Low-Income Consumers Perspectives' on Determinants of Health Services Use

Key Implications for Decision Makers

A deeper understanding of factors that influence low-income consumers' use of health services will help policy decision makers create policies that are inclusive and present no barriers to access. They will also help managers to better identify the service needs of this population, to target and tailor services accordingly. This study identified patterns and determinants of health services use from the perspectives of Canadians living in poverty. It also identified actions that program managers and planners, policy makers, and the public can take to improve health care for low-income consumers. These actions include the following:

Service managers and program planners should:

  • Increase accessibility, including:
    • longer hours (including weekends)
    • less waiting
    • more free services
    • easier transportation and better co-ordination between services
    • remove bureaucratic barriers
  • Improve quality of service, including:
    • confidentiality
    • sensitivity training (for factors such as gender, poverty, unemployment)
  • Increase consumer participation
  • Communication better about services and people's entitlements to those services
  • Provide advocacy to navigate the system
  • Expand services:
    • dental, eyeglasses, extended health care, mental health, emergency rooms, physicians' services
    • also recreational, extracurricular, employment, and child care services)
  • Improve ways for the public to have input into service delivery for low-income people

Policy makers should:

  • Focus more on broad determinants of health and meet basic needs by:
    • increasing income levels, in ways such as guaranteed income, changing social assistance rates
    • providing good, affordable housing
    • improving subsidies for basic needs
  • Extend health care services and increase their quality
  • Expand the range of health, social and community programs, supports, and services
  • Focus more on broad determinants of health (such as housing, income, recreation)
  • Increase consumer participation in service delivery
  • Move past identifying problems and into actual policy change
  • Be more responsive to the needs of low-income people

The public should:

  • Communicate concerns to service providers, politicians and the media
  • Volunteer in community organizations
  • Contribute to meetings, elections and advocacy groups
  • Present a united voice

Executive Summary

The Context

A significant number of Canadians live in poverty. This is an issue of increasing importance to policy makers and service providers. Poverty affects health status and life expectancy, and limits activities. Poverty also affects health services use. This research is important to service managers and policy makers because of these factors, as well as factors relating to the organization of health services, the way services are distributed, and the gaps in knowledge about determinants of services use among the poor.

Despite growing evidence from Canadian studies on barriers to health services use, no study has looked into why and how low-income people use these services. This study therefore examined the patterns and determinants of health services use from the perspectives of Canadians living in poverty, with the view to informing programs and policies that address the factors influencing health services use by the poor. Research questions guiding this study were centred on low-income consumers' perspectives on the health services they access; factors influencing health services use; accessibility, quality, relevance and appropriateness of available health services; and how services, programs and policies could be altered and improved to meet their needs

Implications for Service Managers and Program Planners

Low-income people regard community agencies and services as essential for their health and well-being. However, they recommend:

  • improving the quality of services and behaviours of service providers
  • increasing accessibility and awareness about available services
  • enhancing existing services and making available additional (free) programs and services
  • establishing mechanisms to ensure consumer input
  • reducing barriers

Advocates, service managers and policy influencers spoke of the need to improve the role of agencies in the community, and to enhance the types of available services. Services could be enhanced by

  • better integration and coordination
  • allocation of more resources and funding
  • improvement of transportation and housing
  • making services more community oriented
  • expanding consumer participation
  • increasing opportunities for advocacy
  • staff sensitivity training

These participants' recommendations reinforced those of low-income people regarding increasing accessibility and quality of services.

Implications for Policy Makers

Low-income participants recommended direct courses of action to improve health services by:

  • increasing government funding to improve coverage
  • establishing more services for particular issues
  • improving accessibility.

Indirect courses of action suggested were:

  • more funding to reduce workloads in order to avoid burnout
  • services for specific groups
  • licensing doctors with foreign qualification
  • increasing income levels, subsidizing post-secondary education
  • making the systems less bureaucratic, and providing quality and affordable housing

Service managers and policy influencers focused on:

  • providing a guaranteed income
  • extending publicly accessible health care
  • increasing social assistance and welfare rates.
  • provision of quality affordable housing
  • increasing mental health and chronic care facilities
  • increasing integration and coordination of services
  • making services more client-oriented, enhancing accountability
  • increasing participation of low income people

Implications for the Public

The low-income participants recommended ways to improve service delivery ranging from individual to group action. Individual efforts include: completing surveys or participating in research studies, attending committee meetings, documenting concerns, using suggestion boxes, speaking with service providers directly, signing petitions, communicating with politicians, avoiding providers that do not show concern for clients, writing letters, running for boards, volunteering, voting in elections, participating in community activities (for example, big parent initiatives), making use of role models, and advocacy by higher-income people. Group actions suggested were: coming together as communities to present a voice, and uniting to elect representatives who relate to concerns of low-income people.

The Approach

This was an exploratory, descriptive and qualitative study of the determinants of health services use by low-income consumers. Three main sources of data were; socio-demographic data forms, individual interviews using interview guides (Phase 1), and focus groups (Phase 2). The study was also participatory in nature - trained low-income interviewers conducted interviews with low-income users of health services.

The Results

Many participants reported using some form of health services and/or community-based services to survive. Services were also viewed as a means to alleviate isolation and cope with stress. The main themes to emerge from the analysis of Phase 1 data include factors influencing utilization of and experiences with health services, and recommendations for improving services and changing policies. Diverse factors influenced use of a variety of agencies and services by having an impact on ability or desire to use services. Competence, confidentiality and the need to be self-reliant emerged as major factors influencing use of services. The ability of providers to listen to, understand, empathize with low-income people, and treat them with respect, influenced use of services. Access to services also depended on proximity, affordability, and convenience of services, knowledge of their existence, and inequity based on low-income status, racism, physical appearance, and the surrounding neighbourhood. Many of the responses revealed people's experiences with services, as well as needs for services that were met and those that were not. Participants mentioned informal (such as self-diagnosis/treatment) and formal strategies (such as religiosity) that they used to cope with everyday demands. Participants indicated that their low-income status left them with little choice of services to access.

In Phase 2 low-income focus groups reinforced the findings cited above. Participants highlighted the gaps in coverage of existing services. Apart from identifying services that do not meet their needs, participants also pointed out a variety of needed services that are not available. In discussing the action they had taken to address their concerns, participants mentioned corresponding with officials and attending meetings. Participants concurred that there was a need to promote awareness about poverty and create links between the poor and advocacy community organizations to communicate their messages.

The focus groups conducted with advocates, service providers, and policy makers supplemented and reinforced the interviews with low-income consumers. Disjointed policy making, the growing gap between rich and poor, government inaction on issues such as housing, mental and public health were cited as causes of poverty. At a policy level, impediments to quality service provision were identified such as a sluggish and overburdened system, difficulty moving past problem identification toward effective policy creation, and inequitable treatment of low-income people. At a services level, participants spoke of problematic service provider behaviours, high service provider turnover due to burnout, and long waiting lists. The ineffectiveness of agencies and their current practices in dealing with poverty compounded these barriers. There was unanimous agreement that strategies for improving health should be more preventive, focusing on systemic changes that address major determinants of health such as income and housing. Other strategies recommended were: intersectoral action (at higher levels), better integration and co-ordination of services at the community level, staff sensitivity training, redefining poverty, increased accessibility and promotion of (free) programs, and greater consumer input.