Low-income Canadians’ experiences with health-related services: Implications for health care reform☆
Introduction
This study explored low-income Canadians’ experiences with health-related services1 by drawing on the perspectives of low-income people, service providers, and managers, advocacy group representatives, and senior-level public servants. Debates about the funding and delivery of health care services have long captured the attention of Canadians [1], [2]. In recent years, these debates have centred around, and been shaped by, several federal and provincial health care reform commissions (e.g., the Commission on the Future of Health Care in Canada [3], Standing Senate Committee on Social Affairs, Science and Technology [4], Alberta Premier's Advisory Council on Health [5], Saskatchewan Commission on Medicare [6], Quebec Commission on Health and Social Services [7], National Forum on Health [8]). Even though Canadians have expressed concern in recent years that the health care system is deteriorating [9], [10], the majority (55–60%) continue to assign fairly positive ratings to the overall quality [10], [11], [12]. Furthermore, few Canadians (13%) report that they did not receive needed health care in the previous year [13]. Nonetheless, the vast majority (87%) of Canadians also believe that there is a need for all levels of government to renew the health care system by acting on the findings from studies [14].
While the outcomes of health care reform are relevant to all Canadians, government decisions affecting the cost, delivery, and access to health care services have particularly significant implications for low-income Canadians. People living with low incomes are less healthy and have more medical conditions and symptoms of illness and disease than their counterparts with higher incomes [15], [16], [17]. Consequently, low-income people tend to have greater health care needs than do higher-income people. However, despite their needs, low-income Canadians are more likely than other Canadians to report that they did not receive needed health care in the past year [13], [18]. In sum, it seems that low-income Canadians have much to gain – or lose – from changes that are made to health care in Canada.
Researchers have examined the relationships between income and the use of health care services [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37] and the barriers to health care experienced by low-income Canadians [38], [39], [40], [41], [42], [43], [44], [45]. These studies have provided important descriptive information about low-income people's use and non-use of health care services. However, little is known about factors that influence low-income people's decisions regarding health care service-use, which is important information for policy makers to consider as they explore new strategies and arrangements for funding, administering, and delivering health care. In addition, previous studies have focused primarily on treatment-focused and preventive services offered by health care professionals. Researchers have yet to examine a broad range of community-based services, supports, and programs that low-income Canadians use to be healthy (e.g., recreation programs, food banks, support programs). Furthermore, there is a lack of research that explores these questions from the perspectives of low-income Canadians. To begin to address some of the gaps in previous research, we conducted a study on low-income Canadians’ experiences with health-related services. The specific objectives of our study were to:
- (1)
identify the health-related services that low-income people use to attain, maintain, and promote their health;
- (2)
determine the factors that influence low-income people's use of health-related services;
- (3)
identify improvements that should be made to policies, programs, and services to meet the health needs of low-income Canadians.
A determinants of health perspective [46], [47], [48], [49], [50] provided a theoretical framework for our study. According to this perspective, health is a positive state of physical, emotional, and spiritual well-being that is integral to quality of life. It is not only an end but also a resource that provides people with opportunities to make choices and to lead socially satisfying and economically productive lives [50], [51]. Another key premise of a determinants of health perspective is that health care provided by physicians and other health care professionals is only one of many factors that influence health. Health is also influenced by a broad range of community-based services, supports and programs, and by relationships between and among people's personal health practices and coping skills, living and working conditions, and socio-economic, political, and physical environmental contexts [15], [17], [46], [47], [48], [49], [50], [52], [53], [54], [55]. Accordingly, a determinants of health perspective casts our attention beyond the narrow range of health care services that low-income Canadians use when they are ill to a broad range of services, supports, and programs that they use to maintain and promote their health—what we refer to as health-related services. Prior to describing the methods and findings from our study, we offer both a brief overview of the health-related services that are available to low-income people in Canada and a summary of recent research findings about health-related service-use by low-income Canadians.
Like all residents in Canada, low-income people have access to publicly funded physician and hospital services without direct charges [56].2 The provision of these services is coordinated by provincial/territorial health care plans, and in most provinces/territories, local health regions are responsible for delivering health care services. In addition to a broad range of physician and hospital services, provincial health care plans tend to include limited coverage for chiropractic care, physiotherapy, and podiatry, whereas prescription medications, routine dental care, and counselling by psychologists are not covered. In addition, there is variation regarding the extent to which each provincial/territorial health care plan covers some services, such as eye care (e.g., optical examinations). For instance, in Alberta, yearly eye examinations are only covered by the provincial health care plan for children and seniors; adults between 19 and 64 years old are charged Canadian$ 55 [58]. In contrast, the health care plan in Ontario covers the cost of eye examinations for children and seniors every year and for adults between 20 and 64 years old every 2 years [57].
Some groups of low-income Canadians are eligible for comprehensive health care benefits that allow them to access some services beyond those provided by provincial health care plans, including prescription medications and dental care. For instance, the federal department of Indian and Northern Affairs provides comprehensive health care coverage to Aboriginals with treaty status, and provincial/territorial social service/human resource ministries provide similar coverage to people receiving social assistance [56]. Furthermore, some provincial/territorial governments provide comprehensive health benefits to children [59], [60] and parents [61] living in working low-income families and to parents making the transition from social assistance to the labour market [62], [63].
In addition to physician and hospital services provided under provincial/territorial health care plans, community-based social service organizations offer a broad array of services, supports, and programs to low-income people in Canada. These organizations, which are often part of the non-governmental non-profit sector, help low-income Canadians by providing food (e.g., food banks and co-ops), clothing (e.g., clothing exchanges), housing (e.g., subsidized housing, shelters), free and/or subsidized medications and dental care, family support services (e.g., parenting programs, counselling), and employability programs (e.g., job training, educational upgrading) [64]. In addition, some recreational programs offered by municipal government departments waive or subsidize fees for low-income people [65], [66].
As noted previously, there is limited research about low-income people's use of community-based services, supports, and programs. As such, current knowledge about health-related service-use by low-income Canadians is largely drawn from studies about treatment-focused and preventive health care services. These studies consistently have shown that, compared to higher-income Canadians, those with low incomes are heavier users of general practitioner, mental health, and hospital services [19], [20], [21], [22], [23], [24], [25], [26], [27]. Some researchers have speculated that low-income people are heavier users of these treatment-focused health care services because they have lower levels of health and more health problems than do people with higher incomes. Findings from the few studies that have explored this hypothesis are, however, inconsistent [19], [20], [27]. Moreover, there is mounting evidence that low-income Canadians are disadvantaged in terms of their receipt of some specialized treatment services, such as coronary care and joint replacements [23], [28], [29].
In contrast to findings about the negative relationship between income and use of general practitioner, mental health, and hospital services, low-income Canadians are less likely than their higher-income counterparts to receive services, such as chiropractic and routine dental care [24], [35], [36], which are not fully covered by provincial health care plans. When low-income Canadians do get dental care, it is less likely to be preventive in nature than the care obtained by higher-income people [36]. Furthermore, the disparity between the percentage of high- and low-income Canadians obtaining dental care has been increasing since the mid-1990s [24]. Similar to the under-use of health care services that are not fully covered by provincial health care plans, low-income Canadians are less likely than higher-income Canadians to use preventive services including cervical cancer screening [30], [31], [37], eye examinations [32], prenatal care [33], and prenatal classes [34].
In addition to studies that have explored the relationships between income and the use of both treatment-focused and preventive health care services, there is a growing body of research on the barriers that prevent low-income Canadians from obtaining health care. Limited financial resources, lack of comprehensive health care coverage, and lack of affordable transportation are common barriers experienced by low-income Canadians. In fact, low-income Canadians are 10 times more likely than other Canadians to report unmet health care needs due to cost or transportation [38]. Limited financial resources and lack of comprehensive health care benefits particularly limit access to services not covered by provincial health care plans, such as dental care and prescription and over-the-counter medications [39], [40], [41]. Other barriers that prevent low-income Canadians from obtaining health care services include discrimination related to ethnicity and poverty, insensitivity of health care workers, negative past experiences with the health care system, lack of childcare, lack of knowledge about available services, inability to get time off work, culture, and language [40], [42], [43], [44], [45].
Section snippets
Methods
We conducted our examination of low-income people's experiences with health-related services in Edmonton and Toronto from 1999 to 2000. In the latter part of the 1990s, more than one-fifth of residents in both cities had incomes below the Statistics Canada low-income cut-offs [67].3
Results
The three objectives guiding our study provide an organizing framework for the findings from the individual and focus group interviews. The findings are highlighted by direct quotes from participants.
Discussion
Our study enhances current understanding of low-income Canadians’ experiences with health-related services by providing insights into the types of services that are used by low-income people in two large Canadian cities to attain, maintain, and promote their health. The study also extends previous research by uncovering factors that influence urban-dwelling low-income people's use and non-use of health-related services. The consistency of findings across both data collection sites, as well as
Summary and conclusions
Examination of findings from this study in relation to recommendations by recent health care reform commissions leaves little doubt that low-income Canadians have much to gain from some of the proposed changes to health care delivery. In particular, low-income people's ability to access a broad range of health-related services would be enhanced with the implementation of three specific recommendations: (1) the expansion of the comprehensiveness of publicly funded health care services; (2)
Acknowledgements
We gratefully acknowledge financial support for this study from the Canadian Health Services Research Foundation, Alberta Heritage Foundation for Medical Research, Boyle McCauley Health Centre, Health Canada (Health Promotion and Programs Branch, Ontario), the United Way of Capital Region, and Edmonton Community Lotteries Board. In addition, we are grateful to Deana Shorten and Sharon Thurston for bringing the idea for the research to us, and for working with us to design the study. We thank
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This manuscript is an expanded version of a presentation made at the Canadian Public Health Association's 91st Annual Conference, Ottawa, ON, October 2000.