taking into account the
age, sex, and province.
72
Measuring socio-economic status
To measure SES, both education and income are commonly used [23, 24]. In this
study, educational level is based on the highest educational attainment in the family.
To determine educational level, the educational attainment of the reference person
was compared with his/her partner, if present. Educational level is categorized in
three groups: higher (higher education), middle (higher secondary school or Alevel), and lower (no education, primary school, or lower secondary school). Income
is defined using the equivalent household income based on the total household
income and the number of household members. Equivalent income was categorized as lower (<500–750 euro), middle (750–1500 euro), and higher (> 1.500 euro).
Measuring health status
The measures of health status used in this study are self-rated health, reporting
two or more chronic diseases, psychological distress, and self-reported disability.
Self-rated health is measured by a validated WHO instrument, recoded in three
categories: very bad–bad, fair, and good–very good [25]. Chronic diseases are questioned by means of a checklist of chronic conditions and the question whether the
respondent experienced any of these conditions in the past 12 months. The cut-off
point for analysis was set on having two or more chronic conditions. Disability
due to chronic conditions or diseases is categorized in three categories (severe to
Chapter 3: Research papers
moderate disability, light disability, trouble of chronic disease without disability
to neither trouble nor disability due to chronic disease). Psychological distress is
measured using the mental health scale of the GHQ12 questionnaire (cut-off point
at 90% probability for having psychological distress).
Health care utilization
Registered data on health care utilization were obtained from the Sickness Funds.
The utilization of the health care delivered by the family physician and specialist
is studied in terms of the number of consultations during the two years’ reference
period (1996–1997). These number of consultations were recalculated from two
years to one year for a better understanding and interpretation of the analysis.
Data analysis
Considering that we are working with an over-dispersed count date (when the
conditional variance exceeds the conditional mean), we used a negative binomial
regression. We modelled the number of visits to a FP and the number of visits to a
specialist. The dependent variables were the number of visits to a FP (model 1) or
a specialist (model 2) and the independent variables were income and education.
Furthermore, the models controlled for age, sex, self-rated health, chronic conditions, disability, and mental distress. The level of statistical significance was set at p
< 0.05. All analyses were performed using SPSS 19.
Ethics approvement
This study was approved by the Ethics Committee of the Ghent University Hospital
(Dossier No. 2001/64).
Results
Description of the research sample
Table 1 shows the distribution of the study sample according to sex, age, educational
level, income, and health status.
There are slightly more women (51.4%) than men (48.6%) in the sample. More than
half (65.1%) are aged between 25 and 65. With regard to educational level, 34.9%
of the respondents have a lower educational level; 33.2% have a middle educational
73
Chapter 3: Research papers
level; and 32.0% have a higher educational level. The proportion of the respondents
with a higher, middle, and lower equivalent income is, respectively, 25.8%, 61.5%,
and 12.7%. For self-rated health, 3.5% reported bad to very bad health compared with 20.5% and 75.9% with fair and good to very good health, respectively.
Considering chronic diseases and disability, 16.7% suffered from two or more
chronic diseases, and 11.5% experienced moderate to severe disability. With regard
to mental health, 9.8% had a bad mental health status.
The number of consultations a year with a FP varied between 0 and 208. 25% had
seven or more consultations with a FP. The number of consultations with a specialist
varied between 0 and 32. 25% had three or more consultations with a specialist.
Table 1: Distribution of the study sample
74
Variable
Sex
Men
Women
Age
15–24
25–65
65+
Educational level
Lower Middle
Higher
Equivalent income
Lower Middle
Higher
Self-rated health
Good–very good
Fair
Bad–very bad
Chronic diseases
< 2
> 2
N (%)
7364
3578 (48.6)
3786 (51.4)
7364
11106 (15.0)
4792 (65.1)
1466 (19.9)
7331
2556 (34.9)
2431 (33.2)
2344 (32.0)
7019
1810 (25.8)
4316 (61.5)
894 (12.7)
6950
5278 (75.9)
1427 (20.5)
245 (3.5)
7362
6131 (83.3)
1231 (16.7)
Chapter 3: Research papers
Disability due to chronic disease
Severe to moderate disability
Light disability
Troubles of chronic disease without disability
to neither troubles nor disability
Mental health
< 90%
> 90%
Number of consultations with FP
Q 25
Q 50
Q 75
Number of consultations with specialist
Q 25
Q 50
Q 75
7318
838 (11.5)
644 (8.8)
5836 (79.3)
5836 (79.3)
7156
6453 (90.2)
703 (9.8)
1
3
7
0
1
3
The association between SES and the number of consultations with
a FP
In table 2, the associations between the number of consultations and education
and income after controlling for age, sex, education, income, and health status are
shown. As established by literature, we find significant effects for age, sex, self-rated
health, chronic diseases and disability on the number of consultations with a FP.
Women have a higher ratio of visiting a FP than men (odds ratio 1.318, p < 0.001).
People with bad health have a higher ratio of visiting a FP than respondents with
good health (odds ratio 1.607 p < 0.001). Also those with a fair health have a higher
ratio of visiting a FP compared to people with a good health (odds ratio 1.416,
p<0.001). People aged 65 years or older have a higher ratio of visiting a FP than
those aged between 15 and 24 years (odds ratio 1.847, p<0.001). Those aged between
25 and 65 years also have a higher ratio of visiting a FP compared to people older
than 65 years (odds ratio 1.099, p=0.007). Furthermore, people with more than
two chronic conditions have a higher ratio contacting a FP than people with no or
less than two chronic conditions (odds ratio: 1.286, p < 0.001). Respondents who
experience no disability due to their chronic conditions have a lower ratio to visit a
75
Chapter 3: Research papers
FP compared to those perceiving moderate to severe disabilities (odds ratio 0.726,
p<0.001). No significant results were found for those perceiving a light disability
compared to those with a moderate to severe disability (p=0.622). Furthermore, no
significant results were found for mental distress (p=0.841).
After controlling for these health measures, we find significant results for educational
level and income on the number of consultations with a FP. For educational level,
we find a social gradient in visiting the FP: people with a higher educational level
have a lower ratio of visiting a FP, compared to people with a lower educational
level (odds ratio 0.751, p<0.001). But also people with a middle educational level
have a lower ratio of visiting a FP than those with a lower educational level (odds
ratio 0.867, p<0.001).
For income, we find a significant association for middle versus lower income: people
with a middle income have a higher ratio in contacting a FP compared to those
with a low income (odds ratio 1.079, p=0.008). No significant association was found
between higher and lower income people.
76
Table 2: Negative binomial distribution for visiting a FP during the reference period and
socio-economic status adjusted for age, sex, and health care status
Sex
women vs men
B
SE
0.276
0.0240
Odds ratio
1.318
95% CI
p*
1.257-1.381 < 0.001
Age 65+ versus 15–24 0.628
0.0425
1.874
1.724-2.037 < 0.001
25–65 versus 15–24
0.095
0.0349
1.099
1.026-1.177
0.007
Educational level
Higher versus lower -0.286
0.331
0.751
0.704-0.802 < 0.001
Middle versus lower
-0.142
0.0296
0.867
0.818-0.919 < 0.001
Equivalent income
Higher versus lower
-0.16
0.0464
0.985
0.899-1.078
0.737
Middle versus lower
0.076
0.0289
1.079
1.020-1.142
0.008
Self-rated health
Bad versus good
0.474
0.0722
1.607
1.395-1.851 < 0.001
Fair versus good
0.348
0.0337
1.416
1.325-1.512 < 0.001
Chronic disease
0.252
0.0343
1.286
1.203-1.376 < 0.001
Chapter 3: Research papers
Disability
Troubles of chronic disease without disability
to neither troubles nor
Severe to moderate
0.0444
0.726
0.666-0.792 < 0.001
0.026
0.0529
1.026
0.925-1.139
0.622
-0.008
0.0406
0.992
0.916-1.074
0.841
disability versus
Light disability vs severe
-0.320
to moderate
Mental health
*All significant results are indicated in bold.
The association between SES and the number of consultations with
a specialist
The results of the analysis on the use of specialist care are depicted in table 3. As
with the number of consultations with a FP, we also find significant results for age,
sex, self-rated health, chronic diseases and disability on the number of consultations
with a specialist.
Women have a higher ratio of contacting a specialist than men (odds ratio 1.615,
p<0.001). People aged older than 65 years have a higher ratio of contacting a specialist compared with people aged between 15 and 24 (odds ratio 1.489, p<0.001)
and people aged between 25 and 65 years also have a higher ratio of visiting a
specialist compared to people aged between 15 and 24 years (odds ratio 1.220,
p<0.001). People suffering from more than two chronic conditions have a higher
ratio of visiting a specialist compared to people with less than two or no chronic
conditions (odds ratio 1.342, p<0.001). Respondents who experience no disability
due to their chronic conditions have a lower ratio to visit a specialist compared to
those perceiving moderate to severe disabilities (odds ratio 0.693, p<0.001). No
significant results were found for those perceiving a light disability compared to
those with a moderate to severe disability (p=0.616). We find no significant results
with regard to mental distress (p=0.691).
After controlling for health status, only a significant association between educational level and the number of consultations with a specialist is found: people with
a higher educational level have a higher ratio of contacting a specialist compared
to those with a lower educational level (odds ratio 1.196, p<0.001). People with a
middle educational level have a higher ratio of contacting a specialist compared to
77
Chapter 3: Research papers
those with a lower educational level (odds ratio 1.137, p=0.001). For income, we
find no significant associations between those with a higher versus lower income
and those with a middle versus lower income (odds ratio resp. 1.085, 1.073).
Table 3: Negative binomial distribution for visiting a specialist during the reference period
and socio-economic status adjusted for age, sex, and health care status.
Sex
women vs men
B
0.479
SE Odds ratio
0.0310
1.615
95% CI
P*
1.520-1.716 < 0.001
Age 65+ versus 15–24 0.398
0.0561
1.489
1.334-1.662 < 0.001
25–65 versus 15–24
0.199
0.0460
1.220
1.115-1.335 < 0.001
Educational level
Higher versus lower 0.179
0.427
1.196
1.100-1.301 < 0.001
Middle versus lower
0.128
0.0388
1.137
1.054-1.227
0.001
Equivalent income
78
Higher versus lower
0.081
0.0583
1.085
0.967-1.216
0.164
Middle versus lower
0.070
0.0377
1.073
0.997-1.155
0.062
0.001
Self-rated health
Bad versus good
0.307
0.0919
1.359
1.135-1.627
Fair versus good
0.338
0.0439
1.402
1.286-1.528 < 0.001
Chronic disease
0.294
0.0437
1.342
1.232-1.462 < 0.001
Disability
Troubles of chronic
to neither troubles nor
Severe to moderate
disease without disability
0.0566
0.693
0.620-0.774 < 0.001
-0.034
0.0670
0.967
0.848-1.103
0.616
-0.021
0.0516
0.980
0.885-1.084
0.691
disability versus
Light disability vs severe -0.367
to moderate
Mental health *All significant results are indicated in bold.
Chapter 3: Research papers
Discussion and conclusion
Studies exploring the social gradient in health care utilization are often impeded by
important methodological limitations. Many are based on self-reported utilization
data that are subject to under- or overreporting. When registered data are used,
detailed information on health and health care need is often lacking [9, 12].
This study aims to examine equity in the use of primary care and specialist care in
Belgium by linking the data on health and social status from the respondents from
the Belgian Health Interview Survey with their corresponding registered medical
utilization data delivered by the Sickness Funds.
This study shows that the specialist is not the doctor of the rich, but the doctor of
the higher educated, and the FP is not the doctor of the poor, but the doctor of the
lower educated: higher-educated people have more contact with a specialist and
less contact with a FP than the lower-educated people. While for income, only a
significant result was found on the number of contacts with a FP for middle income people compared to lower income people. No significant results were found
in relation to specialist care. Attention is needed when interpreting the results on
income as literature shows that the measurement of income is far less stable and
valid than the measurement of education [26, 27].
These results contrast with findings reported in studies using self-reported utilization
data. A study using the Belgian Health Interview Survey indicates that the social
gradient in the utilization of FP care disappears when health status is taken into
account [7]. A study on the health care use in 21 OECD countries reports that
contacting a FP is distributed according to need and not much according to income
[10]. With regard to the use of specialist care, our findings are consistent with the
evidence based on self-reported data: Taking into account the disease burden, higher SES people seek specialist care more often than do lower SES people [8, 10].
A limited number of other studies have linked population survey data with registered utilization. The study from Nova Scotia using the 1990 Nova Scotia Nutrition
Survey reported a higher use of FP and underuse of specialist care by people in
lower income groups. However, this study did not adjust for health status [16]. A
study on the Ontario portion of the 1994–1995 National Population Health Survey
found an increased use of specialist care among those with a higher educational
level but not among those with a high income. This study controlled for health
status as being self-reported health as a single measure [17]. A more recent study
on the 2000–2001 Canadian Community Health Survey examined equity in the use
of FP and specialist care in Ontario, after controlling for health status using both
79
Chapter 3: Research papers
self-reported and diagnosis-based measures. They found no differences according
to income or education with regard to primary care use. With regard to specialist
care, they found inequity favouring the well-educated people [11]. Important to
notice on these studies is that they were all conducted in Canada which provides
a universal health care coverage for all its residents.
80
This study, in the context of a health care system with free choice of FP and specialist
care (no gate-keeping), seems to indicate that the inequity in health care use in Belgium is an education issue where higher educated visit more frequently a specialist
and lower educated visit more frequently a FP, independent of the patient’s health
status. No significant associations were found for specialist care and primary care
for low income people compared to high income people. These findings confirm
the accessibility of primary care in Belgium for vulnerable population groups such
as low-income or low-educated people.
The social differences in utilization patterns could partly be explained by the complex social context that this patient group is confronted with and by the greater
health-damaging environment they live in: lower-educated patients are often simultaneously exposed to multiple health-threatening risk factors (e.g. low income,
unhealthy working and living conditions) and experience a greater impact when
exposed to risk factors than higher-educated patients [6]. Next to the social context,
there could also be the issue of the cultural access to health care such as language
barriers, miscommunication between health care provider and patient due to different priorities on the patient side, not explaining things in a way patients can
understand, the attitude of the health care provider,… [6]. It might be possible that
FP’s have a better doctor-patient relationship with their patients than specialists do
and have better understanding of the needs and priorities of patients from lower
social classes, resulting in a preference of consulting a FP instead of a specialist
when needing medical care among lower educated people. The results indicate that
education has an important role in the health care use in Belgium. First of all, there
is the aspect of health literacy. Higher educated people suffering from a disease
or condition wherefore specialist care is needed will probably go immediately to a
specialist because they believe it’s the best care for that disease. While people with
a low educational level might visit the FP because they do not know where else to
go with this disease. Furthermore, there is also the organization of the health care
system. It is possible that lower educated people find the health care system too
complicated (e.g. waiting lists, appointments,…). This stresses the importance of
the central function of the FP. The FP can navigate people through the different
Chapter 3: Research papers
health services and is able to mobilize the support of other facilities by referring
patients or calling on the support of specialized services [28].
This study finds no significant results for specialist care and FP care for low income people. This might indicate that the health care system in Belgium has little
financial barriers. There is a reduced co-payment for lower socio-economic groups
in the fee-for-service system, there is the third-party payment (where the patient
only has to pay the co-payment), the maximum bill (where the total amount of
co-payment each year is limited to a certain amount), and the capitation system in
the Community Health Centres and some larger group practices.
Another important finding of the study is that middle income people have a higher
use of the FP than lower income people. It is possible that the measures in order
to reduce the financial barriers to health care use for vulnerable populations, have
made it more easily for middle income people to visit the FP. However, we cannot
make statements on the excessive or underuse of certain populations groups. This
study only describes that there are social differences in the utilization patterns of
FP and specialist care after controlling for health status.
This study has strengths and limitations. Among its strengths, we used both education and income to determine socio-economic status, took into account health
status using several measures for physical and mental health, and created a linkage
with registered health care data. By doing so, we overcome the bias of under- or
over-reporting health care use when using self-reported health care utilization data.
These strengths also touch the limitations of this study. We used self-reported
educational level and income as a measure for socio-economic status. Including
recorded information on income might add to the validity of the results seen the
sensitivity of people providing information on their personal income [26]. Further,
it would be interesting for further studies to take into account other determinants
of care, such as the strength of the patient’s social network or his/her coping abilities. Furthermore, we did not have information on the “reasons for encounter”, but
instead we used self-rated health, chronic conditions and disability due to chronic
conditions to measure the respondent’s health status. Taking into account reasons
for encounter might add to the validity of the results. Another limitation consists of
the drop-out of people by creating a linkage between the two databases. First of all,
for some respondents, no identification number was found, which made linking the
data of these individuals impossible. In addition, the self-employed were excluded
from the research group, because the Sickness Funds do not have complete data
on their consumption patterns. Including the self-employed might give a more
81
Chapter 3: Research papers
complete picture on health care use in Belgium. Another limitation of this study is
the time frame: We analyzed data from the 1997 National Health Interview Survey.
Designing the technical procedure to link the databases, obtaining permission from
the National Privacy Commission and from the administrators of the databases
to link the data, and collecting the data took several years. This could largely be
explained by the fact that it was the first and only time in Belgium that the link
between administrative data and NHIS data was made. Since a similar linkage with
more recent data did not appear possible, this study was done on the 1997 database.
It is possible that since then, the social gradient in health care use changed.
Furthermore, as Van der Heyden et al. already indicated, a weakness of assessing
socio-economic differences based on data from a health survey is that specific subgroups of people such as homeless and illegal immigrants are not included in the
sample. Even though they might be smaller groups in the Belgian society, these
people especially may have major problems with access to health care [7].
82
Health care utilization data are important in health care research, and the accuracy
of this information is of utmost importance. This study shows that analyzing registered utilization data leads to different findings than when self-reported utilization
data are analyzed, especially for the use of FP care. There is an inequity in the use of
primary and specialist care, after taking health status into account. Lower-educated
people have a higher tendency of contacting a FP than do higher-educated people,
whereas higher-educated people have a higher tendency in using specialist care
than do lower-educated people.
The results of this study also stress the importance of taking into account the “need
for health care” when assessing the social gradient in medical care use. By doing so, a
more precise picture of the social difference in the utilization of medical care appears.
Although the Belgian health care system has an almost 100% coverage of the
population, this does not lead to an equitable utilization pattern. An explanatory
factor could be the lack of a gate-keeping system in the context of a fee-for service
with co-payments, which might lead to the higher utilization (taking into account
health needs) of specialist care by higher-educated people.
Competing interests.
The authors declare that they have no competing interests.
Chapter 3: Research papers
Authors’ contribution
SW contributed to the application for the National Privacy Commission to obtain permission to use and link the data. IP contributed to the data manipulation
and linkage of the data. EV, IP, and SW contributed to the analysis. EV and SW
contributed to the writing of the article. IP and JDM participated in the revision
of the manuscript. All the authors have read and approved the final manuscript.
Acknowledgements
The authors would like to thank all Sickness Funds, the National Institute for Health
and Disability Insurance (NIHDI), the Scientific Institute for Public Health, the
Crossroad Bank for Social Security, and the Federal Agency for Social Security for
their cooperative collaboration.
This article outlines the results of a pilot study conducted as part of a research program concerning the accessibility of the Belgian healthcare system for disadvantaged
people and was funded by the Federal Agency for Social Security.
83
Chapter 3: Research papers
References
1.
Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community
Health 2003; 57:254-8.
2.
Goddard M, Smith P. Equity of access to health care services: theory and
evidence from the UK. Soc Sci Med 2001; 53:1149-62.
3.
Culyer AJ. Equity - some theory and its policy implications. Journal of medical ethics 2001; 27:275-83.
4.
Bayoumi AM. Equity and health services. Journal of public health policy
2009; 30:176-82.
5.
Hanafin S, Houston AM, Cowley S. Vertical equity in service provision: a
model for the Irish public health nursing service. J Adv Nurs 2002; 39:6876.
6.
Whitehead M, Dahlgren G. Levelling up (part 1): a discussion papar on
concepts and principles for tackling social inequities in health. WHO collaborating Centre for Policy Research on Social Determinants of Health,
University of Liverpool, 2006.
7.
Van der Heyden JH, Demarest S, Tafforeau J, Van Oyen H. Socio-economic
differences in the utilisation of health services in Belgium. Health Policy
2003; 65:153-65.
8.
Bongers IM, van der Meer JB, van den Bos J, Mackenbach JP. Socio-economic differences in general practitioner and outpatient specialist care in The
Netherlands: a matter of health insurance? Soc Sci Med 1997; 44:1161-8.
9.
Fernandez de la Hoz K, Leon DA. Self-perceived health status and inequalities in use of health services in Spain. Int J Epidemiol 1996; 25:593-603.
84
10. van Doorslaer E, Masseria C, Koolman X. Inequalities in access to medical
care by income in developed countries. CMAJ 2006; 174:177-83.
11. Glazier RH, Agha MM, Moineddin R, Sibley LM. Universal health insurance and equity in primary care and specialist office visits: a populationbased study. Ann Fam Med 2009; 7:396-405.
12. Ritter PL, Stewart AL, Kaymaz H, Sobel DS, Block DA, Lorig KR. Selfreports of health care utilization compared to provider records. J Clin Epidemiol 2001; 54:136-41.
13. Bellon JA, Lardelli P, Luna JD, Delgado A. Validity of self reported utilisation of primary health care services in an urban population in Spain. J Epidemiol Community Health 2000; 54:544-51.
Chapter 3: Research papers
14. Roberts RO, Bergstralh EJ, Schmidt L, Jacobsen SJ. Comparison of selfreported and medical record health care utilization measures. J Clin Epidemiol 1996; 49:989-95.
15. Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med 2007;
5:492-502.
16. Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does
universal coverage reduce inequalities in health? J Epidemiol Community
Health 2003; 57:424-8.
17. Finkelstein MM. Do factors other than need determine utilization of physicians’ services in Ontario? CMAJ 2001; 165:565-70.
18. Danchin N, Neumann A, Tuppin P, De Peretti C, Weill A, Ricordeau P,
Allemand H. Impact of free universal medical coverage on medical care and
outcomes in low-income patients hospitalized for acute myocardial infarction: an analysis from the FrenchNational Health Insurance system. Circulation Cardiovascular quality and outcomes 2011; 4:619-25.
19. Tuppin P, Blotiere PO, Weill A, Ricordeau P, Allemand H. [Mortality and
hospital admissions rates and diagnosis among individuals with low income
and full health insurance coverage in France, 2009]. Presse medicale (Paris,
France : 1983) 2011; 40:e304-14.
20. Van oyen H, Tafforeau J, Hermans H, Quataert P, Schiettecatte E, Lebrun
L, Belamer L. The Belgian Health Interview Survey. Arch Public Health
1997; 55:1-13.
21. Demarest S LP, Tafforeu J, Tellier V, Van der Heyden J, Van Oyen H. De
gezondheid van de bevoling in België. Gezondheidsenquête door middel
van interview, België 1997. Brussel: Wetenschappelijk Instituut Volksgezondheid, Afdeling Epidemiologie, 1998.
22. Crossroads Bank for Social Security. Mission. Brussels: Crossroads Bank for
Social Security.
23. Isaacs SL, Schroeder SA. Class - the ignored determinant of the nation’s
health. N Engl J Med 2004; 351:1137-42.
24. Smith GD, Hart C, Watt G, Hole D, Hawthorne V. Individual social class,
area-based deprivation, cardiovascular disease risk factors, and mortality:
the Renfrew and Paisley Study. J Epidemiol Community Health 1998;
52:399-405.
25. de bruin A PH, Nossikov A. Health interview surveys. Toward international harmonization of methods and instruments. Copenhagen:WHO-Europe, CBD Netherlands. 1996.
85
Chapter 3: Research papers
26. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Smith DG. Indicators of
socioeconomic position (part1). J Epidemiol Community Health 2006;
60:7-12.
27. Liberatos P, Link BG, Kelsey JL. The measurment of social class in epidemiology. Epidemiologic reviews 1988; 10:87-121.
28. WHO report 2008: Primary health care now more than ever. 2008.
86
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
RESEARCH ARTICLE
Open Access
Unique health care utilization patterns in a
homeless population in Ghent
Evelyn Verlinde*, Tine Verdée, Mieke Van de Walle, Bruno Art, Jan De Maeseneer, Sara Willems
Abstract
Background: Existing studies concerning the health care use of homeless people describe higher utilisation rates
for hospital-based care and emergency care, and lower rates for primary care by homeless people compared to
the general population. Homeless people are importantly hindered and/or steered in their health care use by
barriers directly related to the organisation of care. Our goal is to describe the accessibility of primary health care
services, secondary care and emergency care for homeless people living in an area with a universal primary health
care system and active guidance towards this unique system.
Methods: Observational, cross-sectional study design. Data from the Belgian National health survey were merged
with comparable data collected by means of a face-to-face interview from homeless people in Ghent.
122 homeless people who made use of homeless centres and shelters in Ghent were interviewed using a reduced
version of the Belgian National Health survey over a period of 5 months. 2-dimensional crosstabs were built in
order to study the bivariate relationship between health care use (primary health care, secondary and emergency
care) and being homeless. To determine the independent association, a logistic model was constructed adjusting
for age and sex.
Results and Discussion: Homeless people have a higher likelihood to consult a GP than the non-homeless people
in Ghent, even after adjusting for age and sex. The same trend is demonstrated for secondary and emergency care.
Conclusions: Homeless people in Ghent do find the way to primary health care and make use of it. It seems that
the universal primary health care system in Ghent with an active guidance by social workers contributes to easier
GP access.
Background
Homelessness is worldwide an important societal issue
as it can be considered as unacceptable and unfair. In
the USA, each year over three million people experience
homelessness of which 1,3 million children [1]. In England 99.5000 households were officially recognised as
newly homeless in 2007 [2]. In the Flemish region each
year 12.000 people get support in residential care for
homeless persons [3].
Compared to a decade ago, the homeless population
today is younger (between 30 and 50 years) with a growing number of women and children. This trend continues both in the USA and in Europe [4-7]. The way
people become homeless can be attributed to a number
of factors such as a disruptive family environment
* Correspondence: [email protected]
Department of General Practice and Primary Healthcare, Ghent University,
Belgium
characterized by extreme poverty, marital discord, addiction, financial problems (no job, no money) and mental
health problems [7-10].
Homelessness and health
Homeless people face many challenges. They lack the
access to basic human needs such as shelter, clothing
and healthy food, and have a disproportionally higher
burden of disease than the average population [11].
They suffer from a wide range of medical problems,
acute as well as chronic, e.g. tuberculosis, [8,12-14]
hepatitis [7,14], HIV [4,7,14-16], influenza [13] and skin
and soft tissue infections [8,13,15,16]. On top of the
physical diseases, homeless people are more frequently
caught in the downward spiral of having mental health
problems or substance abuse: suffering from disorders
such as depression, bipolar disorder or schizophrenia
makes it even more difficult to find a job, stable housing
© 2010 Verlinde et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
87
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
or medical care [4,10,12,15,17]. These higher morbidity
rates within the homeless population are also reflected
in raised mortality rates [4,7,9,15]: studies on the European and US situation report life expectancies between
41 and 47 years [4-6,18,19].
Homeless and health care utilisation
88
The literature concerning the health care utilisation of
homeless people is scarce and almost exclusively reporting on the situation in the UK and the US. These studies show low utilisation rates of primary care among
homeless people, with emergency care often being the
only form of health care use [6,7,14,16,20-23]. As a
result homeless people often consult with severe diseases and complications that could be prevented
through earlier contact with a health care provider [22].
This particular pattern in health care use by homeless
people is largely determined by the way the health care
system is organised [7,20-23]. In the USA, the health
care system relies almost entirely on the private sector
for both the financing [24] and the delivery of the health
care. Most health care facilities are privately owned and
operated. Some vulnerable groups are covered by social
insurance programs such as Medicare, Medicaid and the
State Children’s Health Insurance Program. Even though
these programs contribute to a more accessible health
care for those groups, they are not able to provide
access to all types of medical care nor do they cover all
groups of vulnerable patients [25]. Unsurprisingly, US
based studies reporting on barriers in healthcare by
homeless people describe several financial barriers to
health care because of the lack of insurance (high insurance fees, refusing homeless patients because of missing
identification cards,...), high costs of medication, competing priorities (finding housing or employment is
more important than addressing health problems)
[6,16,20]. Literature from the UK shows a slightly different picture, reflecting the particularity of the UK health
care system. The UK has a universal health care system
free at the point of service if people are registered with
a GP [26]. It is in fact this registration procedure which
forms an important barrier to primary health care for
homeless people in the UK: they often don’t know they
have to register or are scared off by the complexity of
the registration procedure, GPs are reluctant to accept
them on their list,... [7,14,21,23,24].
Although the UK provides a health service for all,
marginal groups, such as homeless people, are poorly
served and sometimes excluded. Since 1997 the NHS
has focused on improved primary health care services
for these special needs groups [27]. Specialised general
practices that register only homeless people have
become more common [28]. But despite the installation
of this selective health care system, parallel to the
Page 2 of 9
universal system, the majority of the homeless is not
aware of its existence and use emergency care as a substitute for primary care [29].
Information on the health care use of homeless people
in other countries and the influence of health system
characteristics seems to lack.
Furthermore, literature also reports on a wide range of
factors and mechanisms not related to the organisation
of the health care system contributing to the particular
health care use patterns of homeless patients. The
majority of these studies emphasize the importance of
the attitude of health care providers towards homeless
patients. Care is often postponed because homeless people feel labelled, stigmatized or considered as “problem
patients”[11,21].
In the region of Ghent (Belgium) the care for homeless people is organised in a unique way. In general, Belgium has a universal health care system with direct
access to any general practitioner or specialist, without
gate-keeping nor a patient-list. There is a fee-for-service
system with about 30% co-payment for primary health
care and 40% for specialist care. The lower socio-economic groups have a reduced co-payment of 8%. This
co-payment is limited each year by an income-based
threshold: the maximum bill [30]. Since 1982, the legal
possibility to work in a capitation system in primary
health care has been put in practice. In the area of
Ghent (a midsized city in Belgium with 225 000 inhabitants) the 19 th century belt of deprived areas is to a
large extent covered by Community Health Centres that
provide interdisciplinary comprehensive primary health
care using a capitation payment system. They adopt a
universal approach in which all people residing in the
neighbourhood can access the services of the centre.
Less privileged residents such as the homeless staying in
the area (e.g. frequenting the night shelters, living in
squats, ...) are actively guided towards the community
health centres by social welfare services. More specifically, there are formal agreements between the shelters
for homeless people and the Community Health Centres
in Ghent; in case people staying in the shelter need
medical care, the nearby Community Health Centre is
warned and (in most cases) a doctor comes to the shelter to see the patient. In rare occasions, the patient consults the doctor in the Community Health Centre (e.g.
when he/she has been there before and he/she is able to
walk to the Centre). Also for the payment of the costs,
arrangements are made: all costs are directly refunded
by the shelter or by the patient’s Sickness Fund. When
the patient is not insured, the Community Health Centres tend to ask no fee. Most homeless people living in
the streets are usually known by the social workers
working in the neighbourhood such as the outreachers
and street corner workers. In case a homeless person
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
needs medical care, the social workers refer him/her (or
go with them) to one of the shelters (and usually do a
follow-up whether the person did go to the shelter) or
takes him/her directly to a doctor. There is no formal
agreement between the street corner workers and the
Community Health Workers, however the strong informal networks between them and the low financial and
other thresholds of the Community Health Centres,
makes that also the street corner workers usually lead
the homeless people towards the Community Health
Centres.
In one part of the area where there is no community
health centre, people are guided towards a large group
practice with a comparable way of working to the community health centres, except for the payment system
which is fee-for-service based without co-payment for
the patient.
Seen the particular organisation of the health care use
in Ghent, we want to describe the accessibility of primary health care services, secondary care and emergency care for homeless people living in an area with a
universal primary health care system and active guidance towards the system.
Methods
The National Health Survey is a rich source of information when studying health and health care use. This
cross-sectional survey is used to collect data from a
representative sample of the non-institutionalised population residing in Belgium. For the 2004 survey, 12.945
Belgians were interviewed using both a face-to-face survey and a self-registering survey. Sampling has been
based on a combination of stratification, multistage sampling and clustering. Stratification was done at the regional level and the level of the provinces. The number of
selected individuals per province was determined by the
proportions of the Belgians living in that province. In
order to keep the fieldwork manageable, the number of
interviews in each municipality should at least be 50.
Per stratum, households were selected by randomly
selecting so called ‘reference persons’ from the State
Register. In every selected household, maximum four
persons were questioned: the ‘reference person’, his/her
partner and one or two other household members. Two
hundred and thirty five inhabitants of Ghent were questioned. Finally, the data were anonymized by a trusted
third party (the National Institute for Statistics) and
made available for external researchers. For this study a
variable was add to the dataset, indicating whether the
participant is an inhabitant of Ghent.
However, homeless people are not included in the
study. Therefore additional data from homeless people
in Ghent was collected using a face-to-face survey,
according to an adapted form of the National Health
Page 3 of 9
Survey protocol and using a reduced version of the
NSH questionnaires.
The final database, used for this paper, contains data
from 235 inhabitants with a fixed address in Ghent and
data from 122 homeless people staying in a shelter in
Ghent.
Participants and sample
For this study the study population was restricted to all
the homeless people making use of the homeless centres
and shelters in Ghent. This choice was partly taken
based on pragmatic reasons (homeless centres and shelters are the places where one can reach the homeless
easily and with a good level of safety for the
interviewers).
The exact total number of homeless people visiting
shelters and homeless centres is not available however
social workers estimated this total number at the time
of the data collection on 250.
All the homeless people who made use of homeless
centres and shelters in Ghent during the inclusion period of five months were invited to participate in the
study by the researchers or the organisation’s personnel
(in most cases the social worker). Hereby no distinction
was made between people occasionally sleeping in the
shelter or people semi-permanently sleeping in the
shelter.
Inclusion criteria for the study were: at the moment of
the survey staying in an emergency or temporary
accommodation in Ghent (shelter, homeless centre,...)
(1), being homeless according to the definition of the
Health Council (2), being aged between 18 and 65 years
(3), and giving oral and written consent (4).
People who were noticeably intoxicated at the
moment of the interview or were aggressive towards the
interviewers were not included in the study as were
those visitors who did not speak Dutch, French or English, or refugees. All participants gave written consent.
This study was approved by the Ethics Committee of
Ghent University Hospital (project EC UZG 2006/060).
Data collection
Data were collected by means of a face-to-face survey
being a reduced version of the Belgian National Health
Survey (questions on the gender, age and nationality of
the respondent, his/her socio-economic status, health
status and smoking, and health care use).
The following variables were used to study the possible confounding influence of other variables. Socio-economic status, based on the highest qualification the
responded acquired and was categorised in 4 categories:
no education/primary school, first 3 years of vocational
school, vocational school completed (6 or 7 years),
higher education/university. Health Status was measured
89
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
by means of subjective health status (How is your health
in general?). Smoking status was measured by ‘Are you a
current smoker’. The utilisation of health care was studied in terms of the likelihood to consult a GP, secondary care and emergency care and defined in terms of
whether or not the individual consulted a general practitioner (GP), secondary care or an emergency department (ED) during the last two months.
Administrating the survey took place in a separate
room of the organisation to respect the participant’s
privacy. Interviews lasted between 30 and 60 mins.
Data analyses
90
The data were collected in the context of a larger study
on the social gradient in health care use. For this paper,
a selection of the database was used. More specifically
the data from the homeless people were compared to
the data from the 18 to 65 year old inhabitants of
Ghent available in the most recent National Health Survey data base (2004). None of the latter were homeless.
Data were analysed using SPSS version 16. Initially, 2dimensional crosstabs with c ² -statistic were built in
order to study the bivariate relationship between the
homeless and non-homeless respondents: controlling for
sex, age, education, nationality, subjective health, smoking behaviour and health care use. Secondly, 2-dimensional crosstabs with c²-statistic were built in order to
study the bivariate relationship between the health care
use of the homeless and possible influencing variables
such as sex, age, education, nationality, subjective health,
smoking behaviour and type of practice. To determine
the independent association between health care use
and being homeless, a logistic regression model was
constructed adjusting for age and sex. An odds ratio
and 95% CI for contact with GP and contact with the
ED in past two months was determined for each variable used in the model. The enterwise method was used
to select the final model. The level of significance was
tested by Wald tests, and P < 0,05 was set as being the
level of statistical significance.
Results
Table 1 describes the homeless respondents compared
to the non-homeless respondents. It demonstrates that
the homeless respondents are significantly younger (p <
0,001) and lower educated (p < 0,001) than the general
population. Also the proportion of males (p < 0,001)
and of people with a nationality other than Belgian (p =
0,002) is significantly higher in the homeless population.
Forty percent of the homeless respondents report to be
in fair, bad or very bad health, compared to 34 percent
in the general population (p < 0,001) and the smoking
rate is almost 3 times as high than in the general population (p < 0,001).
Page 4 of 9
Concerning health care utilisation, bivariate analysis
demonstrate a significant association between being
homeless and the likelihood to consult a GP (p < 0,001),
secondary care (p = 0,005) and emergency care (p <
0,001), with higher likelihoods for all three forms of care
in the homeless people.
Bivariate analysis also show an additional significant
association between likelihood to consult a GP and perceived health status (p = 0,019). For the likelihood to
consult an ED and likelihood to consult secondary care
we found no significant associations (see table 2).
When homeless people consult a GP, they do so at a
group practice (56 % versus 5,4%), more often than
when non-homeless patients consult a GP (see table 3).
To determine the independent impact of being homeless on the likelihood to consult a GP, secondary care
and an ED, three multiple logistic regression models
were built adjusting for sex and age (see table 4). The
model focusing on likelihood to consult a GP explained
13,8% of the variance and demonstrated that even when
adjusting for age and gender, homeless people have a
significant higher likelihood to consult a GP (see table
4). The odds ratio for the homeless is 3,641 representing
the homeless persons’ increase in likelihood to consult a
GP (95% CI = 2,160 - 6,139).
The model focusing on likelihood to consult secondary care explained 8,7% of the variance and demonstrated after adjusting for age and gender, being
homeless increases the likelihood to consult secondary
care. The odds ratio for the homeless is 3,271 representing the homeless persons’ increase in likelihood to consult secondary care (95% CI = 1,800 - 5,943).
The comparable model for likelihood to consult an ED
explained 27,7% of the variance and demonstrates that
being homeless also increases the likelihood to consult
an ED, after adjusting for age and sex (see table 3).
Homeless patients have a 13,351 times higher likelihood
to consult an ED compared to the general population
(OR: 13,351 95% CI = 5,114 - 34,857).
Regression models additionally adjusting for perceived
health status follow the same trend. The explained variance increases to 21,5% for the model focussing on likelihood to consult a GP, to 11,9% for the model focussing
on likelihood to consult secondary care and to 33,3% for
the model focussing on likelihood to consult an ED. In
these models, the OR for a homeless person to be likely
to consult a GP is 2.592, to consult secondary care
2,683 and to consult an ED 10,752.
Discussion and conclusion
Homeless people have a disproportionately higher burden
of health problems than the general population. Existing
studies (mainly from the UK and the US) describe higher
utilisation rates for hospital-based care and emergency
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
Page 5 of 9
Table 1 Homeless people versus non-homeless people: descriptive and univariable results
Homeless
Not homeless
n (%)
n (%)
P*
121
253
< 0,001
Male
101 (83,5)
124 (49,0)
Female
20 (16,5)
129 (51,0)
Sex
Age
121
253
18-29
42 (34,7)
71 (28,1)
30-39
31 (25,6)
51 (20,2)
40-49
50-59
31 (25,6)
15 (12,4)
56 (22,1)
47(18,6)
60-65
2 (1,7)
28 (11,1)
Educational level
121
223
No education/primary school
lower education
17 (14,0)
18 (8,1)
Lower vocational school
23 (19,0)
27 (12,1)
Higher vocational school
74 (61,2)
87 (39,0)
7 (5,8)
91 (40,8)
Higher education/University
Nationality
Belgian
Non-Belgian
122
251
105 (86,8)
16 (13,2)
240 (95,6)
11 (4,4)
Subjective health perception
120
237
Good or very good
73 (60,8)
203 (85,7)
Fair, bad or very bad
47 (39,2)
34 (14,3)
Current smoker
Yes
Contact with GP last 2 months
Yes
Contact with secondary care last 2 months
Yes
Contact with ED in last 2 months
Yes
Type of GP practice
Single handed
Two handed
Group practice
< 0,001
< 0,001
0,002
< 0,001
< 0,001
112
253
100 (89,3)
72 (30,5)
120
238
77 (64,2)
121
104 (43,7)
240
38 (31,4)
44 (18,3)
0,005
120
243
< 0,001
33 (27,5)
7 (2,9)
75
224
27 (36,0)
151 (67,4)
6 (8,0)
61 (27,2)
42 (56,0)
12 (5,4)
< 0,001
< 0,001
* All significant results are indicated in bold.
care, and lower rates for primary care by homeless people
compared to the general population. Some studies indicate
that homeless people do not access primary care at all and
use emergency care as the only form of health care
[6,16,20]. Homeless people are importantly hindered and/
or steered in their health care use by barriers directly
related to the organisation of care [6,7,21,24].
In this study we describe the likelihood to consult a
GP, secondary care and emergency care of homeless
people living in an area with a primary health care system in which homeless people with health problems are
actively guided to low-threshold but universal accessible
(i.e. not selective) community health centres.
Hereto the Belgian National Health Survey Database
was extended with data of 122 homeless persons
residing in one of the night shelters or temporarily
accommodations for homeless people in Ghent.
The homeless respondents in this study are significantly younger, lower educated, more likely to smoke,
have more often a non-Belgian nationality and report to
be in worse health than the general population. These
findings are concordant with other studies reporting
that homeless people have worse health, suffer more
from multimorbidity, have higher smoking prevalence
(up to 80%), and are mostly less educated, decreasing
the chance to find a stable job [4,6,14,18,31,32].
Literature shows a growing number of women in the
homeless population [33]. This could not be confirmed
in this study in which over 80% of the respondents are
male. This could partly be due to a selection bias;
91
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
Page 6 of 9
Table 2 health care use of the homeless people: descriptive and univariable results (total n homeless: 121)
Had contact with
GP
n (%)
Sex
Total
n
Had contact with
ED
P*
Total
n
n (%)
0,151
Had contact with
secondary care
P*
121
0,507
63 (80,8)
29 (87,9)
30 (78,9)
Female
15 (19.2)
4 (152,1)
8 (21,1)
18-29
24 (31,2)
12 (36,4)
12 (31,6)15 (39,5)
30-39
40-49
20 (26,0)
20 (26,0)
11 (33,3)
5 (15,2)
7 (18,4)
4 (10,5)
50-59
11 (14,3)
4 (12,1)
0 (0,0)
60-65
2 (2,6)
1 (30,0)
0,693
Educational level
120
0,621
121
0,466
0,740
No education/primary
school
92
n (%)
Male
Age
lower education
11 (14,1)
6 (18,2)
15 (19,2)
7 (21,2)
9 (23,7)
Higher vocational
school
46 (59,0)
19 (57,6)
25 (65,8)
Higher education/
University
6 (7,7)
1 (3,0)
1 (2,6)
Nationality
0,344
Belgian
66 (84,6)
Non-Belgian
12 (15,4)
Subjective health
perception
Good or very good
Yes
121
0,827
29 (87,9)
33 (86,8)
4 (12,1)
5 (13,2)
0,019
41 (52,6)
19 (50,0)
37 (47,4)
19 (50,0)
0,426
64 (87,7)
Type of GP practice
Single handed
113
0,683
28 (87,5)
121
0,274
121
0,171
121
0,274
121
0,989
121
0,116
113
0,257
0,396
19 (31,7)
76
0,629
33 (94,3)
76
8 (44,4)
0,647
10 (40,0)
Two handed
5 (8,3)
1 (5,6)
1 (4,0)
Group practice
36 (60)
9 (50,0)
14 (56,0)
women (often with children) who become homeless
usually stay in crisis centres for women and children
which were not included in this study. However, possibly there are also less homeless women in Belgium than
in other countries because of the relatively good safety
net for women with children; they have priority in getting social housing or -in case of the unavailability of
social housing-emergency housing (temporarily housing
in a premises owned or rented by the council).
Table 3 Type of practice
Type of practice
P*
3 (7,9)
Lower vocational
school
Fair, bad or very bad
Current smoker
Total
n
Homeless
Ghent sample
Solo
32,2%
64,6%
Duo
8,5%
28,3%
Group practice
59,3%
7,1%
Multivariate analyses show that homeless persons in
Ghent have a higher likelihood to consult a GP (i.e.
have consulted the GP at least once in the 2 months
prior to the interview) than the general population after
adjusting for sex, age and perceived health status. This
finding indicates that in Ghent the homeless people find
the way to primary health care and use it.
This contrasts with studies from other countries. Several US based studies show lower utilisation rates of
ambulatory care and up to 5 times higher utilisation
rates of acute hospital-based care and emergency care in
the homeless population compared to the US average
[6,16,20]. Studies from the United Kingdom describe the
same trend: homeless people contact secondary services
more frequently than the housed population. Some studies describe that a considerable proportion of the
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
Page 7 of 9
Table 4 Logistic regression model for going to the GP, the ED and secondary care in the past two months
Variable
Estimate
SE
Wald
P*
Odds ratio
95% CI
5,926
0,015
1,835
1,126-2,993
Contact with GP
Sex
0,607
0,249
19,895
0,001
30-39
-0,146
0,313
0,218
0,641
0,864
0,468-1,595
40-49
0,070
0,305
0,052
0,819
1,071
0,589-1,951
50-59
1,173
0,359
10,672
0,001
3,233
1,599-6,537
60-65
Homeless in Ghent
1,242
-1,292
0,457
0,266
7,381
23,523
0,007
0,000
3,462
3,641
1,413-8,480
2,160 -6,139
Sex
-0,032
0,475
0,005
0,969
0,382-2,456
5,929
0,205
30-39
-0,107
0,450
0,057
0,811
0,898
0,372-2,168
40-49
-1,214
0,563
4,655
0,031
0,297
0,099-0,895
50-59
60-65
-0,743
0,149
0,621
0,866
1,434
0,030
0,231
0,863
0,476
1,161
0,141-1,605
0,213-6,339
-2,592
0,490
28,016
0,000
13,351
5,114-34,857
0,002
2,470
1,387-4,398
Age
18-29
Contact with emergency department
0,946
Age
18-29
Homeless in Ghent
Contact with secondary care
Sex
0,904
0,294
9,441
4,362
0,359
30-39
40-49
0,391
-0,089
0,359
0,376
1,187
0,056
0,276
0,813
1,478
0,915
0,732-2,986
0,438-1,911
50-59
0,355
0,405
0,768
0,381
1,426
0,645-3,151
0,819
0,509
2,587
0,108
2,268
0,836-6,150
-2,592
0,305
15,130
0,000
3,271
1,800-5,943
Age
18-29
60-65
Homeless in Ghent
* All significant results are indicated in bold.
Nagelkerke R² contact with GP: 0,138. Nagelkerke R² contact with ED: 0,277, Nagelkerke R² contact with secondary care: 0,087
homeless population does not find the way to primary
health care at all: a survey conducted by Crisis (the
national charity for solitary homeless people in the UK)
in 2002 reported that homeless people were three times
more likely not to have had contact with a GP in the
last year and were nearly five times more likely than the
general population to attend the emergency departments
[34].
A 2002 survey conducted in the UK also looked at the
likelihood to consult a GP. They found that homeless
persons were 3 times more likely not to contact their
GP in the last year than the general population[34].
This higher likelihood in Ghent to consult a GP in
the homeless population compared to the general
population could be explained by the fact that primary
health care for homeless people in Ghent is organised
in a way that contributes to the reduction of some of
the barriers demonstrated in others types of primary
health care organisation such as financial barriers
(insurance status), registration, accessibility, stigmatisation,... [7,11,14,21,23,24].
Tracing homeless people with health problems and
active guidance towards primary care centres by social
workers, might contribute to an easier access to the GP.
The Community Health Centres are situated close the
shelters and social restaurants, so transportation is often
not an issue. There are also agreements on the payment
procedure so the homeless people do not need to worry
about money, reducing the financial barrier. Additionally, Community Health Centres are known not to stigmatise or refuse patients because of being homeless or
having no money. This hypothesis is supported by the
finding that the homeless people who visit a GP, do this
considerably more often at a group practice (including
the health centres) (56% versus 5,6% in the general
population).
Also, the universal approach of the primary care centres (providing care to everyone residing in the geographical area) leads to less stigmatization and labelling
than in a selective setting focussing solely on the homeless population. In this study, the higher likelihood to
consult a GP does not go hand in hand with a lower
93
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
94
likelihood to consult the emergency department or secondary care. This indicates that homeless people,
although they have a higher likelihood to make use of
the primary health care system, have not totally abandoned the way to emergency care. Probably this can
partly be explained by the particularity of the health
problems homeless people experience (e.g. postponing
care until it’s really urgent or care during the evening or
night). Homeless people are also more often the victim
of drug related accidents and road accidents and suffer
from health problems that need more emergency care
than the general population (e.g. hypothermia)[35].
Additionally, this study has a cross-sectional design
which makes that we do not know whether the homeless people would use more frequently the emergency
services if there was the universal primary care system
would have been organised differently. Moreover, since
this study is the first to study the health care use of
homeless people in Ghent, it is not possible to describe
an increase or decrease in the emergency care use of the
homeless population over time.
This study has some limitations. First of all there is no
reliable information available on the response rate of the
homeless people nor on the respondents excluded from
the study. The study was presented to all homeless persons present at different moments in one of the shelters
in Ghent during the five months inclusion period and
everyone was invited when fulfilling the inclusion criteria. However, there was no registration of any information concerning the people who did not want to
participate. This was mainly due to anonymity reasons
thrown up by the managers of the shelters. Also the
exact total number of homeless people visiting shelters
and homeless centres is not available. Most of the crisis
centres have no registration of their visitors.
A second and important limitation of this study is that
only likelihood to consult is studied. The National
Health Survey contains self reported frequencies of
health care use, so analogously these frequencies were
also included in the survey for the homeless people.
However, most of the respondents found it very hard to
remember the exact number of their visits to a care provider. For a more nuanced view on health care use,
information on the number of consultations is necessary. The concept of likelihood to consult is in any case
usable to evaluate whether people know and find their
way to a certain care provider but not to evaluate the
intensity of their health care use. Although this study
cannot prove the impact of a better accessible primary
health care system on emergency care utilisation rates
or on secondary care utilisation rates, a recent study
commissioned by the Belgian government gives an
important indicator of the possible impact. In this report
the authors compared the traditional, fee-for-service
Page 8 of 9
based primary health care services in Belgium with capitation based primary health care services such as the
community health centres. Their findings complement
the findings of our study as they state that the community health centres indeed succeed in reaching the most
vulnerable of society. Additionally this study provides
evidence that people who found their way to these centres tend to contact less frequently the emergency
department or secondary care[36].
The merits of this study lie in the fact that a relatively
large sample of homeless people was questioned (an
estimated third of the homeless population in Ghent visiting a homeless centre in the research period), following the research protocol and instruments of the
National Health Survey as close as possible so that a
comparison with National Health Survey data was made
possible. However, prudence is recommended in the
generalisation of the results. Data were collected from
homeless people seeking help or assistance, mainly for
food or a place to sleep, in the homeless centres or
night shelters in Ghent. Without doubt their help seeking behaviour towards health care is different from that
of homeless people not seeking help in the homeless
centres. Also no information is available on the response
rate and the characteristics of the people who refused to
participate in the study, which makes it very difficult to
evaluate the selection bias.
Further research addressing the health care use of the
homeless people living in Belgium is needed to provide
policymakers with the evidence needed to take action in
order to make the health care system accessible and suitable for every person disregarding their different socioeconomic backgrounds. The performance of universal
primary health care services, as demonstrated in this
study, may stimulate the debate between a universal or
a selective approach.
Acknowledgements
We would like to thank the personnel of the homeless centres and shelters
in Ghent for their cooperative collaboration.
Authors’ contributions
MVDW, TV, BA, SW and JDM contributed to the design of the study. MVDW
and TV contributed to the data retrieval. EV and SW contributed to the
analysis and the writing of the paper. BA, SW and JDM participated in the
revision of the manuscript. All authors have read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 8 April 2010 Accepted: 19 August 2010
Published: 19 August 2010
References
1. Homelessness and Poverty in America. [http://www.nlchp.org/hapia.cfm].
2. Official Homelessness Statistics Overview. [http://www.crisis.org.uk/
policywatch/pages/homelessness_statistics.html].
Chapter 3: Research papers
Verlinde et al. BMC Health Services Research 2010, 10:242
http://www.biomedcentral.com/1472-6963/10/242
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Van Menxel G, Lescrauwaet D, Parijs I: Verbinding verbroken. De zorg voor
thuislozen in het almeneen welzijnswerk. Berchem: Steunpunt Algemeen
Welzijnswerk 2003.
Hwang SW, Lebow JM, Bierer MF, O’Connell JJ, Orav EJ, Brennan TA: Risk
factors for death in homeless adults in Boston. Arch Intern Med 1998,
158(13):1454-1460.
Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR: Emergency department
use among the homeless and marginally housed: results from a
community-based study. Am J Public Health 2002, 92(5):778-784.
Kushel MB, Vittinghoff E, Haas JS: Factors associated with the health care
utilization of homeless persons. JAMA 2001, 285(2):200-206.
O’Carroll A, O’Reilly F: Health of the homeless in Dublin: has anything
changed in the context of Ireland’s economic boom? Eur J Public Health
2008, 18(5):448-453.
Hill RP: Health care and the homeless: a marketing-oriented approach. J
Health Care Mark 1991, 11(2):14-23.
Johnson TP, Fendrich M: Homelessness and drug use: evidence from a
community sample. Am J Prev Med 2007, 32(6 Suppl):S211-218.
O’Toole TP, Conde-Martel A, Gibbon JL, Hanusa BH, Freyder PJ, Fine MJ:
Where do people go when they first become homeless? A survey of
homeless adults in the USA. Health Soc Care Community 2007,
15(5):446-453.
Martins DC: Experiences of homeless people in the health care delivery
system: a descriptive phenomenological study. Public Health Nurs 2008,
25(5):420-430.
Daiski I: Perspectives of homeless people on their health and health
needs priorities. J Adv Nurs 2007, 58(3):273-281.
O’Connell JJ: Dying in the shadows: the challenge of providing health
care for homeless people. CMAJ 2004, 170(8):1251-1252.
Wright NM, Tompkins CN: How can health services effectively meet the
health needs of homeless people? Br J Gen Pract 2006, 56(525):286-293.
Morris DM, Gordon JA: The role of the emergency department in the
care of homeless and disadvantaged populations. Emerg Med Clin North
Am 2006, 24(4):839-848.
Hwang SW: Homelessness and health. CMAJ 2001, 164(2):229-233.
Woollcott M: Access to primary care services for homeless mentally ill
people. Nurs Stand 2008, 22(35):40-44.
Cuddy R: Anonymous demise: mortality in the homeless. J Emerg Med
1997, 15(3):373-374.
Hwang SW, Orav EJ, O’Connell JJ, Lebow JM, Brennan TA: Causes of death
in homeless adults in Boston. Ann Intern Med 1997, 126(8):625-628.
Gelberg L, Gallagher TC, Andersen RM, Koegel P: Competing priorities as a
barrier to medical care among homeless adults in Los Angeles. Am J
Public Health 1997, 87(2):217-220.
Riley AJ, Harding G, Underwood MR, Carter YH: Homelessness: a problem
for primary care? Br J Gen Pract 2003, 53(491):473-479.
Power R, French R, Connelly J, George S, Hawes D, Hinton T, Klee H,
Robinson D, Senior J, Timms P, et al: Health, health promotion, and
homelessness. BMJ 1999, 318(7183):590-592.
Victor CR, Connelly J, Roderick P, Cohen C: Use of hospital services by
homeless families in an inner London health district. BMJ 1989,
299(6701):725-727.
Crane M, Warnes AM: Primary health care services for single homeless
people: defects and opportunities. Fam Pract 2001, 18(3):272-276.
Docteur E, Suppanz H, Woo J: The US Health System: An Assessment and
prospective directions for reform economics department working
papers No. 350. 2003.
Health Care Systems in Transition. United Kingdom. European
Observatory on Health Care Systems 1999.
Lewis R, Jenkins C, Gillam S: Personal Medical Services Pilots in London:
Rewriting the Red Book. London: The King’s Fund 1999.
Wright N: Homelessness: a primary care responde: London. Royal College
of General practitioners 2002.
Little GF, Watson DP: The homeless in the emergency department: a
patient profile. J Accid Emerg Med 1996, 13(6):415-417.
Willems S: The socio-economic gradient in health: a never-ending story?
A desriptive and explorative study in Belgium. Ghent 2005.
Gelberg L, Leake BD: Substance use among impoverished medical
patients: the effect of housing status and other factors. Med Care 1993,
31(9):757-766.
Page 9 of 9
32. van Laere IR, de Wit MA, Klazinga NS: Pathways into homelessness:
recently homeless adults problems and service use before and after
becoming homeless in Amsterdam. BMC Public Health 2009, 9:3.
33. Lewis JH, Andersen RM, Gelberg L: Health care for homeless women. J
Gen Intern Med 2003, 18(11):921-928.
34. Critical condition: Vulnerable Single Homeless People and Access to
GP’s. [http://www.crisis.org.uk/downloads/php/101/GP_policybrief.pdf].
35. Wright NM, Tompkins CN, Oldham NS, Kay DJ: Homelessness and health:
what can be done in general practice? J R Soc Med 2004, 97(4):170-173.
36. Annemans L, Closon J, Heymans I, Lagasse R, Mendes Da Costa E,
Moureaux C, Roch I: Vergelijking van kost en kwaliteit van twee
financiëringssystemen voor de eerstelijnsgezondheidszorg in België. KCE
reprots 85A. 2008.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1472-6963/10/242/prepub
doi:10.1186/1472-6963-10-242
Cite this article as: Verlinde et al.: Unique health care utilization patterns
in a homeless population in Ghent. BMC Health Services Research 2010
10:242.
95
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Chapter 3: Research papers
96
Chapter 3: Research papers
Social differences in postponing a GP visit in Flanders, Belgium: Which low-income patients are most at risk?
1
1
2
3
1
Verlinde E. *, Poppe A. , DeSmet A. , Hermans K. , De Maeseneer J. , Van Au3
1
denhove C. , Willems S.
1Department of General Practice and Primary Healthcare, Ghent University, Belgium
2 Department of Movement and Sports Sciences, Ghent University, Belgium
3 Lucas, Center for Care Research and Consultancy at K.U. Leuven, Leuven, Belgium
*Corresponding author
Abstract
One of the main goals of primary care is providing equitable healthcare, meaning
equal access, equal treatment, and equal outcomes of healthcare for patients in equal
need. Some studies show that patients from lower socioeconomic groups visit a GP
more often, while other studies show that they are more likely to postpone a visit
to a GP.
In this study we want to explore within the social group of low-income patients
living in Flanders, Belgium, which patients have a higher risk of postponing a visit
to a GP. A face-to-face questionnaire was administered among 606 low-income
users of Public Social Services. The questionnaire consisted of questions on socioeconomic and demographic characteristics, social networks, health and healthcare use.
A multivariate logistic regression model was built in order to study the relationship
between postponing or cancelling a GP visit respondents thought they needed and
variables on health and socio-demographic background.
The multivariate regression indicates that depression, self-rated health, and trust in
the GP independently predict postponing a visit to a GP.
Low-income people with a low trust in the GP, people with ill health and people
suffering from a severe depression are more likely to postpone or cancel a GP visit
they thought they needed compared to other low-income patients. This might
indicate that the access to healthcare for low-income people might be hindered by
barriers which are not directly linked to the cost of the consultation.
Keywords:
Primary Care, Health Disparities, Consultation, Doctor-Patient relationship, Social
class, low-income people
97
Chapter 3: Research papers
What is known about this topic:
•
Studies show relatively high rates of postponing a visit to the GP by
patients from lower socioeconomic groups due to factors related to the
health care system.
What this paper adds:
•
•
98
Within a low-income population in Belgium, people with low trust in
the GP, with ill health, and people suffering from a severe depression
have a higher chance of postponing a visit to the GP than other lowincome patients. The inability to make ends meet does not seem to lead
to further postponing of healthcare.
The universal approach for low income people in Flanders seems to be
able to reduce the financial barriers towards health care use, but the access to health care for low income people is still hindered by barriers that
are not directly linked to the price of the consultation
Introduction
The socioeconomic conditions in which people live powerfully influence their chances to be healthy. Poverty, social exclusion, discrimination, poor housing, unhealthy
early childhood conditions, and low occupational status are important determinants
of the systematic variations in health and illness between social groups, both between
and within countries (Whitehead and Dahlgren, 2006). Despite the marked improvements in the health of the general population, these health inequities seem to
persist and even increase for some diseases and/or population groups (Hart, 1971,
Whitehead and Dahlgren, 2006). Massive investment in further stimulating the
rise of (healthy) life expectancy will not automatically lead to less inequity in health.
However, actions that strengthen primary health care might. Evidence shows that a
stronger primary care system—in contrast with specialist care—is associated with
a more equitable distribution of health among populations (Marmot et al., 2010).
The beneficial effects of primary care can be attributed to the cumulative effect of its
main delivery characteristics: the focus on the person rather than on the management of particular diseases, coordinating and integrating care provided elsewhere
or by others in the healthcare system, the provision of a low-threshold entry for
relatively deprived population groups, delivering high-quality clinical care, providing
Chapter 3: Research papers
better access to preventive activities and early management of health problems and
facilitating entry to the rest of the health system (Starfield et al., 2005, WHO).
Thus, one of the main goals of primary care is providing equitable healthcare,
meaning equal access, treatment, and outcomes of healthcare for patients in equal
need. Studies show higher crude utilization rates of primary health care (PHC) (i.e.
utilization rates without taking into account the disease burden) by people from lower socioeconomic groups, in contrast to people from higher socioeconomic groups,
who tend to visit specialists more frequently. When taking into account the higher
morbidity of people from the lower social classes, the difference in PHC utilization
between the higher and lower social classes seems to melt away partially, whereas
specialist care still seems to favor the better off (van der Meer et al., 1996, Van der
Heyden et al., 2003, Regidor et al., 2008, Campbell, 1999, Droomers and Westert,
2004, Veugelers and Yip, 2003). Although these results tell a positive story about
the accessibility of primary healthcare, other studies show relatively high rates of
postponing a visit to the GP by patients from lower socioeconomic groups (Drieskens et al., 2010, Vilhjalmsson, 2005, Burstrom, 2002). In Belgium, each five years
a Health Interview Survey (HIS) is conducted. This is a cross-sectional survey on
health, life style and health care use based on a representative sample of the noninstitutionalized population residing in Belgium who are aged 15 years or older
(Van der Heyden et al., 2003). In the 2008 HIS, 18% of the households with a low
educational level reported having postponed a visit to a GP in the last 12 months
while they actually needed one, whereas only 9% of the households with a high
educational level reported having done the same thing (Drieskens et al., 2010). The
results from the Health Survey in Iceland show that younger individuals, the nonwidowed, the economically troubled, the chronically ill and those who have to pay
high out-of-pocket payments relative to their income were more likely than others
to postpone or cancel a doctor visit they thought they needed (Vilhjalmsson, 2005).
There are several reasons why people might postpone healthcare: Some people rely
more on self-care than others or find informal help for their medical problems in
their social network (eg. from a friend or a relative working in the healthcare sector).
However, sometimes people postpone healthcare because of reasons related to the
organization of the healthcare system. Thus, a distinction can be made between problems in the physical access of care (eg. problems with transportation), the financial
access, psychosocial (eg. feelings of shame or embarrassment) and cultural access
(eg. language problems), administrative access (eg. problems of finding the way in
a complex healthcare system), or doctor-patient communication, which does not
99
Chapter 3: Research papers
succeed in meeting the patient’s need and expectations (Willems, 2005, Willems
et al., 2005, Ahmed et al., 2001).
Postponing or cancelling a needed visit to a doctor might have an important impact
on the patient’s health status. People from a lower social class suffer more often
from a higher disease burden (Droomers and Westert, 2004). Postponing medical
care can lead to more serious health problems that could be prevented in an earlier
stage, but now require hospitalization and specialist care.
In this study, we want to explore within a vulnerable population group, namely of
low-income people, which patients have a higher risk of postponing a needed GP
visit due to factors related to the organization of the healthcare system. We believe
that people who are not able to cope with their monthly income have a higher risk
of postponing a visit to a GP. Furthermore, special attention will be given to the
vulnerable subgroups within a low income population: people without a paid job,
people with young children living with them, people with a poor social network
and people with mental health problems.
100
Methods
Participants, sample, and procedure
This study is a part of the ‘KANS’ project, which aims at describing the use of
healthcare and welfare services among low-income people in eight Flemish regions: Ypres, Ostend, Genk, Ghent, Oudenaarde, Tielt-Winge, Geel, and Antwerp.
Region selection is based on maximal variations in geographical spread, level of
urbanization, socioeconomic profile of the region, and the availability of health and
welfare services (Hermans, 2008).
Between September 2008 and December 2009, social workers of the Public Social
Services in the selected regions invited all their clients who met the inclusion criteria to participate in the study. The inclusion criteria were as follows: master the
Dutch language, living in one of the eight selected regions, being aged between 18
and 65 years and having a low income (being a gross taxable family income lower
than 13.543, 71 Euro, increased with 2.507,30 Euro per additional family member).
People were excluded from the study when the social worker felt that participating
in the study would unnecessarily confuse the client, he/she would feel worse by
participating, or completing the questionnaire would create a larger burden than
Chapter 3: Research papers
the responder could handle. Once clients gave their consent to participate in the
study, a trained interviewer contacted them by phone to set a date for completing
the questionnaire. Data collection took place in the homes of the respondents or at
their regular Public Social Service center by means of a combination of a written
and an oral questionnaire. Filling in both questionnaires took between 45 minutes
and 1h30 min.
A total of 1148 low-income people were included in the study. Overall, 606 people
completed the questionnaire. The interviewers could not contact 339 persons due to
absence of the included person or due to a wrong telephone number. 203 included
respondents refused to participate after all at the moment the interviewer contacted
them. Additional information on these respondents was not available. Furthermore,
no information is available on how many clients were invited to participate in the
study by the social workers.
Instruments
The questionnaire consisted of questions on socio-economic and demographic
characteristics, social networks, health, and healthcare use.
Socio-demographic variables
Socio-demographic variables included gender, age, educational level, subjective
feeling of poverty, urbanization, having young children living with them and having a paid job at the moment of the study. Age was categorized into five groups
(18-24, 25-34, 35-44, 45-54, and 55+). Education was categorized into lower (no
education, primary school or lower secondary school), middle (higher secondary
school or A-level), and higher (higher education) groups. Subjective feeling of
managing with the available income (“To what extent can you manage with your
current available household income?”) was categorized as a dichotomous variable
(“very difficult,” “difficult,” or “rather difficult” versus “rather easy,” “easy,” or “very
easy”). Level of urbanization was categorized into urban or rural. Having young
children was categorized as having children younger than 12 years.
Health care-related variables
The health care-related variables included are as follows: level of trust in the GP
(“complete distrust”, “distrust,” and “trust” versus “complete trust”) and satisfaction
101
Chapter 3: Research papers
with the care delivered by the GP. The latter was measured by questions from the
Consumer Quality Index (CQI) Family Medicine. The CQI contains 11 questions
on what people expect from primary care and 11 questions on to what extent these
expectations are met. Statements regarding the importance of several aspects of
primary care were rated using four categories from “totally unimportant” to “very
important” (0-3). Next, the occurrence of these aspects in the general practice they
usually visit was measured in four categories from “never” to “always” (0–3). The
scores for importance were deducted from the scores for the actual situation. This
way, a score could be interpreted: 0 indicates that the actual situation exactly meets
the desired needs; a negative score indicates a situation where the actual situation
exceeds the needs; and a positive score indicates that the actual situation does not
meet the desired level. Finally, a mean score for all questions regarding what people
find important in primary care and the occurrence of it was calculated. If information on four or more questions was missing, then the mean was not calculated
for this respondent.
102
Health status
Health status is measured by self-rated health, disability due to a chronic condition and mental distress. Self-rated health was measured using a validated WHO
instrument: “poor,” or “very poor” versus “fair” versus “good” or “very good” (de
bruin A, 1996). Disability due to a chronic condition is categorized as: “no chronic
condition”, “chronic condition without or with mild disability”, “chronic condition
with moderate disability”, “chronic condition with severe disability”. The severity
of mental distress is measured by the Beck Depression Inventory (BDI). People
experiencing a form of mental distress based on the validated screening instrument
developed by Whooley (Whooley et al., 1997) were asked to fill out the BDI. The
Whooley instrument contains two questions: “During the past month, have you
often been bothered by feeling down, depressed, or hopeless?” and “During the past
month, have you often been bothered by little interest of pleasure in doing things.”
When people answered positive on one of these questions, they scored positive on
mental distress. Next, the Beck Depression Inventory was administered. The BDI
is a 21-question multiple-choice self-report inventory and one of the most widely
used instruments for measuring the severity of depression. When the test is scored, a
value of 0 to 3 is assigned for each answer and then the total score is compared to a
key to determine the depression’s severity. The standard cut-offs are as follows: 0–9:
indicates minimal depression; 10–18: indicates mild depression; 19–29: indicates
Chapter 3: Research papers
moderate depression; 30–63: indicates severe depression.
Social networks
The aspects of social networks included in the analyses are network diversity and
how often people feel lonely. Network diversity was measured based on the Social
Network Index developed by Cohen et al (Cohen et al., 1997). Network diversity
represents the number of social networks in which the respondent has regular
contact with at least one other person. Lower is defined as zero to three social
networks; middle is defined as four to five social networks; and higher is defined as
six or more social networks. How often people feel lonely is categorized as “never”
to “seldom,” “occasionally,” and “often” to “all the time.”
Postponing a visit to a GP
Respondents were asked whether they, during the past 12 months, had postponed or
cancelled a GP visit they thought they needed. This postponement or cancellation
can be due to reasons related to the organization of the healthcare system: financial
reasons, no transportation, on a waiting list, uninsured, afraid to go to the doctor,
practical reasons (no child care), did not know where to go, did not know how to
express themselves, afraid the GP could not help, ashamed to go, or physically not
able to go. Respondents answering positive on one of these reasons were included
in the variable “postponing a visit with a GP in the past 12 months.”
Data analyses
In order to build the logistic model, two-dimensional crosstabulations with c² test
statistics were used to study the bivariate relationship between having postponed
a visit to a GP during the past 12 months and socio-demographics, health status,
social networks, and healthcare-related variables. The independent variables that
had a p value <0.25 in the crosstabs were used to build the multivariate logistic
regression model. Before the logistic model was build, the variables were checked
with regard to multi-collinearity. The cut-off point used was at a Pearson correlation coefficient of 0.6. The logistic models were fit using enterwise regression. The
level of significance was tested by Wald tests, and a p < 0.05 was set as the level
of statistical significance. An odds ratio and 95% CI were determined for each
variable in the model.
103
Chapter 3: Research papers
Ethics approvement
The study was approved by the Ethics Committee of the Ghent University Hospital
(Dossier No. 2008/343).
Results
Description of the participants
104
In this study, 606 low-income people were interviewed using an oral and written
questionnaire. Table 1 provides a description of the study group. 32.1% postponed or
cancelled a GP visit they thought they needed during the past 12 months. Slightly
more women (327 – 54.0%) than men (279 – 46.0%) participated in the study.
Overall, 75.4% was 35 years or older; 47.1% had a lower educational level; 39.7%
had a middle educational level; and 13.2% had a higher educational level. In fact,
70.6% of the participants perceived difficulties in coping with their current available income. This could be related to the finding that 75.9% does not have a paid
job at the moment of the survey. 16.2% of the respondents had children younger
than 12 years living with them and 63.7% lived in a rural area. Self-rated health
was rated from “very poor to poor” by 20.3% of the participants, 34.3% rated their
health as fair and 45.4% reported experiencing good to very good health. At the
moment of the survey, 39.8% did not suffer from any chronic condition, 8.1% had a
chronic condition but did not perceive any kind of disability of very mild disability,
22.6% had a chronic condition from which they perceived moderate disability and
29.5% had a chronic condition from which they perceived severe disability. 38.1%
did not cope with mental distress, 27.3 % had feelings of minimal depression,
11.5% suffered from mild depression, 11.2% suffered from moderate depression
and 11.9% suffered from severe depression. 41.8% of the respondents had a lower
network diversity; and 26% felt lonely often or all the time. Overall, 66.3% of the
respondents reported high satisfaction with the care delivered by the GP; 45.7%
had complete trust in the GP.
Chapter 3: Research papers
Table 1: distribution of the study sample
Variable
Sex
Female
Male
Age
n(%)
606
327 (54.0)
279 (46.0)
595
18-24
35-44
137 (23.0)
55+
109 (18.5)
25-34
45-54
Education
49 (8.2)
98 (16.4)
202 (33.9)
554
Lower
106 (19.1)
Higher
73 (13.2)
Middle
Perception of coping with income
Rather difficult / very difficult
Rather easy / very easy
Self-rated health
375 (67.7)
591
417 (70.6)
174 (29.4)
606
Poor / very poor
123 (20.3)
Good /very good
275(45.4)
Fair Chronic condition with disability
208 (34.3)
606
No chronic condition
241 (39.8)
Chronic condition with moderate disability 137 (22.6)
Chronic condition without or with mild disability
Chronic condition with severe disability
Mental distress
49 (8.1)
179 (29.5)
598
None
228 (38.1)
Mild
69 (11.5)
Minimal
Moderate
Severe
163 (27.3)
67 (11.2)
71 (11.9)
105
Chapter 3: Research papers
Satisfaction with care delivered by GP
Low satisfaction (needs > actual situation)
118 (25.8)
High satisfaction (needs < actual situation)
303 (66.3)
Perfect match (needs = actual situation)
Trust in the GP
Quite trust / distrust / complete distrust
Complete trust
Postpone a visit to a GP during the past 12 months
Yes
Network diversity
36 (7.9)
579
302 (52.2)
277 (45.7)
474
152 (32.1)
594
Lower 248 (41.8)
Higher
89 (15.0)
Middle
How often do you feel lonely
106
457
257 (43.3)
600
Seldom / never
233 (38.8)
Often / all the time
160 (26.7)
Occasionally
Urbanization
Rural Urban
Having young children
Yes
Having a paid job
Yes
207 (34.5)
606
386 (63.7)
220 (36.3)
606
98 (16.2)
585
141 (24.1)
Postponing a visit to a GP during the past 12 months
The results from the chi-square tests indicated that the variables sex, age, education,
perception of coping with income, self-rated health, trust in the GP, having a paid
job, having young children and mental distress had a p value <0.25 (results not
shown). These variables were included in the multivariate logistic regression model.
Table 2 shows the results of the multivariate model, including the variables sex,
age, education, perception of coping with income, self-rated health, trust in the GP,
having a paid job, having young children and mental distress The model explains
Chapter 3: Research papers
16.5% of the total variance of postponing or cancelling a GP visit respondent
thought they needed during the past 12 months.
The results show that people with a severe depression are 2,209 times more likely to
postpone a visit to a GP than people with no signs of depression or mental distress
(p=0.036, CI: 1.052-4.641). People with a good to very good health also tend to
postpone less frequently a visit to a GP compared to people with a poor to very
poor health (odds: 0.482, p=0.040, CI: 0.240-0.967). People with a complete trust
in their GP tend to postpone less frequently a visit to a GP than those without
complete trust. These results have a trend to significance (odds: 0.649, p=0.064, CI:
0.410-1.026). No significant associations were found for sex, age, educational level,
coping with available monthly income, having young children and having a paid job.
Table 2: Regression model for postponing health care with a GP in the past 12 months*
95% CI
p
0.911-2.305
0.118
Age
0.016
25-34 vs 18-24
0.478
1.613
0.603-4.315
0.341
35-44 vs 18-24
0.379
1.461
0.558-3.829
0.440
45-54 vs 18-24
-0.298
0.742
0.287-1.918
0.538
55+ vs 18-24
-0.820
0.440
0.152-1.281
0.132
Education
0.164
Middle versus low
0.125
1.133
0.700-1.835
0.610
High versus low
-0.611
0.543
0.254-1.161
0.115
-0.370
0.691
0.400-1.194
0.185
Self-rated health
0.080
Sex
Perception of coping with income vs B Odds ratio
0.371
1.449
not coping with income
Fair versus Poor/very poor
-0.213
0.808
0.435-1.500
0.499
Good/very good versus poor/very poor
-0.729
0.482
0.240-0.967
0.040
Complete trust in the GP vs
-0.433
0.649
0.410-1.026
0.064
-0.215
0.807
0.454-1.433
0.464
Having young children vs
0.202
1.224
0.640-2.343
0.541
no complete trust
Having a paid job vs no paid job
no young children
107
Chapter 3: Research papers
Mental distress
0.108
Minimal vs none
-0.290
0.748
0.411-1.364
0.344
Mild vs none
0.039
1.039
0.477-1.364
0.923
Moderate vs none
0.198
1.219
0.587-2.530
0.596
Severe vs none
0.793
2.209
1.052-4.641
0.036
Nagelkerke R²: 0.165
*All significant results are indicated in bold
Discussion
108
Literature indicates that, on the one hand, people from the lower socioeconomic
groups visit a GP more frequently, whereas people from the higher socioeconomic
groups tend to use more specialist care (Van der Heyden et al., 2003, van der Meer
et al., 1996). These higher utilization rates of PHC can partly be explained by a
higher disease burden (Droomers and Westert, 2004). However, on the other hand,
low-income patients are also at risk of postponing a visit to the GP more often
than do patients from the higher socioeconomic groups (Whitehead and Hanratty,
2004, Vilhjalmsson, 2005). This study examines which subgroup of patients with
a low income are particularly at risk for postponing or cancelling a visit to a GP
they thought they needed. Knowing this might contribute to more fine-tuned
actions and interventions that will further improve the accessibility of the primary
healthcare system in Flanders.
The participants of this study are 606 low-income people, aged between 18 and
65 years, visiting a Public Social Service in one of the eight selected areas in Flanders (Belgium). The respondents of the study are in worse health compared with
the Flemish population aged between 18 and 65 years: 54.6% of the respondents
report having fair to poor health compared with 17.6% of the Flemish population
(Van Der Heyden et al., 2010). More than half of the respondents suffer from a
chronic condition (60.6%) compared with 26.2% of the Flemish population (Van
Der Heyden et al., 2010). Additionally, 61.2% have feelings of mental distress, of
which 11.9% cope with a severe depression. Our study reached the low income
people: 75% had no paid job and 70% had difficulties of coping with their available
monthly income. Earlier studies describe that people living in poverty feel lonely
more often and have a higher risk of social isolation than the general population
(Böhnke, 2008). Results from this study confirm these findings. With regard to the
Chapter 3: Research papers
delivery of healthcare, participants are generally satisfied with the care delivered
by their GP, and half of the participants have complete trust in their GP. Despite
the high disease burden and the complex social situation of our respondents, 32%
of the respondents postponed or cancelled a GP visit they thought they needed
during the past 12 months.
The multivariate analysis shows that not the feeling of not being able to cope with
the daily costs of life with the available family income but feelings of depression
and self-rated health are independent predictors of postponing or cancelling a GP
visit respondents thought they needed. Furthermore having no complete trust in the
GP has a trend to independently predict postponing or cancelling a visit to a GP.
First, the finding that people who experience a severe depression are more likely
to postpone a visit to a GP is quite alarming. Literature indicates that people with
a lower social status are more vulnerable for depression than their better of counterparts (Van Der Heyden et al., 2010). Furthermore, studies show that people
from lower social classes and young people are more reluctant and have a negative
attitude towards seeking help for their mental illnesses ( Jagdeo et al., 2009). These
findings suggest that people in the greatest need for services have the poorest attitudes. Therefore there is a need for an outreach to help people who suffer from
a mental illness.
Second, patients with poor self-rated health tend to postpone or cancel a visit to
their GP more often than those with good self-rated health. Nevertheless, patients
with a poor health have a higher likelihood to have multiple conditions and a higher disease burden leading to a higher health care need. But often, low income
patients postpone the needed medical care because they do not know where to
go, have other priorities (getting through the day),…(Willems, 2005). These are
exactly the people who providers need to reach, before their ill health gets even
worse. Effective interventions to improve health care access should not only focus
on financial barriers to care e.g. by increasing the number of insured patients, introducing reduced fees or even free care for low-income patients, … It is as important
to tackle non-financial barriers to health care e.g. by providing walk-in hours, the
availability of public transportation, training healthcare workers in communication
skills, … Also, adapting an outreaching approach could help to identify and help
people who postpone care before they get too ill and hospitalization is needed.
A third finding of this study is that people with complete trust in their GP are less
likely to postpone a visit to their GP compared with those with no complete trust.
109
Chapter 3: Research papers
This strengthens the importance of a good doctor-patient relationship. Several studies show that building an environment which creates trust is crucial in providing
longitudinal care (Ahmed et al., 2001, Ridd et al., 2009) and that people who have
a regular GP receive more continuous care, have better health outcomes (e.g. better
compliance, pregnancy outcomes…), lower service utilization, and lower healthcare
costs (Nutting et al., 2003, Shear et al., 1983, Wasson et al., 1984, Christakis et al.,
2001). In a good doctor-patient relationship, compassion and shared respect are
important factors, leading to a higher level of trust between a patient and a GP
(Teutsch, 2003, Mainous et al., 2001). A Scottish study shows that people from
deprived areas want holistic GPs who understand the realities of life and whom
they can trust as being both competent and genuinely caring. A GP without these
is judged as being socially distant and emotionally detached. Relational continuity,
empathy, and taking sufficient time in consultations are key factors in building a
good doctor-patient relationship (Mercer et al., 2007).
110
Having young children, a paid job, age, sex and perception of coping with income
did not give significant results in the multivariate logistic model. But this does not
mean that these measures aren’t relevant. Removing one of these variables from the
model, reduced the explained variance with minimum two percent.
Contrary to our expectations, this study shows that low-income patients who find
it difficult to manage with their available income do not postpone a visit to their
GP more often than do those low-income patients who are able to make ends
meet despite their low family income. Possible explanations are the success of the
interventions that try to lower the financial burden for low-income patients.
In Belgium, we have a nearly universal healthcare system with direct access to a
general practitioner or a specialist and no gate-keeping or patient list. There is a
fee-for service payment according to which patients pay about 30% co-payment
for primary healthcare and 40% for specialist care. For people with a low income
(being a gross taxable family income lower than 13.543,71 Euro, increased with
2.507,30 Euro per additional family member), there is a reduced co-payment of 8%.
The total amount of co-payment per year is limited by an income-related threshold
(Björnberg et al., 2009).
Furthermore, in the fee-for-service system, low-income patients can visit their GP
for only one euro. Patients visiting Community Health Centres and group practices
using the capitation system can visit the doctor for free when they are registered with
Chapter 3: Research papers
that practice. This kind of universal approach for low-income patients in Flanders
reduces the financial barriers of the Health care system.
An important strength of this study is the success of questioning 606 low-income
patients about their health and healthcare use. When reviewing literature on healthcare use, this population group is often under-represented, making it very difficult
to formulate strong conclusions. In this study, the design was developed based on
actively inviting a large number of potential participants and minimizing the barriers for participation in the study for this specific study group as much as possible.
With the aim of reaching the study population and inviting them to participate in
the study, we collaborated with Public Social Services in the selected areas. Their
massive time investment led to a large number of included participants (n = 1148).
However, using this specific method of inclusion might have led to a selection bias
at the moment of inclusion and to a selection bias because of differential refusal
rates among subgroups. First, although the social workers were asked to invite all
their clients who met the inclusion criteria, they might have made a pre-selection
(e.g. not inviting clients during busy consultation hours, not inviting clients whom
they had a difficult working relationship with). Second, the information on the
number of clients who refused to participate and their profiles is limited. In the
study protocol, the social workers were asked to complete a minimal information
form for each client whom they had invited to participate in the study. This form
included information on the sex and age of the person, whether they responded to
the inclusion criteria, and whether they wanted to participate in the study or not.
In case the person refused to participate, his/her motivation to refuse was asked.
However, filling in this form was considered as being too time consuming, and it
was not rigorously used. This also implies that there was no additional information
available on the respondents who were included in the study but eventually did
not participated.
Several actions were taken to minimize the barriers for participation in the study
for this specific study group. The interviewer made up to 10 attempts to contact
the respondents by phone to make an appointment for the interview. In case this
did not result in contact, for example, because the telephone number was no longer
active, the interviewer contacted the social worker who had included the respondent to trace the respondent’s new contact details. In addition, at the moment of
the interview, the respondents were sometimes not at home, no longer lived at the
provided address, or perceived the timing as inconvenient. In this case, the interviewer made a new appointment. Respondents were also given the option of being
111
Chapter 3: Research papers
interviewed at a place other than their home (e.g. in the premises of the Local
Social Service Center).
Finally, all study material was developed using a clear language and was pre-tested
in the study population, and the procedures were developed to minimize the burden
for the respondent. The interviewers were extensively trained to clearly communicate about the study, to answer the respondent’s questions, and were expected
to be flexible in finding solutions for problems when contacting respondents or
finding a time and location to interview them. This resulted in the participation of
606 respondents completing the entire survey (i.e. a response rate of 54%), which
is, seen the population and the encountered problems, a relatively large sample.
112
When using this specific inclusion procedure, there are also some limitations. First
of all, immigrants or undocumented people who do not speak the Dutch language
cannot participate in the study, although they are often financially vulnerable and
experience important problems in accessing healthcare. Second, all participants in
this study are clients in a Public Social Service. Although these services reach the
majority of low-income Belgians since they administratively arrange the minimum
wages and remittances, we might have missed (the small group of ) people who do
not find access to these services or who lead completely isolated lives. Third, social
workers did not always manage to fill in the selection form or did a pre-selection
without the form. Therefore we have no (complete) information on the number of
people excluded in the study nor the number of people visiting the Public Social
Services during the inclusion period of the study. Fourth, this study was conducted
in eight Flemish regions. Although these regions were selected with care, the results
may not apply to the entire Flemish region.
Furthermore, prudence is called when interpreting the results. Nearly half of the
participants stated to have complete trust in their GP. Due to the skewed distribution, we could not make a comparison between people who trust their GP and
those who did not. So the cut-off point was taken between “complete trust” and
all the other answer categories. Next, the model we used explained 16.5% of the
total variance in postponing a visit to a GP while they actually needed one. This
result stresses the complexity of the problem. Other possible factors explaining the
variance could be: having a regular GP, the availability of public transportation, the
opening hours of the practice,… Therefore a more detailed questionnaire on the
organization of the GP practices is needed.
Chapter 3: Research papers
Finally we have no information on how long people postponed a visit to a GP (a
few days or several months). Furthermore, in Belgium, people are not obligated
to make an appointment with a GP. In that way we can not compare the reported
postponement of a GP visit to registered postponement. This makes it very difficult
for policymakers to identify the magnitude of the problem.
Conclusion
This study shows that especially people suffering form a severe depression, people
with no complete trust in the GP and people with ill health, are more likely to
postpone or cancel a GP visit they thought they needed compared to other lowincome patients. The inability to make ends meet does not seem to lead to further
postponing of healthcare. This might indicate that the access to healthcare for
low-income people might also be hindered by barriers that are not directly linked
to the price of the consultation.
Effective interventions should focus on outreaching activities, a family-friendly
organization of care, physical accessibility of care, and building a trustful doctorpatient relationship. Further research concerning the accessibility and quality of
healthcare for low-income people is needed to provide policymakers with the
evidence needed to take action in order to make the healthcare system easily accessible for every person.
Competing interests
All authors declare that no competing interests exist.
Acknowledgements
EV, AP, AD, JDM, CVA, and SW contributed to the design of the study; EV, AP,
and SW contributed to the analysis and the writing of the article; and AD, KH,
JDM, CVA, and SW participated in the revision of the manuscript. All the authors
have read and approved the final manuscript.
113
Chapter 3: Research papers
References
114
-
AHMED, S. M., LEMKAU, J. P., NEALEIGH, N. & MANN, B. 2001.
Barriers to healthcare access in a non-elderly urban poor American population. Health Soc Care Community, 9, 445-53.
-
BJÖRNBERG, A., GARROFÉ, B. C. & LINDBLAD, S. 2009. Euro
Health Consumer Index 2010. In: POWERHOUSE, H. C. (ed.).
-
BÖHNKE, P. 2008. Art the poor socially integrated? The lkink between
poverty and social support in different welfare regimes. Journal of European
Social Policy, 18, 133-150.
-
BURSTROM, B. 2002. Increasing inequalities in health care utilisation
across income groups in Sweden during the 1990s? Health Policy, 62, 11729.
-
CAMPBELL, J. L. 1999. Patients’ perceptions of medical urgency: does
deprivation matter? Fam Pract, 16, 28-32.
-
CHRISTAKIS, D. A., MELL, L., KOEPSELL, T. D., ZIMMERMAN, F.
J. & CONNELL, F. A. 2001. Association of lower continuity of care with
greater risk of emergency department use and hospitalization in children.
Pediatrics, 107, 524-9.
-
COHEN, S., DOYLE, W. J., SKONER, D. P., RABIN, B. S. & GWALTNEY, J. M., JR. 1997. Social ties and susceptibility to the common cold.
JAMA, 277, 1940-4.
-
DE BRUIN A, P. H., NOSSIKOV A 1996. Health interview surveys. Toward international harmonization of methods and instruments.
Copenhagen:WHO-Europe, CBD Netherlands.
-
DRIESKENS, S., VAN DER HEYDEN, J., HESSE, E., GISLE, L., DEMAREST, S. & TAFFOREAU, J. 2010. Gezondheidsenquête België, 2008.
Rapport V - Sociaal-economische ongelijkheden in gezondheid.
-
DROOMERS, M. & WESTERT, G. P. 2004. Do lower socioeconomic
groups use more health services, because they suffer from more illnesses?
Eur J Public Health, 14, 311-3.
-
EUROPE, T. 2008. European Practice Assessment-EPA. Easy to use and
scientifically developed quality management for general practice. In: EUROPE, T. (ed.).
-
HART, J. T. 1971. The inverse care law. Lancet, 1, 405-12.
Chapter 3: Research papers
-
HERMANS KOEN, D. M. D. A. V. J. M. L. D. M. J. V. A. C. 2008. Werknota “De slectie van de SWVG-onderzoeksregio’s” Programma 1-Kencijfers
en monitoring. Steunpunt Welzijn Volksgezondheid en Gezin.
-
JAGDEO, A., COX, B. J., STEIN, M. B. & SAREEN, J. 2009. Negative
attitudes toward help seeking for mental illness in 2 population-based surveys from the United States and Canada. Can J Psychiatry, 54, 757-66.
-
MAINOUS, A. G., 3RD, BAKER, R., LOVE, M. M., GRAY, D. P. &
GILL, J. M. 2001. Continuity of care and trust in one’s physician: evidence
from primary care in the United States and the United Kingdom. Fam
Med, 33, 22-7.
-
MARMOT, M., ALLEN, J., GOLDBLATT, P., BOYCE, T., MCNEISH,
D., GRADY, M. & GEDDES, I. 2010. Fair Society, Healthy lives. The
Marmot review. Executive Sumary.
-
MERCER, S. W., CAWSTON, P. G. & BIKKER, A. P. 2007. Quality in
general practice consultations; a qualitative study of the views of patients living in an area of high socio-economic deprivation in Scotland. BMC Fam
Pract, 8, 22.
-
NUTTING, P. A., GOODWIN, M. A., FLOCKE, S. A., ZYZANSKI,
S. J. & STANGE, K. C. 2003. Continuity of primary care: to whom does it
matter and when? Ann Fam Med, 1, 149-55.
-
REGIDOR, E., MARTINEZ, D., CALLE, M. E., ASTASIO, P., ORTEGA, P. & DOMINGUEZ, V. 2008. Socioeconomic patterns in the use
of public and private health services and equity in health care. BMC Health
Serv Res, 8, 183.
-
RIDD, M., SHAW, A., LEWIS, G. & SALISBURY, C. 2009. The patientdoctor relationship: a synthesis of the qualitative literature on patients’ perspectives. Br J Gen Pract, 59, e116-33.
-
SHEAR, C. L., GIPE, B. T., MATTHEIS, J. K. & LEVY, M. R. 1983.
Provider continuity and quality of medical care. A retrospective analysis of
prenatal and perinatal outcome. Med Care, 21, 1204-10.
-
STARFIELD, B., SHI, L. & MACINKO, J. 2005. Contribution of primary
care to health systems and health. Milbank Q, 83, 457-502.
-
TEUTSCH, C. 2003. Patient-doctor communication. Med Clin North
Am, 87, 1115-45.
-
VAN DER HEYDEN, J., GISLE, L., DEMAREST, S., HESSE, E. &
TAFFOREAU, J. 2010. Gezondheidsenquête België 2008. Rapport I: gezondheidstoestand. Brussel: Wetenschappelijk instituut Volksgezondheid
Operationele Directie Volksgezondheid en surveillance.
115
Chapter 3: Research papers
-
VAN DER HEYDEN, J. H., DEMAREST, S., TAFFOREAU, J. & VAN
OYEN, H. 2003. Socio-economic differences in the utilisation of health
services in Belgium. Health Policy, 65, 153-65.
-
VAN DER MEER, J. B., VAN DEN BOS, J. & MACKENBACH, J. P.
1996. Socioeconomic differences in the utilization of health services in a
Dutch population: the contribution of health status. Health Policy, 37, 1-18.
-
VEUGELERS, P. J. & YIP, A. M. 2003. Socioeconomic disparities in
health care use: Does universal coverage reduce inequalities in health? J
Epidemiol Community Health, 57, 424-8.
-
VILHJALMSSON, R. 2005. Failure to seek needed medical care: results
from a national health survey of Icelanders. Soc Sci Med, 61, 1320-30.
-
WASSON, J. H., SAUVIGNE, A. E., MOGIELNICKI, R. P., FREY, W.
G., SOX, C. H., GAUDETTE, C. & ROCKWELL, A. 1984. Continuity
of outpatient medical care in elderly men. A randomized trial. JAMA, 252,
2413-7.
-
WHITEHEAD, M. & DAHLGREN, G. 2006. Levelling up (part 1): a
discussion paper on concepts and principles for tackling social inequities in
health. WHO collaborating Centre for Policy Research on Social Determinants of Health, University of Liverpool.
-
WHITEHEAD, M. & HANRATTY, B. 2004. Health care for rich and
poor alike. In: HEALY, J. & MCKEE, M. (eds.) Accessing health care.
Responding to diversity. Oxford: Oxford University Press.
-
WHO. Available: http://www.euro.who.int/en/what-we-do/health-topics/
Health-systems/primary-health-care/country-work/primary-care-evaluation-tool.
-
WHOOLEY, M. A., AVINS, A. L., MIRANDE, J. & BROWNER, W.
S. 1997. Case-finding instruments for Depression. Two Questions Are as
Good as Many. J Gen Intern Med., 12, 439-445.
-
WILLEMS, S. 2005. The socio-economic gradient in health: a never-ending story? A descriptive and explorative study in Belgium., Ghent University.
-
WILLEMS, S., DE MAESSCHALCK, S., DEVEUGELE, M., DERESE, A. & DE MAESENEER, J. 2005. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient
Educ Couns, 56, 139-46.
116
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
ANNOTATED BIBLIOGRAPHY
Open Access
The social gradient in doctor-patient
communication
Evelyn Verlinde1,2*, Nele De Laender1, Stéphanie De Maesschalck1, Myriam Deveugele1 and Sara Willems1
Abstract
Objective: In recent years, the importance of social differences in the physician-patient relationship has frequently
been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing
importance of social inequalities in health care, an actualization of this review seemed appropriate.
Methods: A systematic search of literature published between 1965 and 2011 on the social gradient in doctorpatient communication. In this review social class was determined by patient’s income, education or occupation.
Results: Twenty original research papers and meta-analyses were included. Social differences in doctor-patient
communication were described according to the following classification: verbal behaviour including instrumental
and affective behaviour, non-verbal behaviour and patient-centred behaviour.
Conclusion: This review indicates that the literature on the social gradient in doctor-patient communication that
was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize
the importance of the reciprocity of communication.
Secondly, there seems to be a growing interest in patient’s perception of doctor-patient communication.
Practice implications: By increasing the doctors’ awareness of the communicative differences and by empowering
patients to express concerns and preferences, a more effective communication could be established.
Keywords: Communication, Physician-patient relations, Social class
Introduction
In 1977 a commission under the lead of Sir Francis
Black published the famous Black report, illustrating the
existence of a social gradient in health in the UK. The
publication of this report was the start of a new wave of
research on social inequity [1]. Since then many studies
have confirmed the gradient in health between social
classes [2-4]. Health differences between social groups
due to underlying social mechanisms such as differential
access to care, social exclusion or poverty are a matter
of major concern in today’s public health research but
in spite of marked health improvements of the overall
population and efforts to overcome health inequalities,
higher morbidity and mortality rates for the socio-economically disadvantaged are still found [5-8]. The causes
for these inequalities in health are multiple and
* Correspondence: [email protected]
1
Department of Family Medicine and Primary Health Care, Ghent University,
Ghent, Belgium
Full list of author information is available at the end of the article
complex: a different distribution of power and resources
among social classes, different levels of exposure to
health hazards, same level of exposure leading to differential impacts, life-course effects and different social
and economic effects of being sick [2,9-16]. A prerequisite for equity in health is equity in health care, defined
as equal care for people in equal need of care. As Dahlgren and Whitehead quoted: “Equity in health care
includes fair arrangements that allow equal geographic,
economic and cultural access to available services for all
in equal need of care” [17].
An essential component of the delivery of health care
is the relationship between the patient and the health
care provider [18]. Several studies on communication in
health care have repeatedly shown the importance of
the doctor’s communication skills [19]. By communicating with a patient, a physician gets to know the patient’s
problem and creates a therapeutic relationship necessary
for its management and, if possible, its solution [20].
The quality of the relationship between a doctor and a
© 2012 Verlinde et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
117
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
patient is a key factor in the effectiveness of care. Good
doctor-patient communication is associated with a
higher level of patient satisfaction and better compliance
[19,21]. Furthermore, optimizing doctor-patient communication can lead to better patient health and outcomes
[22,23].
Available evidence suggests that low-income populations and people without health insurance report lower
communication satisfaction and a reduced access to care
[24]. In recent years the importance of social inequalities
in the physician-patient relationship has frequently been
the subject of research [19,21,24]. A previous review
showed that doctor-patient communication indeed varies according to the social class of the patient [25].
Considering the increasing importance of social
inequities in health care, an actualization of the review
seemed appropriate.
If differences in the physicians’ communicative behaviour vary according to the socio-economic status of the
patient, this could be a new focus in the battle against
socio-economic inequities in health.
In this paper we want to answer the following questions based on a systematically review of the literature:
118
Does the doctor-patient communication varies
according to the socio-economic status of the
patient?
If so, which aspects of the consultation are affected?
Are the findings of studies published after 2002 different than those of the publication of the first (and
the latest) review on this topic [25].
Methods
Before starting the review, a protocol was developed,
including the following steps.
Search strategy
In step one, a systematic search in MEDLINE, PsycINFO and Web Of Science was conducted to identify
publications on doctor-patient communication and
social class of the patient. The following search strings
were used:
MeSH: communication AND (physician-patient relations OR provider-patient relations OR physicianfamily relations) AND (social class OR socio-economic factors)
Text-words: (doctor-patient communication OR
physician-patient communication OR providerpatient communication) AND (social class OR socioeconomic status).
The search was limited to publications from 1965 on.
No specific search software was used.
Page 2 of 14
Articles that were not original research articles, opinion articles and reviews were excluded. Furthermore,
the search strategy was narrowed to studies performed
within industrialized countries.
Outcome measures
To make the comparison of results possible, articles
were included when they mentioned the interaction
between the socioeconomic status (SES) of the patient
or one of its indicators (educational level, income or
occupation) as well as determinants of doctor-patient
communication. At the initial stage, doctor-patient communication was not yet defined into specific categories,
in order to obtain a wide range of studies. This means
that studies mentioning any form of doctor-patient
communication were selected. We included as well studies from primary care as specialist care to gain insight
in the overall social gradient in doctor-patient communication. This resulted in a list of 129 articles.
Study selection
Figure 1 provides an overview of the study selection process. Of the 129 studies under review, 51 were excluded
based on title and abstract review since they were after
all not related to doctor-patient communication and
social class. The abstracts of the remaining 78 publications were screened for explicit references to social class
related concepts (education, income or occupation) and
doctor-patient communication. Fourty-six articles determining SES by other variables than education, income or
occupation (e.g. race, gender, health literacy) and articles
focussing on disease-specific communication were
excluded. In the last step of the selection process, an
independent full text analysis of the remaining 32 publications was performed independently by two of the
researchers to confirm the relationship between social
class and doctor-patient communication in the publications. Publications labelled as “doubtful relevance concerning social class and doctor-patient communication”
by one of the reviewers, were discussed until consensus
was reached. Twelve publications were rejected in this
phase. Eventually, 20 publications were labelled as relevant to asses doctor-patient communication and social
class of the patient (Table 1).
Analysis and synthesis of the study findings
A narrative review was conducted. Meta-analysis was not
attempted due to heterogeneity of populations and outcome measures among included studies. Findings were
compared according to investigated communication measure and according to the social class. To cluster the communication variables, several communication assessment
approaches were considered [26]. Communicative behaviour can be categorised in terms of verbal and non-
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Page 3 of 14
119
Figure 1 Selection procedure.
verbal behaviour. Verbal behaviour can be defined as ‘the
spoken communication’. The verbal elements of communication can be divided into instrumental or task-focused
verbal behaviour (e.g. question asking, information giving,
etc.) and affective or socio-emotional behaviour (counselling, positive and negative talk, etc.) reflecting the distinction between cure and care [27,28].
However, some of the determinants of communication
do not fit into the above categories but are related to
the concept patient-centeredness. Patient-centeredness
is about seeing the patient as a person with a unique
personal history and individual needs. We can identify
five dimensions: (1) using the bio-psycho-social perspective, (2) approach the patient as a whole person, (3)
Setting
professional
health care
providers
primary care
multipurpose
clinic,
pediatric
consultation
primary care
primary care
Hall
Street
Street
Martin
Fiscella
direct
observation,
chart audits,
patiënt reports
2538
1972
115
audiotapes
questionnaires
41
157
(mean)
education
occupation
educational
level
education
social class
indices,
education
or income
Nb of
Variable
patients SES
audiovisual
analysis
meta-analysis
Method
time use, preventive tasks,
satisfaction, attributes of
primary care
listening, explaining, advice
giving, examination
partnership building
information giving (diagnostic,
treatment, procedural)
information giving, question
asking, task and interpersonal
competence, partnership
building and socio-emotional
behaviour
Variable communication
doctor
Interpersonal
communication, patient
satifaction
listening, explaining,
advice giving,
examination m
parent’s question asking
and opinion giving
communicative style:
affective expressiveness
More question asking by patient leads
to more information giving.
No relation between educational level
and question asking
Physician information
giving: 0.82
Partnership building:
0.87
Patient’s opinion
giving:0.82
Patient affective
expressiveness: 0.75
Patient’s question
asking: 0.96
Time use: Davis
Observation Code
Attributes of Primary
care:
Components of Primary
Care Instrument Patient
satisfaction: items from
the Medical Outcomes
Survey
Lower education more physical
examination and nutritional counseling,
less time on questions, assessing health
knowledge, negotiation and counseling,
chatting and screening tests.
Patients perceive no difference
Higher social class: more examination,
listening and explaining.
Physician’s perception of consultation:
emphasis on active listening, supporting
and giving advice.
No information available Patient perception of consulation:
emphasis on prescribing, reassuring and
referring
Reliability:
Higher education: more expressive,
- physician response
higher level of opinionated and asking
more questions.
(0.72-0.95)
- patient response (0.680.91)
Personal characteristics less influence on
physician response than own
communication behavior?
Higher educated patients: more
diagnostic and health information.
Higher social class: more overall
communication and more information.
Conclusion of the study
Unitizing reliability for
utterances: Cohen’s
kappa = 0.84
Reliability categorizing:
Correlation and
standard norm deviate
was extracted for each
study if possible
Variable communication Information on
patient
validity and reliability
120
First
author
(Ref. nb.)
Table 1 Overview of the selected articles
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Page 4 of 14
Employees
primary care
primary care
solo &
multispecialty
practices
primary care
primary care
primary care
Taira
Pendleton
Street
Kaplan
McKinstry
Roter
Stewart
8316
41
79
6549
audiotapes
audiotape
RIAS;
questionnaires
140
537
structured
410
interview,
video vignettes
questionnaires
videotaped
consultations
videotaped
consultations
questionnaires
educational
level
income
social class
indices
education
education
social class
income
Table 1 Overview of the selected articles (Continued)
information giving; patiënt
centredness
narrowly biomedical,
expanded biomedical,
biopsychosocial, psychosocial,
consumerist pattern
shared decision making style
PDM (Participatory DecisionMaking) style: involve them in
treatment decisions, give them
a sense of control over
medical care and ask them to
take some responsibility for
care
nonverbal behaviour
consistency and adaptations
amount of information given
to the patiënt
discussion of health risk
idem
health risk behaviours
Same satisfaction as higher educated.
Statement made by
Higer education: more explanation on
doctor: Bales Interaction drug prescription
Process Analysis
Communication on
drugs: scheme
developed by Svarstad
and refined by
Scherwitz and Evans
Reliability physician: 0.76 Lower SES patients prefer narrowly
Reliability patient: 0.81
biomedical pattern.
No information available Lower educated patients: lower
preference for shared decision making.
Data from the Medical
Lower educated patients: less mutual
Outcomes Survey (MOS) decision making, less sense of control
Reliability Participatory
and given less responsibility.
decision making style:
0.74
Cohen’s kappa: 0.82 for Physicians talking with higher educated
speaking turns and
patients used more body orientated talk
response latencies
then they did with lower educated.
0.71 for interruptive
speakovers
0.92 for physicians’ taks
touch
0.85 for illustrators
0.71 for adaptors
0.79 for procimity
0.93 for body
orientation
0.90 for turn duration
0.81 for response
latency
0.83 for pausing within
speaking
0.75 for patient’s anxiety
No information available High SES: more explanations
Lower income: more smoking discussion
No information available High income: more diet and exercise
discussion.
Reliability: doctor
satisfaction = 0.90,
nurse satisfaction 0.72
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Page 5 of 14
121
primary care
primary care
audiotapes
patients, lung
cancer
patients,
patients with
systemic
lupus
erythematosus
oncology
practices
Jensen
Street
Siminoff
audiotapes,
RIAS
survey,
interview
department of telephone
Veterans
interview
Affairs (VA),
universitybased and
county health
care system
Piette &
Schillinger
[39]
survey, PEPPI
breast cancer
treatment
program
405
279
131
752
327
education,
income
education
education,
income
education
education,
income
patient-perceived selfefficacy
educating and counseling the
patient concerning biomedical
and psychosocial issues-ask
patients for information to
indicate understanding,
opinion or permissionattempting to built a
relationship with the patientengagement in conversation
about the patients emotional
status-gathering relevant data
and information
partnership-building;
encourage patient
involvement; supportive talk
patient communicates
biomedical and
psychosocial information;
asking questions; building
relationship with the
physician, engaging in
discussion; expression of
feelings;
asking questions; assertive
responses, expressions of
concern or other negative
emotions
explain things; listen carefully
idem
to what the patient has to say;
show respect; spend enough
time with the patient
Interpersonal Processes of Care
(IPC) questionnaire: general
clarity; explanations; elicitation
of patient’s preferences,
emotional support
interactive information-giving
122
Maly
Table 1 Overview of the selected articles (Continued)
Low education: more emotional support
Doctor-patient
communication: Roter
Interaction Analysis
System (RIAS)
Coding system
developed by Street
and colleagues with
reliability ranging from
0.61 to 0.97 depending
on the behavior and
the study
Questions coming from
the Medical
Expenditures Panel
Survey
Revised scale of the
Interpersonal Processes
of Care (IPC)
questionnaire with
reliability of 0.91
High income patients: receive more
biomedical talk, emotional talk,
psychosocial counseling and education,
ask more question and receive less
questions about their disease than low
income patients.
Patients are more active communicators
when physicians use partnershipbuilding.
Higher educated patients are more
active communicators, ask more
questions and are more assertive, but
they do not express more concerns
Low income perceive some areas of
tension in communication with their
health care provider.
Patients with high literacy skills are
more critical on their physician.
Low SES: better general and diabetesspecific communication than high SES
Self-efficacy: validated
Higher education: more interactive
Perceived
information giving by physician and
Efficacy in Patientgreater perceived self-efficacy.
Physician Interactions
(PEPPI) questionnaire
Language: Marin
Acculturation Scale with
reliability of 0.99
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Page 6 of 14
primary care
Bao
Devoe [24] primary care
american
households
Murray
5978
3209
secondary
16 700
analysis of data
from Medical
Expenditure
Panel Survey
(MEPS) (faceto-face
interview)
patient and
physician
surveys
computerassisted
telephone
interview
educational
attainment,
family
income
Income,
education
education,
income
Table 1 Overview of the selected articles (Continued)
listen carefully; explain things;
show respect; spend enough
time with the patient
self-assessment of
communication; performance
of communication behaviours
when discussing cancer
screening
giving information; decisionmaking style
preferred style of
decision-making;
experienced style of
decision-making;
Questionnaires coming
from the Medical
Expenditure Panel
Survey (MEPS)
Questionnaire from the
Communication in
Medical Care (CMC)
Research Program
series.
Poor patients: receiving less
explanations in a way they understand.
Within-physicians differences by
education.
Between-physicians differences by
income
Low SES patients are more likely to
discuss cancer screening then high SES
patients.
High SES patients are more likely to
experience the preferred style
Lowe SES patients prefer consumerism
and paternalism
No information available High SES patients prefer shared decision
making
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Page 7 of 14
123
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
sharing power and responsibility, (4)building a therapeutic relationship and (5) considering the physician as a
person and acknowledging the influence of its personal
qualities [29,30].
The communication variables in the selected articles
are classified to the following categories: verbal behaviour including instrumental and affective behaviour;
non verbal behaviour and patient-centred behaviour.
The selected studies were grouped and analysed by the
researches according the three communication variables.
Results
Verbal/non-verbal behaviour
Verbal behaviour: instrumental behaviour
124
Instrumental behaviour is considered as all interactions
that serve the “cure” part of the consultation. It can be
defined as technically based skills that are used in problem solving e.g. giving directions, giving information,
asking clarification, asking questions, counselling, etc.
[26,31]. Eleven studies explored the interaction between
the instrumental behaviour of the physician and/or the
patients, and the SES of the patient.
A meta-analysis conducted by Hall et al. explored the
correlation between physicians’ communicative behaviour and the patient’s outcome variables. Social class
was measured by income, education or other non-specified social class indices. The study revealed a positive
relationship between patient’s social class and information giving. Patients of a higher social class received not
only more overall communication but also more information [32]. Not only patients’ social class but also his/
her communication style influences the doctor-patient
communication. In a study by Street et al., social class
was measured by educational level. Physicians’ information giving was positively influenced by the patient’s
communicative style such as question-asking, affective
expressiveness and opinion-giving. More affective
expressiveness and being assertive on the patient’s sidewhich is strongly related to his/her educational levelleads to more information giving on the doctor’s side.
More educated patients receive more diagnostic and
health information than their lower educated counterparts. However this study did not find a relation
between the frequency of the patients’ question asking
and his/her educational background [33].
The fact that adaptations in the physicians’ responses
may, besides a function of patients’ personal or social
characteristics per se, also are the result of the patients’
communicative actions, was confirmed by a second
study by Street et al. In this study they compared the
degree to which parents’ personal and interactive characteristics accounted for variation in doctor-parent
interactions during paediatric consultations. Social class
was measured as educational level. More educated
Page 8 of 14
parents are not only more expressive and assertive but
they also ask more questions. All three of these communication aspects lead to more information and direction
giving by the physician. Additionally, this study shows
that the parent’s personal characteristics have less influence on the physicians’ responses than their own communication behaviour [34].
Besides patient’s communication style, doctors’ and
patients’ perceptions are an important aspect of the consultation and for the outcome of the consultation. In an
observational study, Martin et al. looked at how both
physicians and patients perceive what happens during
the consultation. Social class was measured by occupation. From the patients point of view most emphasis of
the consultation is put on prescribing, reassuring and
referring. Whereas physicians report that emphasis is
put on active listening, supporting and giving advice.
Furthermore, physicians perceived they explained and
listened more to patients from higher social classes and
also examined them more than patients from lower
social classes, but gave the latter more “other help”
which was not specified. They also said to examine
more and to give less advice to patients from lower
social classes. However, patients did not report having
experienced any of these differences [35]. The study of
DeVoe et al. where social class was determined by
family income and educational level, shows different
results. This study suggests that patients’ perceptions of
communication in healthcare settings vary widely by
demographics and other individual patient characteristics. The poorest patients were less likely to report that
providers always explained things so that they understood. Surprisingly, different levels of education were
not independently associated with any of the investigated communication measures [36]. These results are
in line with the results from the study of Fiscella et al.,
exploring whether educational level affected the visits of
family physicians. Patients with a low educational level
had a slightly larger proportion of the consultation time
spent on physical examination and nutritional counselling. Less time was spent on patients’ questions, assessing their health knowledge, negotiating and counselling,
chatting, and less screening tests were provided to them.
One could say that less educated people are approached
in a more directive way during the consultation. Less
educated patients also saw their expectations less met
during the consultation, although they were as satisfied
as the more educated patients [37]. When looking at the
outcome of the consultation, Maly et al. studied the
impact of physician-patient communication on women’s
receipt of, or planning for, breast reconstructive surgery.
Social class was determined by educational level and
was included as a potentially confounding factor.
Women who had graduated from high school were
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
more likely to report planning of breast reconstructive
surgery. This is positively associated with interactive
information-giving by the physician and greater patient
perceived self-efficacy. These two communication factors weakened the negative influence of education barriers. Empowering aspects of patient-physician
communication and self-efficacy may overcome the
negative effects of a lower education on receipt or
planned breast reconstructive surgery [38].
In line with the different consultation style, Taira et al.
investigated whether the patients’ income level had an
influence on the physicians’ discussion of health risk
behaviours. Concerning patients at risk, physicians
tended to discuss diet and exercise more with high
income patients and smoking more with low income
patients [39]. Discussing health risk behaviour is very
important in consultation, especially for chronic conditions like diabetes. In a cross-sectional survey by Piette
et al., general communication processes and diabetesspecific communication was examined. Socio-economic
status was measured by means of educational achievement. Patients with lower education levels reported better general and better diabetes-specific communication
than their less-vulnerable counterparts. This could be
due to the fact that these patients have lower expectations of their patient-provider relationship or greater
discomfort with criticizing them. Another introduced
explanation could be that health care providers spend
more time counseling patients which they perceive as in
need for extra attention or explanation [40].
Pendleton et al. considered four types of information
giving. SES was measured by social class. There was a
significant difference in voluntary explanations given to
patients from different social classes, independent of the
different types of problems; higher SES patients receive
significantly more explanations even when the explanation was not explicitly requested by the patient [41].
Also the study from Siminoff et al. where social class
was measured by income and educational level showed
that more biomedical talk was provided to higher
income patients compared to medium and low income
patients and to patients with higher educational achievement. In general, physicians provided little psychosocial
counseling and education, however, they provided more
to their high and medium income patients as compared
to low-income patients. Patients that had more than a
high school education and patients that reported a medium or high income asked more questions and showed
more proactive behavior such as volunteering information to the physician unasked. Physicians on their side
asked less educated patients and low income patients
more questions about their disease and medical history
[42].
Page 9 of 14
Verbal behaviour: affective behaviour
The affective behaviour in doctor-patient communication is part of the emotional domain [19] and consists
of all forms of social behaviour and social talk. Possible
affective expressions are: showing concern, reassurance,
reflection, signs of agreement or disagreement and paraphrasing [27,28]. Only three studies investigated the
effects and outcomes of affective behaviour.
The meta-analysis by Hall et al. (supra) explores the
socio-emotional behaviours such as social talk and positive and negative talk. Although a link between the
aspects of affective behaviour and the patients’ satisfaction and compliance can be identified, none of these
determinants were found to be related to any determinant of the patients’ social class [32]. On the other
hand, the studies of Street et al. (supra) concluded that
doctors provided more comments of reassurance, support and empathy to the parents of children with cancer
which were more affectively expressive (more specifically
who expressed more negative affect). As patients with a
higher educational level are more affectively expressive
than their counterparts, it can be assumed that physicians show more affective behaviour towards these
patients [33,34].
In the observational study from Siminoff et al. (supra),
the emotional expressions by physicians varied by
patient’s demographic variables, with more emotional
utterances from their physician [42].
Non-verbal behaviour
Non-verbal behaviour is one of the least investigated
topics of doctor-patient communication, especially when
looking at its interaction with determinants of social
class. The effect of non-verbal behaviour is only mentioned in two of the selected articles [41,43]. Non-verbal
behaviour can be operationalised in different ways such
as eye contact, tone of voice, laughter, facial expression,
physical distance, nodding, etc. [26].
The meta-analysis by Hall et al. (supra) could not
find any research that was done on the association
between the physicians’ non-verbal behaviour and the
patients’ social class [32]. The same year of the Hall
review, Street and Buller examined the non-verbal
behaviour in doctor-patient interactions and the relationship with patient’s age, sex and social class measured as educational level. No differences were found
in the level of non-verbal communication towards
patients with different educational level. However,
when talking to higher educated patients the physicians reciprocated their body orientations more than
they did with lower educated patients. Finally, this article refers to specific difficulties in coding non-verbal
behaviour, which is much more complex than categorising the verbal interactions [44].
125
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Patient-centeredness
126
Patient-centeredness can be classified into several
aspects such as supportive talk, being attentive to
patients’ psychosocial as well as physical needs, enabling
the disclosure of patients’ concerns, conveying a sense
of partnership and actively facilitating patient involvement in the decision-making [45]. In 10 of the 20
selected articles, patient centeredness in relationship
with the Social class of the patient is described.
First of all there is the relationship between patients’
social class and the decision making style of the doctor,
described in three studies. In a study by Kaplan et al.
social class was measured as educational achievement.
Patients with a high school education or less were less
involved in treatment decisions, less given a sense of
control over treatment decisions and less asked to take
responsibility for care than patients with post-graduate
college education [46]. Also McKinstry observed the
patients’ preference for shared decision making. Social
class was determined by education. Patients’ preference
for shared decision style or directive approach was associated with their social class, age, the scenario and their
perception of the consultation style of their own physician being shared or directive. A lower social class predicted a lower preference for shared decision making
style [47]. Murray et al. attempted to determine the congruence between patients’ preferred style of clinical decision-making and the style they usually experienced.
Social class includes household income and educational
achievement. People of high SES were more likely to
prefer shared decision-making, and people of low SES
were more likely to prefer consumerism and paternalism. Wealthier patients also were more likely to experience their preferred style of shared decision making.
The results also point out that SES was strongly associated with reporting having enough information.
Respondents who had not completed high school were
less likely than those with an advanced degree to report
having enough information to make the right decision
[48].
Roter et al. Studied the preferred communication style
of the patient. They described five communication patterns and their relationship with several patient characteristics, among social class measured as income.
Patients approached in the narrowly biomedical pattern
were more likely to be poorer than patients approached
in other patterns [49]. Jensen et al. surveyed whether literacy, numeracy and optimism are related to satisfaction
with health care providers’ communication skills. Participants’ social class was measured as educational level
and admitted as a predictor variable. Almost half of the
low-income patients were displeased with the amount of
time health providers spent with them during interactions. As displayed in earlier studies, communication
Page 10 of 14
dissatisfaction appears to be more common in lowincome adults than in higher income adults [50].
Certain aspects of communication can vary widely
among different doctors or among patients. Bao et al.
aimed to determine the extent to which socio-economic
differences (income and education) in cancer screening
discussion between a patient and his or her primary
care physician are due to inter-physician versus intraphysician variation. Patients with low SES were less
likely than their high-SES counterparts to have discussed
cancer screening with their physicians. Differences by
income are mainly ‘between-physicians’ While the
‘within-physician’ differences by income were minimal.
The education gradient in cancer screening discussion
mainly existed in ‘within physicians’. Except for mammogram the rate of discussion more than doubled
among college graduates compared with those with a
less than high school education. This may indicate that
education plays an important role in determining what
happens during clinical encounters [51].
Not only the communication style of the physician,
but also patient participation in an essential topic in
patient-centeredness. Street et al. examined the extent
to which patient participation in medical interactions is
influenced by the patient’s personal characteristics
(among social class measured by education), the physician’s communication style and the clinical setting.
Patients with at least some college education tended to
be more active communicators than were less educated
patients. Although the more educated persons asked
more questions and are more assertive than less educated patients, they do not more often express concerns.
The degree to which patients actively participate in
medical encounters is a function of multiple patient,
physician and contextual factors. It seems that patients
are more active participants when interacting with physicians who more frequently engaged in partnershipbuilding and supportive talk [52].
A final aspect described in three studies is building a
relationship between patient and physician. The study of
Siminoff (supra) et al. shows educational level as significant independent factor on relationship building. It
seems that both patients and their physicians spent
more time trying to establish an interpersonal relationship with each other. Nevertheless, patients did more
effort in relationship building than did their physicians.
These results confirm previous evidence that providers
communicate differently with patients by education and
income [53]. In the study of Maly et al. (supra) on
patients with breast cancer both the physician information-giving and patient empowerment in interacting
with physicians were found to be significant determinants of breast reconstructive surgery, controlling for
possible confounders. These two communication factors
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
diminished the negative influence of education barriers
and acculturation [38]. The study of Stewart, where educational level was a measure for social class, showed that
physicians were more likely to appeal to the intellect of
a patient with a university degree by justifying the drug
prescription while on the other hand they offer more
emotional support and solidarity to patients with a
lower educational level [54]. As presented above, the
amount of information given to patients is related to
patients’ characteristics and to the patients’ communicative style. Hereby, the patients’ communicative style is
not only influenced by his/her educational level but also
by the level of partnership building of the physician
[33,34]. In the observational study mentioned above by
Street et al. it appeared that higher educated patients
received more partnership building utterances [33].
Discussion and conclusion
The aim of the current review is to give the state of the
art on the social gradient in doctor-patient communication, to describe which aspects of the consultation are
affected by this social gradient, and whether an evolution
over time can be noticed comparing the results of older
studies with those of newer studies. In this review we
found that patients from lower social classes (measured
by income, education or occupation) receive less socioemotional talk, a more directive and a less participatory
consulting style characterised by for example less involvement in treatment decisions; a higher percentage of
biomedical talk and physicians’ question asking; lower
patient control over communication; less diagnostic and
treatment information and more physical examination.
Doctors give more information, more explanations, more
(emotional) support and adapt more often a shared decision making style with higher SES participants.
This review also indicates that the literature on the
social gradient in doctor-patient communication that
was published after 2002, at least addresses new issues
and themes. Firstly, in the period 1965-2002, 42 articles
were selected for this review, while for the period 20022011, 87 articles were selected. These numbers indicate
that doctor-patient communication becomes a more
emerging topic in the research on delivering qualitative
care. Secondly, most of the more recent studies emphasize the importance of the reciprocity of communication: the doctor might communicate differently
according to the social status of the patient, and patients
may adapt a different communication style according
their social class. Patients with a high SES tend to ask
more questions, ask for explanations, are more expressive and have a higher level of being opinionated than
their lower SES counterparts [33,34,42,55].
Furthermore, there seems to be a growing interest in
patient’s perception of doctor-patient communication.
Page 11 of 14
While in the past, patient’s perception was not taking
into account or no differences in perception were found,
more recent studies show that low SES patients have the
feeling doctors fail to explain things in a way they can
understand and spend less time with them [21,24,41].
These findings emphasise that doctor-patient communication is a complex interactional system. To depict
this complexity, Street et al. (2007) applied an ecological
model that takes into account the interplay of multiple
physician, patient and contextual factors that collectively
influence doctor-patient interactions [56]. The influence
of any variable (e.g. ethnicity) may vary depending on
the presence of other factors (e.g., the patients’ level of
education, income, doctors’ communication style) [53].
The ecological approach recognizes that within the context of any medical encounter, a number of processes
affect the way physicians and patients communicate and
perceive one another. There are four important sources
of potential influence: the physician’s communication
style, patients’ characteristics, physician-patient demographic concordance and the patients’ communication.
First, how a physician communicates with a patient may
depend on his or her style. Some physicians provide
more information, ask more questions, are more supportive and use more partnership-building than other
physicians [33,34,49]. Second, variability in physicians’
communication and perceptions may be related to the
patients’ demographic characteristics (education,
income, occupation) [57]. Finally, the patients’ communication style can have a strong effect on physician
behaviour and beliefs [18].
Important in this model is that patient interaction not
only depends on the physician’s behaviour but also on
patients’ characteristics and preferences. Patients from
lower social classes more often suffer from (multiple)
chronic conditions and more severe acute conditions
[58]. But also they often have lower levels of health literacy-the degree to which persons have the capacity to
obtain, process and understand basic health information
and services needed to make appropriate health decisions [59,60]. Furthermore lower social class is associated with a lower sense of personal control also
known as external locus of control. This means that the
person perceives that certain events such as health and
sickness are beyond his/her control [61]. This might
explain why low SES people show lower levels of participation. Also, because they are less used to or feel less
capable to interact during consultation, they might prefer a more directive consultation style. Recently, an
international consortium of research teams in the UK,
the Netherlands, Italy and Belgium set up the Gulliver
study which focuses on the patient’s preferences in doctor-patient communication. Analysing a possible social
127
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
gradient in these preferences is hereby one of the points
of attention of the researchers.
Limitations of the study
128
Many of the limitations the review of 2005 encountered
are still applicable today. Affective and non-verbal behaviour are important aspects in physician-patient communication e.g. through their influence on patient satisfaction
[44]. Still a limited number of studies described the interaction between social class and non-verbal physicianpatient communication. All studies indicates the difficulties measuring and coding non-verbal behaviour. Therefore, these limited number of studies entails important
methodological difficulties and does not allow us to draw
conclusions concerning non-verbal and affective behaviour. Further research on this topic is still needed.
Secondly, it is very difficult to compare the results of
the studies due to the great diversity of measurements
and frameworks organising these measurements in the
different studies. Socio-economic status of the patient
was measured by means of educational level, income or
occupation [3,62]. An alternative to determine SES is to
use “proxy” measures e.g. the insurance status, house
tenure, car ownership, socio-demographic measures
(race, etc.). Articles using proxy-variables as the only
measure for SES were excluded. However, some of the
selected articles used these variables in combination with
educational level, income or occupational class. Next to
the SES of the patient, also communication variables can
be classified in many different ways. The variables used
in these classifications are not always comparable, making if very difficult to compare the studies using different
classification systems. We chose to categorise most of the
communication variables according to the axis verbal/
non-verbal behaviour. The determinants of communication that did not fit into the categories of this axis were
related to patient centeredness.
In order to improve the comparability of future
research, the use of a uniform definition and classification of communication variables is indispensable.
Practice implications
This review of the literature has revealed the complex
relationship of doctor-patient communication and reinforces the practice implications of the former review.
Physicians behave differently with patients from different SES and patients communicate differently with their
doctor depending on their SES. The finding that the
physician’s communicative behaviour is related to the
communicative style of the patient and to his/her personal or social characteristics, may have important implications for the daily practice of the physician.
Physicians need to be aware of the differences in giving information to and involving patients from lower
Page 12 of 14
social classes in the consultation, as well as of the
underlying causes [63]. It is important that physicians
pay attention to the attitudes that they have toward
patients, and have to remain aware of how their feelings
might impact their behaviour and thus be perceived by
patients [64]. They should consider the possibility that
conscious or unconscious stereotyping may influence
their behaviours, including their interpersonal style [65].
Physicians have to encourage patients to discuss their
concerns and to ask questions, and they should listen
actively. Communication skills and attitudes training can
be an important tool to improve these defaults: the
effects of such training have been proven and can persist over time [66].
Patients have a certain power to control communication during the consultation and to influence the physicians’ communicative behaviour. However, patients from
lower social classes seem to exercise this control less
than patients from higher educated groups. It seems
that not only patient’s personal characteristics but more
importantly their communicative behaviour has an influence on the doctor-patient communication. Therefore it
is important to empower the patients towards more
self-efficacy and towards learning how to express their
concerns and preferences [33,34,38,67].
It has been shown that interventions to increase the
participation of patients with low education obtain a
good response and lead to measurable and clinically
important improvements in health outcomes [68]. By
understanding processes that facilitate or hinder patient
involvement, physicians should be better able to adapt
their own communication and office practices to help
patients more effectively participate in medical encounters [52].
On the other hand, it is important not to take patientcentered care as the obvious and only choice. When
working patient-centered, physicians should not only
focus on normative thinking regarding participatory decision making but they also have to pay greater attention
to a broader set of considerations relating to respect for
patients as individuals. It is important to enable and
empower patients but it is perhaps even more important
to enable and empower them to the degree that they
desire. As McKinstry states: “Doctors need both communication skills and time in consultations, along with
knowledge of their patients, to determine at which times,
with which illnesses, and at which level their patients
wish to be involved in decision making” [47].
Future research should further investigate low-SES
patients’ perceptions and expectations of their health
care providers’ communication skills and of being
involved in the decision making process. Special attention
should be paid to the relationship between patient skills,
patient activism and communication satisfaction [50].
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
Authors’ contributions and acknowledgements
VE, NdeL, WS and MdeS equally contributed to the
research and the report of the study, DM helped formulating the core idea and was involved in the final editing
of the manuscript. All authors read and approved the
final manuscript
Author details
1
Department of Family Medicine and Primary Health Care, Ghent University,
Ghent, Belgium. 2Verlinde Evelyn, Department of Family Medicine and
Primary Health Care, Ghent University, UZ-1 K3, De Pintelaan 185, B-9000
Ghent, Belgium.
Competing interests
The authors declare that they have no competing interests.
Received: 17 November 2011 Accepted: 12 March 2012
Published: 12 March 2012
References
1. Inequalities in health: Report of a research Working Group London: DHSS;
1980.
2. Field KS, Briggs DJ: Socio-economic and locational determinants of
accessibility and utilization of primary health-care. Health Soc Care
Community 2001, 9:294-308.
3. Mackenbach JP, Kunst AE: Measuring the magnitude of socio-economic
inequalities in health: an overview of available measures illustrated with
two examples from Europe. Soc Sci Med 1997, 44:757-771.
4. Mackenbach JP, Stirbu I, Roskam AJ, Schaap MM, Menvielle G, Leinsalu M,
Kunst AE: Socioeconomic inequalities in health in 22 European countries.
N Engl J Med 2008, 358:2468-2481.
5. Health for all in the 21st century. Proceedings of the WHO 50th
anniversary congress. World Health Organisation; 1998.
6. Lynch J, Smith GD, Hillemeier M, Shaw M, Raghunathan T, Kaplan G:
Income inequality, the psychosocial environment, and health:
comparisons of wealthy nations. Lancet 2001, 358:194-200.
7. Turrell G, Mathers C: Socioeconomic inequalities in all-cause and specificcause mortality in Australia: 1985-1987 and 1995-1997. Int J Epidemiol
2001, 30:231-239.
8. Mackenbach JP, van de Mheen H, Stronks K: A prospective cohort study
investigating the explanation of socio-economic inequalities in health in
The Netherlands. Soc Sci Med 1994, 38:299-308.
9. Dahlgren G, Whitehead M: European strategies for tackling social
inequities in health: Levelling up Part 2. 2006.
10. Power C, Matthews S: Origins of health inequalities in a national
population sample. Lancet 1997, 350:1584-1589.
11. Benzeval M, J K, Whitehead M: Tackling inequalities in health. 1995.
12. van de Mheen H, Stronks K, Looman CW, Mackenbach JP: Does childhood
socioeconomic status influence adult health through behavioural
factors? Int J Epidemiol 1998, 27:431-437.
13. Lundberg O: The impact of childhood living conditions on illness and
mortality in adulthood. Soc Sci Med 1993, 36:1047-1052.
14. Sturm R, Gresenz CR: Relations of income inequality and family income
to chronic medical conditions and mental health disorders: national
survey. BMJ 2002, 324:20-23.
15. Alter DA, Naylor CD, Austin P, Tu JV: Effects of socioeconomic status on
access to invasive cardiac procedures and on mortality after acute
myocardial infarction. N Engl J Med 1999, 341:1359-1367.
16. Wyke S, Hunt K, Walker J, Wilson P: Frequent attendance, socioeconomic
status and burden of ill health. An investigation in the west of Scotland. Eur
J Gen Pract 2003, 9:48-55.
17. Whitehead M, Dahlgren G: Concepts and principles for tackling social
inequities in health: Levelling up Part 1. 2006.
18. Street RL Jr: Millay B: Analyzing patient participation in medical
encounters. Health Commun 2001, 13:61-73.
19. Bensing J: Doctor-patient communication and the quality of care. Soc Sci
Med 1991, 32:1301-1310.
Page 13 of 14
20. Bensing JM, Kerssens JJ, Vanderpasch M: PATIENT-DIRECTED GAZE AS A
TOOL FOR DISCOVERING AND HANDLING PSYCHOSOCIAL PROBLEMS IN
GENERAL-PRACTICE. Journal of Nonverbal Behavior 1995, 19:223-242.
21. Jensen JD, King AJ, Guntzviller LM, Davis LA: Patient-provider
communication and low-income adults: age, race, literacy, and optimism
predict communication satisfaction. Patient Educ Couns 2010, 79:30-35.
22. Cheraghi-Sohi S, Bower P, Mead N, McDonald R, Whalley D, Roland M:
What are the key attributes of primary care for patients? Building a
conceptual ‘map’ of patient preferences. Health Expect 2006, 9:275-284.
23. Duberstein P, Meldrum S, Fiscella K, Shields CG, Epstein RM: Influences on
patients’ ratings of physicians: Physicians demographics and personality.
Patient Educ Couns 2007, 65:270-274.
24. DeVoe JE, Wallace LS, Fryer GE Jr: Measuring patients’ perceptions of
communication with healthcare providers: do differences in
demographic and socioeconomic characteristics matter? Health Expect
2009, 12:70-80.
25. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J:
Socio-economic status of the patient and doctor-patient
communication: does it make a difference? Patient Educ Couns 2005,
56:139-146.
26. Ong LM, de Haes JC, Hoos AM, Lammes FB: Doctor-patient
communication: a review of the literature. Soc Sci Med 1995, 40:903-918.
27. van den Brink-Muinen A, Verhaak PFM, Bensing JM, Bahrs O, Deveugele M,
Gask L, Mead N, Leiva-Fernandez F, Perez A, Messerli V, et al:
Communication in general practice: differences between European
countries. Family Practice 2003, 20:478-485.
28. Schouten BC, Meeuwesen L, Tromp F, Harmsen HAM: Cultural diversity in
patient participation: The influence of patients’ characteristics and
doctors’ communicative behaviour. Patient Education and Counseling 2007,
67:214-223.
29. Zandbelt LC, Smets EMA, Oort FJ, Godfried MH, de Haes H: Patient
participation in the medical specialist encounter: Does physicians’
patient-centred communication matter? Patient Education and Counseling
2007, 65:396-406.
30. Mead N, Bower P: Patient-centredness: a conceptual framework and
review of the empirical literature. Soc Sci Med 2000, 51:1087-1110.
31. Roter DL, Hall JA, Katz NR: Relations between physicians’ behaviors and
analogue patients’ satisfaction, recall, and impressions. Med Care 1987,
25:437-451.
32. Hall JA, Roter DL, Katz NR: Meta-analysis of correlates of provider
behavior in medical encounters. Med Care 1988, 26:657-675.
33. Street RL Jr: Information-giving in medical consultations: the influence of
patients’ communicative styles and personal characteristics. Soc Sci Med
1991, 32:541-548.
34. Street RL: Communicative styles and adaptations in physician-parent
consultations. Soc Sci Med 1992, 34:1155-1163.
35. Martin E, Russell D, Goodwin S, Chapman R, North M, Sheridan P: Why
patients consult and what happens when they do. BMJ 1991,
303:289-292.
36. DeVoe JE, Wallace LS, Fryer GE: Measuring patients’ perceptions of
communication with healthcare providers: Do differences in
demographic and socioeconomic characteristics matter? Health
Expectations 2009, 12:70-80.
37. Fiscella K, Goodwin MA, Stange KC: Does patient educational level affect
office visits to family physicians? J Natl Med Assoc 2002, 94:157-165.
38. Maly RC, Liu YH, Kwong E, Thind A, Diamant AL: Breast Reconstructive
Surgery in Medically Underserved Women With Breast Cancer The Role
of Patient-Physician Communication. Cancer 2009, 115:4819-4827.
39. Buetow SA: What do general practitioners and their patients want from
general practice and are they receiving it? A framework. Soc Sci Med
1995, 40:213-221.
40. Piette JD, Schillinger D, Potter MB, Heisler M: Dimensions of patientprovider communication and diabetes self-care in an ethnically diverse
population. J Gen Intern Med 2003, 18:624-633.
41. Pendleton DA, Bochner S: The communication of medical information in
general practice consultations as a function of patients’ social class. Soc
Sci Med Med Psychol Med Sociol 1980, 14A:669-673.
42. Siminoff LA, Graham GC, Gordon NH: Cancer communication patterns and
the influence of patient characteristics: disparities in information-giving
and affective behaviors. Patient Educ Couns 2006, 62:355-360.
129
Chapter 3: Research papers
Verlinde et al. International Journal for Equity in Health 2012, 11:12
http://www.equityhealthj.com/content/11/1/12
130
43. Stewart MRD: Which facets of communication have strong effects on
outcome-a meta-analysis. Communicating with medical patients. 1989.
44. Street RL, Buller DB: PATIENTS CHARACTERISTICS AFFECTING PHYSICIANPATIENT NONVERBAL-COMMUNICATION. Human Communication Research
1988, 15:60-90.
45. Mead N, Bower P, Hann M: The impact of general practitioners’ patientcentredness on patients’ post-consultation satisfaction and enablement.
Soc Sci Med 2002, 55:283-299.
46. Kaplan SGB, Greenfield S, Rogers W, Ware J: Patient and visit
characteristics related to physician’s participatory decision making style.
Med Care 1995, 1176-1187.
47. McKinstry B: Do patients wish to be involved in decision making in the
consultation? A cross sectional survey with video vignettes. BMJ 2000,
321:867-871.
48. Murray E, Pollack L, White M, Lo B: Clinical decision-making: Patients’
preferences and experiences. Patient Education and Counseling 2007,
65:189-196.
49. Roter DL, Stewart M, Putnam SM, Lipkin M Jr: Stiles W, Inui TS:
Communication patterns of primary care physicians. JAMA 1997,
277:350-356.
50. Jensen JD, King AJ, Guntzviller LM, Davis LA: Patient-provider
communication and low-income adults: Age, race, literacy, and
optimism predict communication satisfaction. Patient Education and
Counseling 2010, 79:30-35.
51. Bao YH, Fox SA, Escarce JJ: Socioeconomic and racial/ethnic differences in
the discussion of cancer screening: “between-” versus “within-”
physician differences. Health Services Research 2007, 42:950-970.
52. Street RL, Gordon HS, Ward MM, Krupat E, Kravitz RL: Patient participation
in medical consultations-Why some patients are more involved than
others. Medical Care 2005, 43:960-969.
53. Siminoff LA, Graham GC, Gordon NH: Cancer communication patterns and
the influence of patient characteristics: Disparities in information-giving
and affective behaviors. Patient Education and Counseling 2006, 62:355-360.
54. Stewart M: Patient characteristics which are related to the doctor-patient
interaction. Fam Pract 1984, 1:30-36.
55. Street RL Jr, Gordon HS, Ward MM, Krupat E, Kravitz RL: Patient
participation in medical consultations: why some patients are more
involved than others. Med Care 2005, 43:960-969.
56. Street RL Jr: Gordon H, Haidet P: Physicians’ communication and
perceptions of patients: is it how they look, how they talk, or is it just
the doctor? Soc Sci Med 2007, 65:586-598.
57. Burgess DJ, Fu SS, van Ryn M: Why do providers contribute to disparities
and what can be done about it? J Gen Intern Med 2004, 19:1154-1159.
58. Droomers M, Westert GP: Do lower socioeconomic groups use more
health services, because they suffer from more illnesses? Eur J Public
Health 2004, 14:311-313.
59. Parker RM, Gazmararian JA: Health literacy: essential for health
communication. J Health Commun 2003, 8(Suppl 1):116-118.
60. Beck RS, Daughtridge R, Sloane PD: Physician-patient communication in
the primary care office: a systematic review. J Am Board Fam Pract 2002,
15:25-38.
61. Kraus MW, Piff PK, Keltner D: Social class, sense of control, and social
explanation. J Pers Soc Psychol 2009, 97:992-1004.
62. Van Berkel-van Schaik AB TB: Naar een standardoperationalisatie van
sociaal-economische status voor epidemiologisch en sociaal-medisch
onderzoek. 1990.
63. Epstein AM, Taylor WC, Seage GR: Effects of patients’ socioeconomic
status and physicians’ training and practice on patient-doctor
communication. Am J Med 1985, 78:101-106.
64. Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA: Are physicians’
attitudes of respect accurately perceived by patients and associated
with more positive communication behaviors? Patient Educ Couns 2006,
62:347-354.
65. Piette JD, Bibbins-Domingo K, Schillinger D: Health care discrimination,
processes of care, and diabetes patients’ health status. Patient Education
and Counseling 2006, 60:41-48.
66. Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, Till J:
Doctor-patient communication: the Toronto consensus statement. BMJ
1991, 303:1385-1387.
67. Waitzkin H: Information giving in medical care. J Health Soc Behav 1985,
26:81-101.
Page 14 of 14
68. Kaplan SH, Greenfield S, Ware JE Jr: Assessing the effects of physicianpatient interactions on the outcomes of chronic disease. Med Care 1989,
27:S110-S127.
doi:10.1186/1475-9276-11-12
Cite this article as: Verlinde et al.: The social gradient in doctor-patient
communication. International Journal for Equity in Health 2012 11:12.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Chapter 3: Research papers
Socio-economic status of the patient: does it influence the
decisions of the GP?
Verlinde E., Bonte E., Willems S.
Corresponding author
Verlinde Evelyn
Department of Family Medicine and Primary Health Care,
Ghent University, Belgium
De Pintelaan 185 – 6K3
9000 Ghent
[email protected]
Telephone: 0032 9 332 6082
Fax: 0032 9 332 49 67
Bonte Eleonora
Department of Family Medicine and Primary Health Care,
Ghent University, Belgium
Willems Sara
Department of Family Medicine and Primary Health Care,
Ghent University, Belgium
Abstract
Objectives:
Our aim is to explore the influence of the SES of the patient on the clinical management decision of GPs in a country with a universal health care system.
Methods:
Eleven semi-structured interviews with GPs from varied practice settings in Flanders.
Results:
The attitude of GPs towards low SES patients differs according to the number of
patients visiting the practice. Physicians with frequent contacts have the feeling to
cope with prejudices and a fatalistic view. All physicians indicated that they changed
131
Chapter 3: Research papers
their clinical decisions according to the SES of the patient. Those with occasional
contacts with low SES patients said to made changes in order to enhance the outcomes for the patients while GPs with frequent contacts said the changes were not
always in favor of the patients.
Conclusion: Physicians working frequently with low SES patients feel caught
between delivering a good standard of care and tailoring the care according to the
needs and possibilities of the patients.
Practice implications: Additional training, supervision, (psychological) coaching
and other forms of remuneration could support physicians working with low SES
patients.
Keywords:
social class, General Practice, attitude.
Introduction
132
Since many years, equity in healthcare is an important topic in global health policy [1]. People with a low socio-economic status (SES) suffer disproportionate
more from ill health and from multiple chronic conditions than their higher
class counterparts [2, 3]. Similarly, the use of available health care is also not
distributed across socio-economic groups according to the principle of equity. An
equitable distribution of health care implies equal care for people in equal need,
yet several studies show the opposite: patients with a lower socio-economic status
less frequently visit a specialist (despite their higher disease burden) or a dentist,
receive less chronic and preventive care (e.g. fewer mammograms, diabetic eye examination) and the received care is often from a lower quality compared to higher
socio-economic groups [4-7].
An equitable health care system does not only succeed in equitable outcomes of
care (e.g. equal vaccination rates or success rates after surgery in patient groups
with the same health care need, independent from their socio-economic or cultural
background or their sex) but also in equity in access to care and equity in treatment.
Nor does it only reach equity in the structural components of care (e.g. an equal
distribution of GPs in deprived areas as in affluent areas) but also in the process
components of care. Concerning the latter, the doctor patient relationship is of
crucial importance and can be a source of inequity but also a major contributor to
Chapter 3: Research papers
more equality in care for people in equal need for care.
Variations in doctor-patient relations depend on the knowledge, skills, preferences, perceptions, attitudes and prejudices of both patient and health care provider
[8]. Physicians are expected and expect themselves not to judge patients on their
social class and above all, not to treat patients differently because of their sociodemographic characteristics [9]. Literature on the influence of socio-economic
status on the clinical decisions physicians make is scarce and almost exclusively
reporting on the situation in the US. Bernheim et al. interviewed 18 primary care
physicians in different practice settings on the influence of patients’ socio-economic
status on their clinical management decisions. Physicians indicated that patient’s
SES did affect their decisions. Some doctors reported that the changes were made
to enhance patient outcomes, others had the feeling the outcomes were not always
in favor of the patient. An important finding of Bernheim and colleagues is that
physicians said to no longer accept Medicaid patients, leaving the most vulnerable
patients out of the loop [10].
We believe that, based on qualitative studies with patients, physicians working with
low SES patients make changes in their clinical decision which not always favor
the outcomes for the patient[11].
The aim of this study is to explore the influence of the socio-economic status
of the patient on the clinical management decision of general practitioners in a
country with a universal health care system for the patients. The universal Belgian
health care system covers over 98% of the population and provides direct access
to a general practitioner or specialist without gate-keeping or patient-list. There is
a fee-for service payment system with reduced co-payment for the less privileged
(about 1 euro per consultation with a GP). In 1982 the legal possibility to work in
a capitation system in primary care was introduced in order to reduce the financial
barrier towards primary health care. This payment system is mostly but not solely
used in the Community Health Centres. These centres provide interdisciplinary
comprehensive primary health care which all people residing in the neighbourhood
can access without cost.
133
Chapter 3: Research papers
Methods
Study Design and Participants
To explore general practitioners’ perceptions on working with patients from lower
social classes and their vision on how this might influence their clinical decisions
and the outcomes for the patients, we choose for a qualitative research design.
In the selection of the participants we strived for maximum variation regarding the
GPs age, sex, ethnicity (country of birth of both parents), years of experience, type
of practice (solo, duo, group practice), location of the practice (rural versus urban)
and frequency of contacts with patients with a low SES. The number of interviews
was not pre-defined and interviews were conducted until thematic saturation was
reached. Eleven semi-structured interviews with physicians were conducted.
134
The participants in this study were selected in three phases. In the first phase, 25
primary care physicians were identified based on the above characteristics. They were
selected from the Flemish Community Health Centers and from lists of primary
care physicians who previously participated in research conducted by the department of General Practice and Primary Health Care, practices that were known to
the Department as outplacement practice for students or were informally known
by Department staff. They were sent an invitation to participate in the study and
received an information leaflet. Two weeks later, they were all contacted by phone.
Six primary care physicians agreed to participate in the study. Based on the characteristics of the included doctors, and with the aim of maximum variation in mind,
two additional physicians were added to the sample. They were identified by the
physicians in the first phase by means of the snowball technique. After the second
phase of inclusion, interviews were conducted. However, thematic saturation was
not yet reached. Therefore, in the third phase of the inclusion the characteristics
of the physicians were checked a last time. Ethnicity of the physicians and contact
with patients with low SES did not yet vary enough. By means of the snowball
technique another three physicians were identified and all were willing to participate.
The reasons physicians gave for not participating in the study were: ‘already participating at other studies’ or ‘no time to participate’.
Chapter 3: Research papers
Data collection
All interviews were conducted by a medical student – researcher (E.B.). Prior to the
study, the interviewer received an intensive training in interviewing and during this
phase of the data collection she was permanently supervised by a senior researcher
in qualitative research methods (E.V.). The interviews took place in the physician’s
office and lasted between 40 and 75 minutes. An interview guide was developed
including open-ended questions and additional prompts and was tested in two interviews with physicians working at the Department of Family Medicine and Primary
Health Care of Ghent University. The interviews started with the question whether
the doctors frequently saw patients with a low SES in their practice and how they
experienced these consultations. Next, physicians were asked to reflect on how the
patient’s SES influences the care they give, including their clinical decision making.
Physicians were prompted to give examples of changes in their clinical decision
process. The concept of “SES” was not pre-defined by the researchers because one
of the aims of this study is to gain insight into how physicians perceive and define
this patient characteristic. Additionally, all physicians completed a brief written
questionnaire on their demographic background, type of practice, payment system
and years of experience. All interviews were recorded on audiotape and transcribed
verbatim by the researchers.
Data Analysis
To code and analyze the interviews we used the software program NVIVO 9.
Line-by-line open coding was used to develop the coding structure. Analysis was
undertaken by the first two authors, EB and EV. Interview transcripts were coded
by the researchers independently from each other. Consensus on the meaning of
codes and the code structure was reached through numerous discussions. Coding
and interviewing occurred simultaneously and as new concepts were identified
during the coding, the interview guide was modified to reflect these emerging
themes. To guard the quality of the coding, the researchers reviewed data within
codes several times to ensure consistency in their use and full understanding of
their scope and meaning.
Ethics approval
Participants were provided with written information about the study and all gave
written consent. Any potentially identifying information that was given on the
135
Chapter 3: Research papers
consent form or during the interviews was removed from the file before analysis.
The interview tapes were deleted six months after the end of the study. The study
was approved by the Ethics Committee of the Ghent University Hospital (Project
number 2009/448).
Results
136
A total of 11 primary care physicians participated the study (table 1); five men and
six women. Six GPs were younger than 40, three were aged between 40 and 50
and two were older than 50. Five had less than 10 years of experience as a GP, four
practiced between 10 and 20 years and two had more than 20 years of experience.
One physician was not born in Belgium, the others were born in Belgium and had
Belgian (grand) parents. They practiced in different settings: one physician had a
solo practice, one had a duo practice, four physicians were part of a group practice
and five physicians worked in a Community Health Centre. Five physicians predominantly treated patients with a low SES, five physicians predominantly treated
patients with a middle or higher socio-economic status and one physician had
almost no patients of lower social class in his patient population.
Variable
n (%)
Sex
Male
5 (45.0)
Female
6 (55.0)
<40
6 (55.0)
40-50
3 (27.0)
>50
2 (18.0)
Age
Years of experience
<10 years
5 (45.0)
10-20
4 (36.0)
>20
2 (18.0)
Country of Birth
Born in Belgium
Other country
10 (91.0)
1 (9.0)
Chapter 3: Research papers
Type of practice
Solo
1 (9.0)
Duo
1 (9.0)
Group
4 (36.0)
Community Health Centre
5 (45.0)
Location practice
Antwerp
2 (18.0)
Vlaams-Brabant
1 (9.0)
Oost-Vlaanderen
4 (36.0)
West-Vlaanderen
4 (36.0)
Number of patients with low SES
Small number
1 (9.0)
Average
5 (45.0)
Large number
5 (45.0)
Table 1: characteristics of the physician sample
Perception of socio-economic status of the patient
When asking the physicians how they defined the socio-economic background of
their patients this resulted in a very diverse pallet of answers. They firstly referred
to economic aspects such as being unemployed, being entitled with a social welfare
benefit, being uninsured, homeless, tenants, or having a lot of debts. Secondly, they
also referred to socio-cultural aspects (being immigrant, having a low educational
level, being illiterate, having a restricted social network or living in social isolation
or having a large family), living conditions (low quality housing, living in a deprived
neighborhood, lack of personal hygiene, poor diet), health challenges (addiction,
multi-morbidity, mental health problems, more unexpected pregnancies), childhood
education, attitude and knowledge about health (poor health literacy, competing
priorities, postpone health care, not interested in prevention, very susceptible to
advertisements). Physicians used a combination of both positive (e.g. loyal) and
negative (e.g. disrespectful) connotations to describe their perceptions of low SES
people.
137
Chapter 3: Research papers
Attitude towards low SES patients
All GPs showed a higher commitment and were more concerned about these
patients. Physicians said it is very important to be empathic with these patients.
However, they indicated that it is not always easy to work with low SES patients.
Annotations about working with patients from lower social class varied from “challenging” to “very frustrating” and “out of control, no matter how hard they tried”.
How physicians cope with these feelings seems to correlate with the number of
patients of low social class visiting the practice.
Physicians with occasional contacts with low SES patients seemed to perceive
them as more grateful and very loyal patients. They described working with these
patients as a positive challenge and very enriching, nevertheless the difficulties that
also come across.
“They are very dedicated to you, because they feel supported by you (physician 8).”
138
Physicians with frequent contacts with low SES patients and the one physician
barely seeing low SES patients reported a less positive feelings towards low SES
patients.
“Sometimes I have the feeling they don’t appreciate you. You do a lot of effort for
these people, but these are the kind of patients who take it for granted
(physician 1).”
They report to lower their expectations towards low SES patients e.g. concerning
drug adherence or progression in healthy eating habits. Often this is induced by
earlier experiences of failure when setting targets, leading to frustration and a kind
of “tiredness” in staying motivated.
“ You always have some kind of expectations, but you never achieve them
(physician 6). “
As a result of this frustration or “tiredness” the physicians in this study report to
sometimes acquiesce in the patient’s situation or behavior, not trying to motivate the
patient to change their behavior (eg. smoking habits, dietary habits) or to take action
(eg. to find a healthier house) anymore. Earlier failures with patients might result
in less attempts to motivate other patients with a similar socio-demographic profile.
“After a while, you make peace with the situation. For non-urgent matters, it’s often
not possible to make a change (physician 10).”
Chapter 3: Research papers
The participating physicians were aware of their so called fatalistic view and emphasize the danger of prejudices.
“ You are confronted with your own prejudices, I have to be aware not being too
fatalistic (physician 10).”
“ You have to be careful with prejudices. Sometimes I think: “Should I really need to
explain this, they won’t understand it anyway”. But it’s not because they have a lack
of money, that they don’t have brains (physician 5).”
Influence of patients’ SES on treatment
All physicians stated they try to work evidence based, although they had the feeling this was not always possible. Sometimes they had to adapt the treatment or
medication in order to achieve the best possible outcome.
“Sometimes you have to do it yourself. The patients need specialist care, but he/she
cannot afford it. You have to try with trial and error until you succeed
(physician 1).”
The one physician barely seeing low SES patients said always to work evidence
based and made no exceptions.
Also on drug prescribing, referring, additional tests and payment all physicians
aligned. However, those with fewer contacts often did more effort. All physicians
prescribed generic medication or tailored the medication to an easier scheme.
GPs with fewer contacts with low SES patients made additional agreements with
pharmacists e.g. on payment or phased delivery. Sometimes these GPs also gave
free samples of medication when they felt that their patients could not afford it.
“When prescribing medication, I look for the cheapest medication. Euhm, while
with other patients you prescribe the medication you are used to prescribe. You put
more effort in searching for cheaper medication (physician 1).”
All physicians thought twice before referring a patient to a specialist or performing
additional tests. They only referred a person or made an extra test if this could
determine or change the treatment.
“…, another aspect is that you try to avoid additional cost, by thinking twice. Will
the referral or the extra test add something to my decision (Physician 8).”
139
Chapter 3: Research papers
All physicians tried to make agreements with certain specialists to drop the copayment in order to make specialist care financially more accessible for their low
SES patients. Physicians not working under the capitation system, adapted the
third-party payment (where the patient only needs to pay the co-payment and the
physician gets paid by the sickness fund) to lower the financial burden of the consultation. GPs with fewer contacts with patients of lower SES sometimes adapted
their own payment rule (e.g. drop the co-payment, pay later,…)
“… If we use the third-party payment it is no problem to let them come back for
follow up. This lowers the financial burden. So I think we removed a huge obstacle
in this way (physician 4).”
140
Physicians with less contact with patients from lower social classes often performed
more home visits. They stated that working with appointments creates a higher
burden for the organization of the consultations and patients often forget or don’t
show up. These physicians found house visits especially functional for the follow
up of chronic conditions. They go see the patient once or twice a month to make
sure he/she is fine. This way they also have more control on the therapy compliance,
which was stated by all physicians to be a large problem among patients from lower
social classes.
“We do more house visits for these patients. Making an appointment or transportation is often a problem. By doing more house visits, we try to tackle these problems
(physician 4)”.
Physicians who frequently have contact with low SES people, work almost solely
on appointment.
All physicians agreed that working with low SES patients takes more time and has
an influence on their consultation length. They have to explain things better, ask
more questions to see if the patient actually understands what they have said,…
“ You make sure you have enough time for the consultation… You put them on them
last on the day, so you don’t have to stress when the consultation takes longer (physician 8).”
All physicians agreed on the basics of delivering patient-centered care and shared
decision making. They found it important to consider the patient as a person and
to listen to their individual needs even if these needs are not health care related
(e.g. housing problems).
Chapter 3: Research papers
“For example a patient whose refrigerator is broken at the moment, so he cannot
store his insuline… Euhm so this patient, it’s something we see now and then, he
lives in a hard socio-economic situation. He doesn’t know anybody in the neighborhood, therefore there is nobody he can ask to store his insulin. So now his insulin
is getting warm, he keeps on using it, but you can see that it has lost its effect. So
we switch temporary to oral medication until he has a new refrigerator. These are
things that often happens within this group of patients (physician 10).”
Influence of patients’ SES on the decision making and the outcomes for the
patient
All physicians stated that they do make changes in their decisions according to
the SES of the patient. However, the outcomes of these decisions varied according
to the number of patients of low social class visiting the practice. Physicians with
less contact with patients from lower social classes said to do the best they can to
give each patient the same treatment and strive for equal health outcomes. They
do make changes in their clinical decisions but these changes are made to enhance
the patient’s outcomes.
“I think in most cases, the outcomes are in favor of the patient (physician 3).”
Physicians with frequent contact with patients from lower social classes stated always to start with equal treatment, but they feel it is not always possible to achieve
this. Some said it is even not always possible to give good qualitative care to these
patients. They must make the best decision within a limited number of options.
Evidence based medicine is not always an option. Some physicians have the feeling that the changes they make do not always favor the patients, some even say
the decisions may disfavor the patient.
“First, we do not change our behavior according to the socio-economic status of the
patient. We will try, wherever possible, to give the same treatment we give to anybody (physician 10).”
“I think that the quality of care is less. Because it is difficult to communicate with
these people, which is the biggest obstacle. Also for some matters you need a financial
reserve (physician 2).”
“Interviewer: do you have the feeling that these changes are in favor of the patient?”
Physician 2: “No, not at all.”
141
Chapter 3: Research papers
“There was a patient who needed an MRI scan, however, this patient had no health
insurance, so I decided not to perform the test (physician 5)”.
“Sometimes it is difficult to prescribe the right medication. For example, the patient has a respiratory infection. Paracetamol would be the best way to relieve his
symptoms, however, paracetamol does not get reimbursed. So we prescribe NSAID’s
(non-steroidal anti-inflammatory drug) because they get reimbursed.
(physician 10)”.
Discussion
The aim of this study was to explore how patients’ SES influences the perceptions and
the decision making of the GP, and how this could affect the health care outcomes.
142
First of all, SES was not defined by the researchers but by the perception of the
physicians. Physicians did not define SES solely in terms of occupation, educational level or income, the indicators most commonly used for SES in research
[12-14]. Physicians gave a much broader explanation including economic aspects,
socio-cultural, childhood conditions, health literacy,… These results confirm the
complexity of measuring SES in daily practice.
All physicians said that working with low SES patients takes more time and can
sometimes be frustrating. However, handling these kinds of feelings seemed to
vary according to the number of contacts with patients from lower social classes.
Physicians with occasional contacts with low SES patients perceived working with
these patients as more enriching and a positive experience. They put more effort
in these patients (e.g. more house visits) and perceived them rather as loyal and
grateful. While physicians with frequent contacts with low SES patients said to
sometimes lower their expectations towards their patients and accept situations as
they are. Some said to have a fatalistic view and caught themselves on prejudices.
Regarding to the changes made in the clinical decisions, the results also vary according to the number of contacts with low SES patients physicians have. On the
one hand, the physician with nearly no contact with low SES patients said not to
change his/her decisions or treatment according to the social class of the patient.
All other physicians on the other hand, said to change their treatment or decisions
according to patients’ SES. Those with less contact with low SES patients, put a
Chapter 3: Research papers
lot of effort in treating all patients equal. The changes they made (medication,
house visit, payment system,…) were made in order to enhance the outcomes for
the patient. For example: thinking twice before referring a patient to a specialist,
avoiding unneeded additional costs could enhance the outcomes for the patient in
terms of good qualitative care. Those with frequent contacts with low SES patients
felt that they were not always able to give qualitative care due to a limited number
of options and resources. They strive for equal treatment, but often have to change
their treatment or decisions. They are concerned that the outcomes not always
favor the patients.
These results point out some important issues when caring for low SES patients
in a primary care setting.
First of all, all physicians said to make changes in their care and decision making
according to the SES of the patient. These changes, they say, are not always in favor
of the patient’s outcomes. This may contribute to the socio-economic disparities in
health care. Physicians make changes on what they believe is best for the patient.
However, this does not necessarily reflect the needs and the values of the patients.
Secondly, physicians with occasional contacts with patients from lower social classes
often try harder: out-of-office visits, samples of medications, making appointments
with a specialist,… As stated before, they make these changes in order to enhance
the outcomes for the patients. However, next to the positive aspects of these changes
(good qualitative care) these changes could lead to more passive patients. Patients
are getting used that their GP does everything for them and as a consequence they
show less interaction during the consultation. As a physician, it is important to
empower patients towards higher levels of self-efficacy and interaction during the
consultation. It has been proved that interventions on more patient-interaction
and patient control lead to better health outcomes [15].
Thirdly, there seems to be a difference in the perceptions and health care outcomes for the patients, between GPs with frequent contacts with low SES patients
and those with occasional contacts. GPs with frequent contacts seem to feel more
often frustrated, fatalistic and sometimes cope with prejudices. They feel caught
between delivering a good standard of care and tailoring the care according to
the needs and possibilities of the patients. Sometimes they feel that delivering
good qualitative care is not always possible due to a lack of (financial) resources.
A Belgian study has indicated that these feelings and the additional load when
caring for low SES people, raises the chances of a burn-out for the GP [16]. Next
143
Chapter 3: Research papers
to these personal strains, another aspect when caring for low SES patients could
be the financial strain. The physicians with frequent contact with low SES patients
mostly worked in Community Health Centers. These centers apply the capitation
payment system. Within this system the health centres are paid a specified sum of
money for the ongoing care of a patient for a particular period over time no matter
how much or little this patient uses this service [17]. Physicians stated that care
for low SES patients often takes more time and more visits. Within the capitation
system, based on the average cost of a patient, there is no financial compensation
for this more intense care. A possibility of tackling this problem is the principle of
weighted capitation, where GPs working with a deprived population group, get a
higher share. This system is already successfully applied in the UK with the Jarman
underprivileged area-score [18].
144
There are several strengths and limitations to our study that must be taken into
account. First of all, we limited our sample to physicians working in Flanders.
Therefore, the results cannot be generalized for Belgium. Secondly, when sampling the physicians, special attention was given to the diversity of the physicians
(age, gender, ethnicity, years of experience), type of practice and their contact with
patients from low SES. Nevertheless, the largest part of the physicians worked in
an urban area. The perceptions of physicians working in a rural area could differ,
due to a different sample of patients. Thirdly, there could be a selection bias in the
recruiting of the physicians: physicians with a positive attitude or caring for low
SES patients could be more likely to participate the study than those not working
with low SES patients. In order to reduce this selection bias, we aimed at maximal
variation according to the number of low SES patients in a GP practice. Fourth, we
only interviewed the physicians, the patient’s side nor the progress of the consultation was taken into account. Physicians could make subconscious changes in their
behavior which can only be defined when videotaping the consultation. Fourth,
the interviewer was a medical student inexperienced in qualitative research. This
could lead to possible biases in reporting the results. For this reason, all interviews
were additionally coded by a second investigator, a health services researcher with
substantial qualitative research experience and experience in quality of care. Finally,
SES was not predefined, so we were able to gain insight into physicians’ own conception of SES and of which factors associated with SES they believed influenced
their management decisions.
Chapter 3: Research papers
Conclusion
Physicians make changes in their clinical management decision according to the
social class of the patient. The impact on the quality and outcomes of care seems to
differ according to the number of contacts physicians have with low SES patients.
Physicians caring for many low SES people say to have difficulties finding the
balance between providing good quality of standard care and tailoring the care to
the capacities and needs of low SES patients. When caring for too many low SES
patients, GPs seem not to be able to maintain their high standard of qualitative
care (figure 1).
Quality
Additional
resources
Critical
number
145
N° of
patients with
low SES
Figure 1: Additional resources supporting physicians working with low SES patients.
Practice Implications
Additional support should be given to GPs caring for low SES people in order to
maintain this standard of care.
First of all, medical training focuses on adapting communication behavior (such as
explaining things in a non-medical way) to patients with low SES. However it does
not focus on the challenges and the personal and financial constraints physicians
perceive when working with patients from low SES. Through early and repeated
exposure of students in undergraduate curriculum to people living in poverty, these
future GPs learn to know and how to handle this population group. Secondly it is
Chapter 3: Research papers
important to give additional training on the available financial measures (existing
and new) in order to lower the financial burden for the patient. A Belgian study
showed that the Belgian GPs have a limited knowledge of the available financial
measures [19]. Thirdly, additional resources e.g. supervision, (psychological) coaching , administrative and financial (other forms of remuneration) support, could
help physicians maintaining delivering good quality of care for a large number of
low SES patients.
Authors’ contribution
EV and SW contributed to the design of the study. EB and EV contributed to the
data retrieval and the analysis. EV, EB and SW contributed to the writing of the
paper.
Acknowledgements
146
We would like to thank the participating physicians for their motivation to participate in their interest in this research theme.
Competing Interests
All authors declare that no competing interests exist.
Chapter 3: Research papers
References
1.
Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, Geddes I:
Fair Society, Healthy lives. The Marmot review. Executive Sumary; 2010.
2.
Droomers M, Westert GP: Do lower socioeconomic groups use more
health services, because they suffer from more illnesses? Eur J Public Health
2004, 14(3):311-313.
3.
Westert GP, Satariano WA, Schellevis FG, van den Bos GA: Patterns of
comorbidity and the use of health services in the Dutch population. Eur J
Public Health 2001, 11(4):365-372.
4.
Van der Heyden JH, Demarest S, Tafforeau J, Van Oyen H: Socio-economic differences in the utilisation of health services in Belgium. Health Policy 2003, 65(2):153-165.
5.
Veugelers PJ, Yip AM: Socioeconomic disparities in health care use: Does
universal coverage reduce inequalities in health? J Epidemiol Community
Health 2003, 57(6):424-428.
6.
van Doorslaer E, Masseria C, Koolman X: Inequalities in access to medical
care by income in developed countries. CMAJ 2006, 174(2):177-183.
7.
Fiscella K, Franks P, Gold MR, Clancy CM: Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA
2000, 283(19):2579-2584.
8.
Goddard M, Smith P: Equity of access to health care services: theory and
evidence from the UK. Soc Sci Med 2001, 53(9):1149-1162.
9.
van Ryn M, Burke J: The effect of patient race and socio-economic status
on physicians’ perceptions of patients. Soc Sci Med 2000, 50(6):813-828.
10. Bernheim SM, Ross JS, Krumholz HM, Bradley EH: Influence of patients’
socioeconomic status on clinical management decisions: a qualitative study.
Ann Fam Med 2008, 6(1):53-59.
11. Willems S: The socio-economic gradient in health: a never-ending story?
A descriptive and explorative study in Belgium. Ghent: Ghent University;
2005.
12. Oakes JM, Rossi PH: The measurement of SES in health research: current
practice and steps toward a new approach. Soc Sci Med 2003, 56(4):769784.
13. Shavers VL: Measurement of socioeconomic status in health disparities
research. J Natl Med Assoc 2007, 99(9):1013-1023.
147
Chapter 3: Research papers
14. Adler NE, Newman K: Socioeconomic disparities in health: pathways and
policies. Health Aff (Millwood) 2002, 21(2):60-76.
15. Kaplan SH, Greenfield S, Ware JE, Jr.: Assessing the effects of physicianpatient interactions on the outcomes of chronic disease. Med Care 1989,
27(3 Suppl):S110-127.
16. Jonckheer P, Stordeur S, Lebeer G, Roland M, De Schampheleire J, De
Troyer M, Kacenelenbogen N, Offermans A, Pierart J, Kohn L: Burnout bij
Huisartsen: preventie en aanpak. Health Services Research (HSR). In. Edited by (KCE) FKvG, vol. KCE Reprots 165A; 2011.
17. Physicians funding and health care systems - an international perspective.
In: A summary of a conference hosted by the WHO, WONCA and RCPG
at St John’s College, Cambridge. Edited by Brown PS.
18. Art B, De Maeseneer J: Forfaitaire betaling: een beter systeem voor patiënt
en huisarts. [Capitation system: a better system for the patient and doctor].
148
19. Broeckaert O, De Troeyer K: Sociale dienstverlening en financiële tegemoetkomingen voor de patiënt: hoe ver reikt de kennis van de huisarts?
[Social services and financial measures for the patient: what is the knowledge of the GP?] ; 2011.
Chapter 4
Discussion
149
150
Chapter 4: Discussion
4. Discussion
4.1 What this thesis adds: summary of the results
This doctoral thesis focuses on the equity in primary health care in Belgium in
terms of equal access, equal treatment and equal outcomes for vulnerable population
groups in equal need compared to non vulnerable population groups. Figure eight
provides an overview of the hypotheses of this thesis. Five studies were set up: one
qualitative study focusing on the influence of the patient’s socio-economic status
on the clinical management decisions of the GP, one systematic literature review on
the impact of patient’s social class on the doctor-patient communication and three
quantitative studies focusing on the social inequities in health care use in Belgium
and on the health care use of two vulnerable population groups namely homeless
people and low-income people.
Equity in Health Care
151
Equal treatment for
patients in equal need
Equal access to care for
patients in equal need
e.g. communication, attitude, decision making
Equal outcomes for
patients in equal need
e.g. financial, cultural and
geographical access
Hypothesis 1
The specialist is the doctor of the high income
people and the GP is the doctor of the low to
middle income people (paper 1).
Hypothesis 2
Homeless people have a higher likelihood to
consult the emergency department than the
general population. A universal primary
health care system with active guidance for
homeless people towards this system might
counter this (paper 2).
Hypothesis 3
People who are not able to cope with their
available income have a higher likelihood to
postpone a visit to a GP (paper 3).
Hypothesis 4
The social gradient in doctor-patient communication persists, where patients from lower
socio-economic classes are less involved during
the consultation, receive less control and a
more paternalistic consultation style
(paper 4).
Hypothesis 5
Physicians have a negative attitude towards
patients with a low SES and as a result make
changes in their clinical decision which do not
favor the outcomes for the patient (paper 5).
Figure 8: an overview of the main focus of this thesis, the hypotheses and the research papers
Chapter 4: Discussion
Exploring the social gradient in health care utilization in Belgium using
registered data on health care use.
In paper one, we linked data from the Belgian Health Interview Survey with corresponding registered medical utilization data provided by the Sickness Funds.
Despite the nearly universal health care system, we found inequity in utilization
patterns according to educational level. The findings of this study indicate that the
specialist is not the doctor of the ‘rich people’, but rather is the doctor of the higher
educated. While the GP is not the doctor of the ‘poor’, but the doctor of the lower
educated. Patients with a lower or middle educational level have a higher ratio for
contacting their GP compared to higher educated patients, even after controlling
for health care need (including subjective health, chronic diseases and disability).
When looking at specialist care, this picture changes: higher educated patients have
a higher tendency in contacting a specialist compared to lower educated people.
These results remain significant even after controlling for health care need. However,
attention is needed when interpreting results on income as the measurement of
income is far less stable and valid than the measurement of education.
152
These results contrast with findings reported in studies using self-reported utilization data. Data from the Belgian Health Interview Survey indicate that the social
gradient in the utilization of the GP disappears when health status is taken into
account [1]. With regard to the use of specialist care, our findings are consistent with
the evidence based on self-reported data: taking into account the disease burden,
higher SES people seek specialist care more often than do lower SES people [2, 3].
The conclusions of this study are fourfold. First of all, this study stresses the importance of using accurate information on health care utilization. Secondly, these
findings indicate that primary care succeeds in being accessible for vulnerable
population groups such as low-income people or low-educated people. Third, primary care teams are in a position to take on a coordinating role by helping people
navigate through the health system and mobilizing support by referring the patients
or calling on the support of specialized services. Fourth, in a health care system
without gate-keeping, higher educated tend to utilize relatively more specialist care
compared to lower-educated people (paper 1).
Chapter 4: Discussion
Exploring the health care use of two vulnerable population groups: lowincome people and homeless people.
Both homeless people and low income people are vulnerable population groups
facing a higher disease burden leading to a higher health care need [4-6]. However,
despite their higher health care need, these people do not always find the way to the
appropriate health care service, or they postpone medical care [7-11]. In paper 2 and
3 we aim to explore the healthcare use of these two vulnerable population groups.
The homeless people residing in Ghent have a higher likelihood to consult a GP
than the non-homeless people in Ghent, even after adjusting for age and sex. The
same trend is seen for secondary care and the use of emergency care. This contrasts
with findings from existing studies (mainly from the UK and the US) describing
higher utilization rates for hospital-based care and emergency care and lower rates
for primary care by homeless people compared to the general population [5, 7,
12]. The higher likelihood in Ghent to consult a GP in the homeless population
compared to the general population could be explained by the fact that primary
health care for homeless people in Ghent is organized in a way that contributes to
the reduction of some of the barriers such as financial barriers, accessibility, registration,… The area of Ghent is to a large extent covered by Community Health
Centers that provide interdisciplinary comprehensive primary health care using a
capitation system without co-payments. Additionally, homeless people with health
problems are actively guided towards Community Health Centres and large group
practices by social workers. These practices are located close to homeless shelters
and social restaurants so transportation is not an issue. There are agreements on the
payment procedure – even for those with administrative problems with health insurance- so the financial barriers are minimalized. Furthermore, Community Health
Centers, are known not to stigmatize or refuse patients because of being homeless
or having no financial resources. This hypothesis is supported by the finding that
the homeless people who visit a GP, visit more often a group practice compared to
the general population (56% versus 5.6% in general population in Ghent) (paper 2).
In the third paper, 606 low-income people were interviewed on their health care
use. Nearly one in three respondents postponed or cancelled a visit to the GP while
they actually needed one. The reasons for postponing these visits were reasons that
were linked to the health system such as accessibility, stigmatization, not knowing
where to go,… The sub-groups within the low-income people that have a higher
tendency to postpone a visit to a GP were people suffering from a severe depres-
153
Chapter 4: Discussion
sion, people with a poor self-rated health, and people with moderate or low trust
in their GP. Against our expectations, having difficulties to cope with the available
monthly income had no effect on postponing a visit to a GP. These findings could
indicate that the health care system in Flanders does not create huge financial
barriers. Possible explanations are the success of the interventions that try to lower
the financial burden for low-income patients such as the third-party system and
the reduced co-payment in the fee-for-service payment system and the usage of
the capitation system in the Community Health Centers and some larger group
practices. However, these results also indicate that the access to primary care for
low-income patients might be hindered by barriers which do not directly link to
the costs of consultation. Such as: finding appropriate child care, not knowing
where to go with a particular health problem, being afraid or ashamed, thinking
the doctor will not be able to solve the problem or having the feeling the doctor
does not understand their struggle to survive and its implications for their health
and compliance (paper 3).
154
Doctor-patient interaction: the role of patient’s socio-economic status on the
doctor’s communication style
In the studies on the health care use of homeless and low-income people described
above, the doctor-patient interaction and relationship is mentioned as a possible
barrier or facilitator in the utilization of medical care in Belgium (paper 2 and
3). Also other studies conclude that the interaction between the patient and the
health care provider is an essential component of the delivery of health care. A good
doctor-patient relationship adds to a better quality of care, better compliance and
a higher level of patient satisfaction. When building a doctor-patient relationship,
one of the components is doctor-patient communication [13, 14].
Paper four presents the findings of a systematic literature review. Since the review
by Willems et al. in 2005, the social gradient in doctor-patient communication
persists. Patients from lower social classes receive less socio-emotional talk, a more
directive and less participatory consultation style characterized by for example
less involvement in treatment decisions, a higher percentage of biomedical talk
and physician’s question asking; lower patient control over communication; less
diagnostic and treatment information and more physical examination. While with
patients from higher social classes, doctors gave more information, more explanations, more (emotional) support and adapted more often a shared decision making
Chapter 4: Discussion
style. Since 2005, emphasis is on the importance of the perception of the patient
and the reciprocity of the communication: doctors may communicate differently
according to the social status of the patient, but also patients may (subconsciously)
adapt a different communication style according to their social class (paper 4).
The role of the socio-economic status of the patient on the clinical decisions
made by their GP
Variations in doctor-patient interactions depend on the knowledge, skills, preferences, perceptions, attitudes and prejudices of both patient and health care provider
[15]. Physicians are expected and expect themselves not to judge patients on their
social class and above all, not to treat patients differently because of their sociodemographic characteristics [16].
Paper five presents the results of a qualitative study on the influence of the socioeconomic status of the patient on the perception, attitude and clinical decision
making of the GP and the health outcomes for the patient. There seems to be a
difference in the perception and attitude of GPs towards patients from lower social
classes according to the number of patients with a low SES visiting the practice.
All physicians agree that working with low SES patients takes more time, is often
beyond the control of the GP and can lead to frustration. How GPs handle these
feelings seems to depend on the number of low SES patients visiting the practice.
GPs with occasional contacts with patients from low SES perceive working with
low SES patients more often as a positive challenge. They take more time for these
patients and invest more energy (for example: more house visits, distribution of
free samples of medication, helping with paperwork,…). They perceive their low
SES patients as loyal and thankful. However, among GPs who have very often
contact with patients from low SES, frustration can lead to a fatalistic view and
prejudices. Next to the differences in attitude and perception, there are also differences in the decision making process and the health outcomes according to the
number of contacts with low SES patients. All physicians acknowledge that they
change their clinical decisions according to the social class of the patient. Those
with occasional contacts with low SES people reported that the changes were made
in order to enhance the health outcomes for the patient, while those with frequent
contacts were not always sure that their changes in decision led to better health
outcomes for the patient. These results stress the challenges for a GP when caring
for patients with low SES. GPs feel caught between delivering a good standard of
155
Chapter 4: Discussion
care and tailoring the care according to the needs and possibilities of the patients.
Sometimes delivering high quality care seems not possible due to a lack of (financial) resources (paper 5).
Box 4:What this thesis adds
•
The specialist is not the doctor of the higher-income people but the doctor
of the higher educated people. While the GP is not the doctor of the lowerincome people, but the doctor of the lower-educated people. These findings
indicate that the Belgian health care system is financially accessible, but still
has other access issues related to the educational level of the patient.
•
Low-income people suffering from bad health, those suffering from a severe
depression and those with moderate or low trust in their GP have a higher
risk of postponing a visit to a GP. People not able to cope with their monthly
income do not have a higher risk of postponing a visit to a GP.
•
A universal health care approach for homeless people, with active guidance
by social workers, seems to be far more effective than a selective setting
focusing solely on that specific population. This universal approach leads
to less stigmatization and labeling than a selective categorical approach,
leading to a higher use of these services.
•
The social gradient in doctor-patient communication persists over time,
where patients from lower social classes receive less socio-emotional talk,
a more directive and less participatory consultation style characterized by
less involvement in treatment decisions, lower patient control over communication, less diagnostic and treatment information and more physical
examinations.
•
The attitude and decisions of GPs toward patients from lower social classes
depend on the number of contacts physicians have with this population
group. GPs with occasional contact with patients from low SES take more
time for these patients, invest more energy and see it as a positive challenge.
They make changes in their clinical decisions, but these changes are made
in order to enhance the patients’ outcomes. However, when the number
of low SES patients is too large, GPs say they are not always capable to
maintain providing good quality care. They have the feeling that the changes
they make in their decisions are not always in favor of the outcomes for the
patient.
156
Chapter 4: Discussion
4.2 Conclusion
In order to provide equitable primary health care, equal access, equal treatment and
equal outcomes for patients in equal needs is essential [17].
4.2.1 Equal access for equal need
Since 2007, a set of policy measures are taken in Belgium to strengthen the accessibility of the health system, to assure health care quality and to maintain the
financial sustainability of the system [18]. The studies in this doctoral thesis confirm
the strengths of the Belgian health care system in its accessibility.
First of all, the health care system in Belgium does not create huge financial barriers:
(1) low income people in Flanders who have the feeling not being able to manage
with their available income do not postpone more often primary health care than
those having the feeling being able to cope with their income; (2) homeless people
in Ghent do find their way to the primary care centers, which contrasts the findings
from other countries (3) low-educated people find their way to primary care.
Belgium has already come a long way in reducing the financial barriers towards
health care. Looking at primary care, there is the reduced co-payment for the less
privileged, the maximum bill limiting the health care expenses, the third-party system, the introduction of the capitation system; the preferential reimbursement,….
However, the success of the primary health care for homeless people is not solely the
result of a low financial threshold but also of the active guidance by social workers
towards the primary health care system.
In contrast to these positive results concerning the financial access, there still seems
to be inequity on the other dimensions of access to health care: (1) lower educated
people have a higher likelihood of consulting a GP compared to higher educated
people, while higher educated people have a higher likelihood to consult a specialist
compared to lower educated people. These results persist even after taking into account patients’ health need; (2) low-income people with no complete trust in their
GP tend to postpone more often a needed medical care visit compared to people
who completely trust their GP.
These inequities could be explained by cultural barriers such as language barriers
and miscommunication between the patient and the health care provider. Lower
educated persons might not always understand the things a specialist explains or
157
Chapter 4: Discussion
they are afraid of being labeled as not smart or being stigmatized. But there is also
often a gap between the priorities of a low SES patient and those of a health care
provider. Often people from lower social classes focus on getting through the day,
providing food for the children, finding shelter… instead of caring for their own
health problems [19].
Next to these communication barriers, there are also practical barriers (for example
finding child care or transportation), the organization of the health care system, the
attitude of the health care provider and the doctor-patient relationship. Having trust
in the GP leads to a more efficient and longitudinal health care [13, 14]. In order
to develop a trust-creating environment, a good doctor-patient communication
and a regular source of care are essential components. Having the opportunity to
visit the same GP, who knows your medical history, but also your personal strains
and worries, who you feel comfortable to talk to and who you can trust adds to the
quality of the delivered health care.
158
The results indicate that primary care favors access to care for the population in
general and vulnerable populations in particular. By taking on a coordinating role,
primary care can counteract the current fragmentation of health care by guiding
patients through the system where necessary [20]. Furthermore, a gate-keeping
system could even strengthen these effects.
Finally, one of our studies indicates that a universal approach for specific population
groups, such as the homeless people, seems to be far more effective than a selective
setting focusing solely on that specific population. This universal approach leads to
less stigmatization and labeling than a selective approach, leading to a higher use
of these services. Moreover, it may contribute to more social cohesion in the local
community.
4.2.2 Equal treatment and equal outcomes for equal need
Next to some inequities in the access to health care, this thesis illustrates inequities
in treatment and outcomes of health care: (1) doctors communicate differently
according to the social class of the patient (lower SES patients receive less socioemotional talk, a more directive consultation style, receive lower patient control,
less diagnostic and treatment information,…); (2) the perception and attitude of
GPs working with low SES patients varies according to the number of contacts
with these patients: GPs with frequent contacts feel more fatalistic than GPs with
occasional contacts; (3) GPs change their clinical decisions according to the social
Chapter 4: Discussion
class of the patient; (4) the outcomes of these changes in decision-making always
seem to favor the low-SES patient.
It is important to draw special attention on these findings. First of all, there is the
aspect of the reciprocity of the communication: the doctor might communicate
different according to the social status of the patient, but also the patient may communicate different according to their social class. Patients from lower social classes
seem to exercise less control on the consultation than patients from higher social
classes. Patients from lower classes often have lower levels of health-literacy (the
degree to which persons have the capacity to obtain, process and understand basic
health information and services needed to make appropriate health decisions), a
lower sense of personal control and often feel not capable to interact during the
consultation [21, 22]. Besides teaching communication skills to GPs and providing
attitude-training (e.g. through early and repeated exposure of students in undergraduate curriculum to people living in poverty [23]), it is important to empower
the patients towards more self-efficacy and towards learning how to express their
concerns and preferences [24]. However, this empowerment should include the
capabilities and perspectives of the patient: it is important that a GP empowers a
patient, but it is even more important to empower a patient to a degree he/she desires.
Secondly, GPs working occasionally with low SES patients said to try harder when
working with these patients and to make changes in their decisions in order to
improve the health outcomes for these patients. This can enhance the quality of
the delivered care (medication, referring, tests,…). However, trying too hard for
these patients can lead to positive (health) outcomes on short term, but can lead to
negative (health) outcomes on long term. For example: if the GP always makes the
appointments with a specialist or makes arrangements for medications or always
does home visits, the patient never “learns” to do it himself. This can lead to passive
patients in the long run with even lower levels of health-literacy and interaction.
Guiding patients in the health care process, is more intense in the beginning, but
might lead to better self-efficacy and better health outcomes for the patient (health)
and lowers the long term work burden for the GP.
Thirdly, physicians working frequently with low income people report more often
frustrations which can lead to prejudices on the one hand, and a fatalistic outlook
on the other. This might result in a less adequate treatment and less quality of care,
leading to worse health outcomes for the patient. But these feelings also form a
higher risk of burn-out for the doctors. In figure 9 we illustrate a hypothesis on
159
Chapter 4: Discussion
the quality of care and on the need for additional resources when working with
low SES patients. A GP needs a certain number of patients with low SES in their
practice in order to give good qualitative care. However, when caring for too many
low SES patients (critical number), it seems not possible to maintain this high
standard of qualitative care. Providing physicians with additional resources (financial,
administrative,…) could help them to maintain good quality of the delivered care
for a larger number of low SES patients. In Belgium, this critical number might
be highly context dependent. For example: physicians working in an area with a
shortage of GPs, an area with a high population density or in a deprived area can
have the advantages of the Impulseo I fund (grant interest-free loans and subsidies).
With these additional resources they can improve access and maintain the quality
of care for social vulnerable population groups in the population. In order to increase the critical number even further, other, probably non-financial, resources will
be needed (e.g. administrative support, organizational, multidisciplinary team…).
Quality
160
Additional
resources
Critical
number
N° of
patients with
low SES
Figure 9: Additional resources supporting physicians working with low SES patients.
Chapter 4: Discussion
4.3. What this thesis could not add: suggestions for future
research
It is important when doing research on the inequity in health care use, that accurate
and valid data are used. We have showed that it is possible to link registered medical
utilization data with data coming from Health Interview Surveys. We suggest that
this is implemented as a routine in survey-analysis. However, we noticed that people
are reluctant to give information on their income and therefore income is not valid
as a measure for socioeconomic status. Including recorded information on income
might add to the validity of the results. These data for Belgium are available in the
“Datawarehouse Arbeidsmarkt” (DWA). Furthermore data on health care need in
the Health Interview Survey is also very subjective. A possibility for overcoming this
issue could be by linking to data coming from Health Examination Survey (HES).
The HES contains high quality data on the most important health indicators (eg.
diabetes, cholesterol, high blood pressure,…). However, HES data for the Belgian
population are not yet available. Another possibility is using the “Permanente
Steekproef ” from the “Inter Mutualistisch Agentschap” (IMA) containing registered
medical utilization data. Linking registered medical utilization data with data from
the DWA and HES could lead to very accurate data and possible new findings on
the equity in health care use in Belgium.
When striving for equity in health care use, it is important not to lose sight of the
quality of care. It has no use striving for the same treatment for all in equal need,
when this treatment does not fulfill the quality issues. Receiving high quality of care
is a fundamental right of every individual. This includes good access to health care
facilities, effective care according to the latest evidence, efficient, well-organized and
safe care processes, and, most of all, care directed to the needs of patients whatever
their demographic background [25]. Nevertheless, there still are disparities in the
quality of health care delivered to different socioeconomic groups in several studies
and countries. A study on socio-economic disparities in health care quality in four
countries, each with a different health system (Canada, England, New Zealand and
the United Sates), found that disparities in a variety of quality indicators persist.
This underscores the importance of further exploring the quality issues outside the
health care system [26].
When studying quality of care, one of the challenges is to develop a valid instruments which captures the perception of quality of the delivered care on the patients’
side as well as on the physicians’ side. For example, in this thesis the study on the
161
Chapter 4: Discussion
influence of patient’s SES on the attitude and clinical decision making of the doctor
shows some interesting results. In order to verify these results, a quantitative study
on the influence of patient’s SES on the attitude, decision making process and the
impact on the quality of care is needed. The challenge is to develop a comprehensive instrument that measures attitude as well as decision making and quality of
care. Quality of the services in primary care covers a wide range of dimensions: the
prescribing behavior, the diagnosis and treatment, the managing of chronic disease,
mental health care, maternal and child care, health promotion and preventive care
[27]. Furthermore, it is also important to take into account the perception of the
patients in terms of satisfaction with the delivered care, perception of quality and
satisfaction with the outcomes of the delivered care.
162
One of the upcoming challenges in providing equitable health care is inequity by
disease. There is an increasing fragmentation of healthcare quality programs, which
often focus on specific groups of patients or diseases. Guidelines may unintentionally
exacerbate this vertical ‘disease management’ approach, leading to fragmentation
of care and a reductionist approach (treat-the-target instead of treat-the-patients).
In that way a new inequity can be created: if the patients does not suffer from a
‘targeted’ disease, they are effectively denied care. Therefore, a paradigm-shift from
“problem-oriented” towards “goal-oriented” care is needed, reorienting the care
towards the goals formulated by the patient [28-30].
When studying the effect of the primary health care system on the health care use
of specific population groups, it is important to use the correct reference population.
For example, in this thesis the study on the health care use of homeless people is
restricted to Ghent. In order to evaluate the effects of a universal health care system
with active guidance, we need to compare the homeless populations living in areas
with a universal health care system to other homeless populations living in areas
with a different, more traditional, health care approach for homeless populations.
Furthermore, the results of this paper only apply to homeless people residing in
Ghent who make use of the homeless centers and shelters in Ghent. This study does
not contain information on the homeless population living on the street who do
not find their way to the shelters. Including this population could lead do different
results according to their (primary) health care use.
Finally, this thesis aims to study the equity in primary health care use in Belgium
in terms of equal access, equal treatment and equal outcomes for patients in equal
need. This work should be considered as a starting point for a more profound study
Chapter 4: Discussion
on equity in the health system in Belgium. A future step could be to evaluate the
equity in primary health care by studying the Belgian primary health care system
in an international context. Some studies already focus on establishing a sustainable
health information and knowledge system on the state and development of primary
care systems in Europe. There is the PHAMEU (Primary Health Care Activity
Monitor for Europe) that monitors the degree of development of primary care
systems by means of a measurement instrument that is applicable to all national
situations in Europe and that is able to capture the essential elements of primary
care. There is also QUALICOPC (Quality and Costs of Primary Care study) which
focuses on equity, avoidable hospitalizations, healthcare costs and identification of
good practices. Nevertheless, in order to counteract the large amount of studies
coming from the US, more European studies on the effect of primary care on tackling health inequities are needed.
4.4. Policy and Practice implications
In order to achieve equity in health care utilization, action is needed on different
levels.
Policy level
Policy plays a crucial role in optimizing the (access to) health care.
First of all, the Belgian health care system appears to have a relatively low financial burden in primary care for patients of lower social class thanks to the several
measures taken. However, the adaption of some financial measures such as third
payer system, preferential reimbursement, maximum bill ... depends on the one
hand on the knowledge of the patient but on the other hand also on the will and
knowledge of the GP. Additionally, some of these financial measures bring a lot of
paperwork for the patient and the GP. In order to tackle the inequity in primary
health care, it is important to strive for a primary health care system without any
financial barriers. This is possible by means of two parallel systems. On the one hand
by adapting the capitation system, the financial burden is nearly non existing. In the
capitation system, the patient has to be registered with a GP or a group of primary
care providers consisting of e.g. GPs, nurses, physiotherapists,... and does not have
to pay for the consultation. On the other hand, for practices not working with the
capitation system but on a fee-for-service basis, adapting the third-party payment
should be generalized and there needs to be an automatic attribution of the financial
163
Chapter 4: Discussion
measures such as the OMNIO and the third-party system for vulnerable people.
This automatic attribution could help lowering the feelings of stigmatization for
the patients and help reaching the vulnerable population groups.
164
GPs working in deprived areas and with a vulnerable population should get additional support financial as well as practical. In Belgium there are the Impulseo funds.
Impulseo I was created to grant interest-free loans (up to 15.000 €) and subsidies
(of 20.000 €) to doctors starting a GP practice in “deprived urban areas” or areas
with a shortage of GPs, or in areas with a population density of less than 125 per
km² and with less than 120 GPs per 100.000 population. Also an additional loan
was provided to self-employed GPs and free administrative assistance was offered
during the first 18 months following the start of the practice. Already 5 % of active
GPs has used this procedure [18].
As the Impulseo funds focus on area characteristics, but not on individual practices,
GPs working with a lot of low social class patients in a non-Impulseo area are left
out of the loop.
A possibility of tackling this problem is the principle of weighted financial mechanisms, where GPs working with a deprived population get a higher share. This
system is already successfully applied in the Netherlands (achterstandsindex) and
in the UK ( Jarman underprivileged area-score, Townsend poverty-index) [31].
It is important to have a universal primary health care system, that is easily accessible at any time for every person. In this universal approach, primary care could
function as the gate keeping system towards secondary care for new health problems
in order to counter the inappropriate use of specialist services and to avoid cost of
high technological tests.
Furthermore, no health care delivery system, even if it scores high on accessibility
and quality, can tackle the diseases related to poverty on his own [32]. Especially
when there are clear social inequities by disease and health care use, intersectoral
action on national and on community level, is essential to redress these inequities
[32-34]. This includes working together with e.g. nurses, dietician, physiotherapists,
but also agriculture, education, housing,… Community Health Centres already
provide a multidisciplinary team, including a nurse, a dentist, physiotherapist,….
But this is also important and possible for GPs not working in Community Health
Centres. Solo-, duo- or group practices can work locally together with nurses, dietician, social workers etc. Collaborating with specific programs and investing in team
building across several sectors can enable the primary care team in a community to
Chapter 4: Discussion
play an important role in the multi-level intersectoral initiative [30, 35]. Providing
additional resources to establish such a cooperation could especially be helpful for
the smaller GP practices such as the solo- and duo-practices.
This coordinating role is a key feature of good quality primary care ensuring that
patients see the most appropriate health care professional for their particular problem. General practice can fill this pivotal role if the structural conditions allow it.
Developing a team around the patients with all kinds of health professionals ( nurses,
dentist, physiotherapist, dieticians,…) will benefit the quality of care. By managing
the interface with other specialties the discipline ensures that those requiring high
technology services based on secondary care can access them appropriately [36].
Furthermore there is a need to harmonize the healthcare and welfare sectors in
first line in Belgium (horizontal integration) in order to provide a better interaction
between health care and welfare providers. An integration of healthcare and welfare
can lead to a more targeted approach towards the patient, keeping in mind his/her
financial and personal situation. However, to establish such a cooperation, action is
needed on several levels: education of health care and welfare providers, creating a
uniform registration and classification system, … To fulfill this achievement should
be a medium-term priority.
Practice level
The findings that the doctor’s communicative behavior, treatment and decision
making is related to the social class of the patients has important implications for
the daily practice of the doctor. Doctors need to be aware of the differences in attitude, information giving and involving patients from lower social classes in the
consultation, as well as of the upstream causes of these differences [37]. But above
all, doctors cannot lose sight of the perception and preferences of the patient. It is
important to empower a patient and involve them into the consultation to a degree
they wish. Therefore schools and universities training doctors, should provide communication skills and attitudes training on low SES patients, so that doctors can
learn how to handle this difficult balance.
This stresses the importance of medical schools to become socially accountable.
Medical schools cope with a different set of challenges: improving quality, equity,
relevance and effectiveness in health care delivery, reducing the mismatch with
societal priorities, redefining roles of health professionals and providing evidence of
impact on people’s health status. To address these challenges, a Global Consensus
165
Chapter 4: Discussion
for Social Accountability of Medical Schools was developed. The Consensus consists of ten strategic directions for medical schools to become socially accountable,
highlighting required improvements to (1) respond to current and future health
needs and challenges in society, (2) reorient their education, research and service
priorities accordingly, (3) strengthen governance and partnerships with other stakeholders, (4) use evaluation and accreditation to assess performance and impact [38].
Physicians caring for low SES people seem to have difficulties finding the balance
between providing good quality of standard care and tailoring the care to the capacities and needs of low SES patients. Additional support should be given to GPs
caring for low SES people. Medical training focuses on adapting communication
behavior (such as explaining things in a non-medical way) to patients with low
SES. However it does not focus on the challenges and the personal and financial
constraints physicians perceive when working with patients from low SES. Additional training, supervision, and (psychological) coaching could support physicians
working with low SES patients.
166
This stresses the importance of translational research, where the results of a research or a study are adapted in practice by local and global communities. In order
to improve health and reduce health-care disparities locally and globally, there
needs to be a continuum that spans discovery and translational science to provide
integrated care delivery and improved global health. New organizational structures,
external partnerships, research priorities, models of education, care delivery and
investments in institutional information systems can make the achievement of this
goal possible [39].
A new generation of educational reform is now needed. It should be a system based
on improving the performance of health systems by adapting core professional
competencies to specific contexts, while drawing on global knowledge [40].
A key role for the discipline of primary care is to provide advocacy, protecting
patients from the harm which may ensue through unnecessary screening, testing
and treatment, and also guiding them through the complexities of the health care
system [41]. The GP continues to serve as the advocate for the patient regardless
of the level of care within the system which the patient requires. Advocacy by the
general practitioner also includes working with government and private authorities
to maximize equitable services to all members of society [42].
Having in mind the goals of Flanders 2020 on establishing more group practices and
Chapter 4: Discussion
the importance of providing longitudinal and a regular source of care, it is important
for group practices that they could work out a system that helps patients always
to see their ‘personal GP’ if possible. Some Community Health Centers in Ghent
already apply such a system. When a patient wants to see a doctor, the receptionist
can see which GP is their regular GP and make an appointment with that GP.
This system is quite efficient, because patients often do not know the consultation
hours of their GP, or they do not dare to ask it, or do not remember the name of
their ‘personal doctor’.
Finally, it will be of utmost importance that every provider integrates continuously
a professional ethical approach, witnessing that health is a fundamental human
right that should be put in practice in a socially just and universal health system.
Patient level
Patients should be informed, taking into account the possible cultural barriers,
how the health care system is organized and how they can make use of the system in the most adequate way. Patients need to know where to go for a particular
health care problem, but they also need to know where they can find this kind of
information. Furthermore it is important to empower patients through education
and enhance their self-efficacy. This includes empowering people to develop their
own solutions, helping them to disseminate the lessons they have learned and
joining forces with them in showing that the competences and skills necessary to
bring about change are within reach [43]. It has been showed that interventions to
increase the participation of patients with low education, obtain a good response
and lead to measurable and clinically important improvements in health outcomes
[44]. However, we should be careful not to “blame the victims”. On the one hand,
capitalizing the relationship of trust is very important. Yet very often GPs have
difficulties to contextualize the condition of the patients. So integrating health and
social welfare is important in order to cope with this challenge. Furthermore, the
context (area deprivation, pollution, job,…) should be integrated in the electronic
patient file so that the physician and primary health care workers are able to relate
possible conditions to the context patients live in.
167
Chapter 4: Discussion
References
168
1.
Van der Heyden JH, Demarest S, Tafforeau J, Van Oyen H: Socio-economic differences in the utilisation of health services in Belgium. Health Policy 2003, 65(2):153-165.
2.
Bongers IM, van der Meer JB, van den Bos J, Mackenbach JP: Socioeconomic differences in general practitioner and outpatient specialist care
in The Netherlands: a matter of health insurance? Soc Sci Med 1997,
44(8):1161-1168.
3.
van Doorslaer E, Masseria C, Koolman X: Inequalities in access to medical
care by income in developed countries. CMAJ 2006, 174(2):177-183.
4.
Droomers M, Westert GP: Do lower socioeconomic groups use more
health services, because they suffer from more illnesses? Eur J Public Health
2004, 14(3):311-313.
5.
Hwang SW: Homelessness and health. CMAJ 2001, 164(2):229-233.
6.
Morris DM, Gordon JA: The role of the emergency department in the care
of homeless and disadvantaged populations. Emerg Med Clin North Am
2006, 24(4):839-848.
7.
Kushel MB, Vittinghoff E, Haas JS: Factors associated with the health care
utilization of homeless persons. JAMA 2001, 285(2):200-206.
8.
Power R, French R, Connelly J, George S, Hawes D, Hinton T, Klee H,
Robinson D, Senior J, Timms P et al: Health, health promotion, and homelessness. BMJ 1999, 318(7183):590-592.
9.
Drieskens S, Van der Heyden J, Hesse E, Gisle L, Demarest S, Tafforeau J:
Gezondheidsenquête België, 2008. Rapport V - Sociaal-economische ongelijkheden in gezondheid. In.; 2010.
10. Gelberg L, Gallagher TC, Andersen RM, Koegel P: Competing priorities
as a barrier to medical care among homeless adults in Los Angeles. Am J
Public Health 1997, 87(2):217-220.
11. Whitehead M, Hanratty B: Health care for rich and poor alike. In: Accessing health care Responding to diversity. edn. Edited by Healy J, McKee M.
Oxford: Oxford University Press; 2004: 71-88.
12. Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR: Emergency department use among the homeless and marginally housed: results from a
community-based study. Am J Public Health 2002, 92(5):778-784.
13. Bensing J: Doctor-patient communication and the quality of care. Soc Sci
Chapter 4: Discussion
Med 1991, 32(11):1301-1310.
14. Jensen JD, King AJ, Guntzviller LM, Davis LA: Patient-provider communication and low-income adults: age, race, literacy, and optimism predict
communication satisfaction. Patient Educ Couns 2010, 79(1):30-35.
15. Goddard M, Smith P: Equity of access to health care services: theory and
evidence from the UK. Soc Sci Med 2001, 53(9):1149-1162.
16. van Ryn M, Burke J: The effect of patient race and socio-economic status
on physicians’ perceptions of patients. Soc Sci Med 2000, 50(6):813-828.
17. Whitehead M, Dahlgren G: Levelling up (part 1): a discussion paper on
concepts and principles for tackling social inequities in health. In.: WHO
collaborating Centre for Policy Research on Social Determinants of Health,
University of Liverpool; 2006.
18. Gerkens S, Farfan M, Desomer A, Stordeur S, De Waroux M, Van de Voorde C, Van de Sande S, Leonard C: Het Belgische Gezondheidssysteem in
2010. In. Edited by research HS. Brussel: Federaal Kenniscentrum voor de
Gezondheidszorg (KCE); 2010.
19. Willems S: The socio-economic gradient in health: a never-ending story?
A descriptive and explorative study in Belgium. Ghent: Ghent University;
2005.
20. Schafer W, Groenewegen PP, Hansen J, Black N: Priorities for health services research in primary care. Quality in primary care 2011, 19(2):77-83.
21. Parker RM, Gazmararian JA: Health literacy: essential for health communication. Journal of health communication 2003, 8 Suppl 1:116-118.
22. Beck RS, Daughtridge R, Sloane PD: Physician-patient communication
in the primary care office: a systematic review. The Journal of the American Board of Family Practice / American Board of Family Practice 2002,
15(1):25-38.
23. Art B, De Roo L, Willems S, De Maeseneer AJ: An Interdisciplinary Community Diagnosis Experience in an Undergraduate Medical Curriculum:
Development at Ghent University. Academic Medicine 2008, 83(7):675683.
24. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J:
Socio-economic status of the patient and doctor-patient communication:
does it make a difference? Patient Educ Couns 2005, 56(2):139-146.
25. Grol R, Dautzenberg M, Brinkman H: Quality Management in Primary
Care. European Practice Assessment. In. Gütersloh: Verlag Bertelsmann
Stiftung; 2004.
169
Chapter 4: Discussion
26. Hussey P, Anderson G, Berthelot JM, Feek C, Kelley E, Osborn R, Raleigh
V, Epstein A: Trends in socioeconomic disparities in health care quality in
four countries. Int J Qual Health Care 2008, 20(1):53-61.
27. Kringos DS, Boerma WG, Hutchinson A, van der Zee J, Groenewegen PP:
The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Serv Res 2010, 10:65.
28. De Maeseneer J, Boeckxstaens P: Care for noncommunicable diseases
(NCDs): Time for a paradigm-shift. World Hospital and Health Services
2011, 47(4):30-33.
29. De Maeseneer J, Roberts G, R., Demarzo M, Heath I, Sewankambo N,
Kidd R, M., van Weel C, Egilman D, Boelen C, Willems S: Tackling
NCDs: a different approach is needed. The Lancet 2011.
30. Willems S, Christiaens T, Narayan T, B. M: Reducing Social Inequities in
Health - The role of primary health care.
31. Art B, De Maeseneer J: Forfaitaire betaling: een beter systeem voor patiënt
en huisarts. In.
170
32. Kotwani N, Danis M: Tackling the health-poverty nexus: primary
care medicine and intersectoral health action. J Gen Intern Med 2007,
22(11):1632-1633.
33. Starfield B: Pathways of influence on equity in health. Soc Sci Med 2007,
64(7):1355-1362.
34. De Maeseneer J, Willems S, De Sutter A, Van de Geuchte M, Billings M:
Primary health care as a strategy for achieving equitable care: a literature review commissioned by the Health Systems Knowledge Network. In.; 2007.
35. WHO report 2008: Primary health care now more than ever. In.; 2008.
36. Physicians funding and health care systems - an international perspective.
In: A summary of a conference hosted by the WHO, WONCA and RCPG
at St John’s College, Cambridge. Edited by Brown PS.
37. Epstein AM, Taylor WC, Seage GR, 3rd: Effects of patients’ socioeconomic
status and physicians’ training and practice on patient-doctor communication. The American journal of medicine 1985, 78(1):101-106.
38. Global Consensus for Social Accountability of Medical Schools [www.
healthsocialaccountability.org]
39. Dzau J, V., Ackerly D, C., Sutton-Wallace P, Merson H, M., Williams R,
S., Krishnan K, R., Taber C, R., Califf M, R.: The role of academic health
science systems in the transformation of medicine. The lancet 2009.
Chapter 4: Discussion
40. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P et al: Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.
Lancet 2010, 376(9756):1923-1958.
41. Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P: The European
Defenition of Genera Practice/Family Medicine. In. Edited by Europe W;
2005.
42. Bentzen G, B., Bridges-Webb C, Carmichael L, Ceitlin J, Feinbloom R,
Metcalf D, MCwhinney I, Rajakumar K: The role of the general practitione/family physician in health care systems: a statement from WONCA.
1991.
43. Ziglio E, Barbosa R, Charpak Y, Turner S: Health Systems confront poverty. Public Health Case Studies, no. 1. In. Edited by Organization WH.
44. Kaplan SH, Greenfield S, Ware JE, Jr.: Assessing the effects of physicianpatient interactions on the outcomes of chronic disease. Med Care 1989,
27(3 Suppl):S110-127.
171
172
Chapter 5
Dankwoord
173
174
Chapter 5: Dankwoord
Dankwoord
“Words do major things, they provide food for the mind and create light for understanding and awareness”
Er is geen moeilijker taak dan goed te bedanken.
De voorbije 4 jaar zijn een aaneenschakeling geweest van verschillende processen,
uitdagingen, gebeurtenissen, waarin telkens iemand je heeft bijgestaan, ondersteund, een duw in de juiste richting heeft gegeven,… Dit maakt het onmogelijk
om iedereen persoonlijk te bedanken. Daarom wil ik op voorhand zeggen in het
geval ik iemand vergeet: “jullie zijn allemaal ongelooflijk bedankt!”.
Enkele personen hebben de evolutie van “pas afgestudeerd” tot “het indienen van
een proefschrift” van dichtbij meegemaakt.
Prof. Dr. Willems, Sara, mijn eerste woord van dank gaat uit naar jou. Ik herinner
mij nog mijn sollicitatiegesprek. Een mooie, zonnige, zomerse dag. Ik was super
zenuwachtig! De week ervoor waren we op reis geweest naar Frankrijk. Daar had
ik de vacature waarschijnlijk 20 keer van voor naar achter gelezen, mijn Frans
geoefend en uitgezocht wat die DWA in godsnaam was.
Beginnen als doctoraatsstudent was dan ook een stap in het onbekende. De personen
die ik kende omschreven het als vier jaren van ware stress en uitputting.
Nu ik terugkijk op deze 4 jaren, dien ik hen ongelijk te geven. Het waren vier leerrijke jaren met, zoals het hoort, de nodige uitdagingen. Je hebt me gedurende deze
jaren geïntroduceerd in de wereld van wetenschappelijk onderzoek. Bij vragen of
moeilijkheden kon ik altijd bij je terecht. Je stimuleerde het zelfstandig werken en
gaf mij ook het vertrouwen dit te doen. Sara, ik wil je bedanken voor je geduld,
je nuchterheid in moeilijke omstandigheden, je opbouwende feedback, de steun,
en nog zoveel meer, maar vooral wil ik je bedanken voor de persoon wie je bent!
Jan, als co-promotor van mijn proefschrift bracht je altijd een nieuwe, frisse wind.
Wanneer ik niet goed wist hoe ik verder moest of moeite had met het interpreteren
van resultaten, dan bracht een discussie met jouw steeds licht in de duisternis. Ik
heb enorm veel van je geleerd tijdens de treinreizen naar Brussel, zowel op menselijk
als op wetenschappelijk vlak. Bedankt!
Daarnaast wil ik ook mijn bureaugenoten bedanken. Sarah, Maaike en Sofie, jullie
hebben het begin meegemaakt en hebben mij vaak geholpen in het organiseren van
175
Chapter 5: Dankwoord
het veldwerk en het zoeken naar creatieve oplossingen. Veerle, Annelien, Evelyne
en Wim, bedankt om het met mij uit te houden in de laatste maanden. Jullie raad
en aanmoediging heeft mij super geholpen! Annelien en Evelyne: bedankt om alles
nogmaals te lezen.
Ook alle collega’s van de vakgroep Huisartsgeneeskunde en Eerstelijnsgezondheidszorg wil ik bedanken. Claudine voor haar kennis Frans, Michèle voor de vele
praktische zaken, Lieselot voor haar organisatietalent, Karine en Emilienne voor
het helpen met de “cijfers”. Aan de “lotgenoten”: het valt echt mee!
Anja, bedankt om de lay-out van dit boekje en de uitnodigingen te verzorgen. Je
nauwkeurigheid en creativiteit heeft zeker zijn vruchten afgeworpen!
176
Daarnaast wil ik ook de co-auteurs bedanken voor de vruchtbare samenwerking:
Eleonora Bonte en Nele De Laender voor jullie ongelooflijke inzet, Tine Verdee,
Mieke Van de Walle, Bruno Art voor de dataverzameling en het concept van het
‘daklozen-artikel’, Inge Pasteels voor haar statistische kennis en input, Prof. Chantal
Van Audenhove, Prof. Koen Hermans, Ann DeSmet en Annelien Poppe als medeauteurs en collega’s bij het KANS onderzoek. Dr. Stéphanie De Maesschalck en
Prof. Myriam Deveugele voor hun communicatieve inbreng.
Een speciaal woord van dank gaat uit naar alle geïnterviewde artsen, patiënten, de
spoeddiensten van de ziekenhuizen, de OCMW’s, CAW’s en de Diensten Maatschappelijk werk van het Ziekenfonds. Daarnaast wil ik ook alle participerende
Hogescholen en studenten bedankten voor hun bijdrage aan de dataverzameling.
Dankzij jullie is dit proefschrift een feit.
Dit proefschrift zou eveneens niet mogelijk geweest zijn zonder de steun van het
Steunpunt Welzijn, Volksgezondheid en Gezin.
Een bijzonder woord van dank gaat uit naar mijn ouders. Ze hebben me steeds alle
kansen gegeven en hebben me gesteund in de keuzes die ik heb gemaakt. Wanneer
ik dringend wat hulp nodig had, stonden ze altijd voor me klaar.
Daarnaast wil ik ook Wouter bedanken. Je hebt deze vier jaar beleefd aan mijn
zijde. Het feit dat je eigenlijk niet zo goed snapte waar ik mee bezig was heeft
ervoor gezorgd dat ik mijn hoofd telkens kon leegmaken toen ik thuis kwam. Die
ontspanning en afleiding deden me goed.
“Alone we can do so little, together we can do so much”
Gent, 03 oktober 2012
Chapter 6
Curriculum Vitae
177
178
Chapter 6: Curriculum vitae
CURRICULUM VITAE
Evelyn Verlinde
Geboren te Roeselare op 8 december 1986
Opleiding
- 2004-2007
Bachelor Geneeskunde
- 2007-2008
Master in de gezondheidsvoorlichting en -bevordering
- 2008-2012
Doctoraatsopleiding Medische Wetenschappen
Getuigschriften
- 19/01/2009
Introductie voor tutoren in probleemgestuurd onderwijs
Docent: Prof. Dr. Anselm Derese, Voorzitter van het Centrum voor Onderwijsontwikkeling
Organisatie: Universiteit Gent
- 8/07/2009 -10/07/2009
Summer-course: three days of qualitative research in health care
Docent: Prof. dr. Paul van Royen, Department of General Practice, University
of Antwerp, Belgium
Organisatie: Universiteit Antwerpen
- 08/2009
Opleiding soft-warepakket Nvivo
Docent: Prof. dr. Paul van Royen, Department of General Practice, University
of Antwerp, Belgium
Organisatie: Universiteit Antwerpen
- 03/2010-05/2010
Mixed and Multilevel models
Master of Statistics
Organisatie: KULeuven
179
Chapter 6: Curriculum vitae
- 01/2011-02/2011
Statistische analyse met behulp van SPSS (2011)- gevorderden,
Docent: Prof. G. Van Maele
Organisatie: Cel biostatistiek Universiteit Gent
- 10/2010-12/2010
Effective Scientific communication
Docent. JL Dumont, Principae
Organisatie: Doctoral Schools
- 02/2011-04/2011
Presentation Techniques
Docent. JL Dumont, Principae
Organisatie: Doctoral Schools
180
- 05/2011
Multilevel Analysis for Grouped and Longitudinal Data
Docent: Prof. Dr. E.Goetghebeur
Organisatie: Centrum voor Statistiek
- 04/2011
Populair wetenschappelijk schrijven.
Docent: Ann de Ron
Organisatie: Doctoral Schools
Professionele loopbaan
- 01/09/2008-30/09/2010
Doctoraatsbeurs KANS onderzoek i.o.v. Steunpunt Welzijn Volksgezondheid
en Gezin
Vakgroep Huisartsgeneeskunde en Eerstelijnsgezondheidszorg, Universiteit
Gent
- 01/10/2010- heden
Assistent
Vakgroep Huisartsgeneeskunde en Eerstelijnsgezondheidszorg
Chapter 6: Curriculum vitae
PUBLICATIES
A. Artikels
A1. Artikels opgenomen in Science Citation Index, Social Science Citation
Index, Arts and Humanities Citation Index
1.
Verlinde E, Verdee T, Van de Walle M, Art B, De Maeseneer J, Willems S.
Unique health care utilization patterns in a homeless population in Ghent.
BMC Health Services Research. 2010; 10(242). IF:1.66
2.
Verlinde E., De Laender N, De Maesschalk S, Deveugele M., Willems S.
The social gradient in doctor-patient communication. Journal for equity in
health.2012,11:12. IF:1.30
3.
Verlinde E., Pasteels I., De Maeseneer J., Willems S. Socio-economic differences in the utilization of FP and specialist care: do patients form lower
social class visit more often a doctor when taking into account their higher
health care need? Annals of Family Medicine. Submitted. IF: 4.45
4. Verlinde E., Poppe A., DeSmet A., Hermans K., De Maeseneer J., Van Audenhove C., Willems S. Social differences in postponing a GP visit: Which
low-income patients are most at risk? Health and Social Care in the Community. Submitted. IF: 1.008.
5.
Verlinde E., Bonte, E. Willems, S. Socio-economic status of the patient:
does it influence the decisions of the GP? International Journal for Quality
in Health Care. Submitted. IF: 2.064
6.
DeSmet A, Hermans K, Verlinde E, Willems S, De Maeseneer J, Van Audenhove C. Integrated care in mental health: need for collaboration, communication and customisation. Psychiatr Prax. 2011;38.
A3. Artikels in nationale tijdschriften met leescomité, niet begrepen in (a1)
of (a2), chronologisch geordend
1.
B.
1.
Willems S, Verlinde E. Sociale ongelijkheid in gezondheid: een maatschappelijk onaanvaardbaar fenomeen. Terzake. November 2011;6; 5-12.
Andere
Verlinde E. Toegankelijkheid, betaalbaarheid en kwaliteit van de gezondheidszorg. In: De Sociale Staat van Vlaanderen. 2011. Noppe J., Vanderleyden L., Callens M. 203-206
181
Chapter 6: Curriculum vitae
C. Rapporten bestemd voor de verspreiding van wetenschappelijk werk
naar buiten
182
-
DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J. &
Van Audenhove, C. (Onderzoeksgroep KANS). Depressieve klachten en
suïcidaliteit in de (I)CAW en OCMW: onderzoek naar de ernst en de relatie tot armoede. Steunpunt Welzijn, Volksgezondheid en Gezin, 2010.
-
DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J. &
Van Audenhove, C. (Onderzoeksgroep KANS). Het hulpaanbod voor
mensen met depressieve klachten in (I)CAW en OCMW: beantwoordt het
aanbod aan de vraag? Steunpunt Welzijn, Volksgezondheid en Gezin, 2010.
-
Poppe, A., Verlinde, E., Willems, S., DeSmet, A., Hermans, K., Van Audenhove, C. & De Maeseneer, J. (Onderzoeksgroep KANS). Beschrijving van
de KANS steekproef: representativiteit, demografische en socio-economische kenmerken, gezondheidstoestand en zorggebruik. Steunpunt Welzijn,
Volksgezondheid en Gezin, 2011.
-
Willems, S., DeSmet, A., Poppe, A., Hermans, K., Verlinde, E., Van Audenhove C. & De Maeseneer, J. KANS, theoretische achtergronden en onderzoeksopzet. Steunpunt Welzijn, Volksgezondheid en Gezin, 2011.
Wetenschappelijke activiteiten
1. Lezingen op nationale congressen, symposia en colloquia
“De kwaliteit van de zorg vanuit het perspectief van de gebruiker (KANS)” (invited
session lecture)
Studiedag “In-Zicht”, Leuven
Steunpunt Welzijn, Volksgezondheid en Gezin, 02/12/2010
“Ongelijkheid in gezondheid: feiten, cijfers en aanbevelingen”
Ontmoetingsdag ‘Ongelijk gezond, een lokale aanpak.’
Provinciehuis Leuven, 14/06/2010
“Gebruik van huisartsenzorg bij financieel kwetsbare zorggebruikers (KANS)”
Studiedag “Wel-en Wee” Leuven
Steunpunt Welzijn, Volksgezondheid en Gezin, 28/10/2011
Chapter 6: Curriculum vitae
Posterpresentatie op internationale congressen
- Verlinde, E., Willems, S., Hermans, K., Van Audenhove, C., & De Maeseneer, J. (2010). The health care and welfare use of people living in poverty in
Flanders: the contribution of the neighborhood level. Poster presentation at
the ESHMS congress. Ghent 2010.
- Verlinde, E., Willems, S., Hermans, K., Van Audenhove, C., & De Maeseneer, J. (2010). Tales of the (un)expected: people living in financial difficulties
and their challenges, Poster presentation Regions for Health Network Conference. Genk, 8-9 november 2010.
- DeSmet, A., Hermans, K., Verlinde, E., Willems, S., De Maeseneer, J., &
Van Audenhove, C. (2010). The potential role of social services in providing
integrated care on mental health and welfare. Paper presentation Regions for
Health Network Conference. Genk, 8-9 November 2010.
Posterpresentatie op nationale congressen
- Verlinde, E., Poppe, A., Willems, S. en De Maeseneer, J. Gebruik van huisartsenzorg bij financieel kwetsbare welzijnszorggebruikers. Steunpunt WVG
studiedag “Wel en Wee in Vlaanderen”. Leuven, Oktober 2011.
- Verlinde, E., Poppe, A., Willems, S. en De Maeseneer, J. Sociaal kapitaal en
gezondheid. Steunpunt WVG studiedag “Wel en Wee in Vlaanderen”. Leuven, Oktober 2011.
- DeSmet, A., Hermans, K., Van Audenhove, Ch. Steunbronnen bij psychisch
onwelbevinden: veerkracht, sociale steun en ‘coping’. Steunpunt WVG studiedag “Wel en Wee in Vlaanderen”. Leuven, Oktober 2011.
- Poppe, A., Verlinde, E., DeSmet, A., Willems, S., Hermans, K., Van Audenhove, C., & De Maeseneer, J. De psychosociale en financiële impact van
chronische aandoeningen bij financieel kwetsbare personen. Posterpresentatie
tijdens de Steunpunt WVG studiedag “Wel en Wee in Vlaanderen”. Leuven,
Oktober 2011.
- Poppe, A., Verlinde, E., DeSmet, A., Willems, S., Hermans, K., Van Audenhove, C., & De Maeseneer, J. Sociaal kapitaal als buffer voor de negatieve gezondheidseffecten bij personen in een financieel kwetsbare situatie. Posterpresentatie tijdens de Steunpunt WVG studiedag “Wel en Wee in Vlaanderen”.
Leuven, Oktober 2011.
183