The access to care of underserved populations: a research among free clinics on the Paris area.
(full text in English: free access by the publisher at
I. Parizot, P. Chauvin
Research Team “Social determinants of health and health care”, INSERM U444, Saint-Antoine
Faculty of Medicine, 27 rue de Chaligny, 75012 Paris. E-mail : firstname.lastname@example.org ( Reprints: P. Chauvin)
Background: Over the past ten years, especially in urban areas, an increase in the number of persons experiencing serious social problems has led to the creation of free clinics intended for people without health insurance or those of modest means.
Methods: We present some of the results of a multidisciplinary (sociology and epidemiology) research project, carried out among patients consulting in five of these centres in the Paris area.
Results:Statistical and qualitative analyses show the diversity of the populations using these centres, why they use them, the nature of the services and help they use there, and in addition, the social relationships which are created in the context of these care facilities.
Conclusions: Results lead us to discuss lessons learned from the research which enhance our understanding of the determinants of health system use, not only among the vulnerable populations cared for in these centres, but perhaps for the population as a whole.
Multidisciplinary studies Qualitative methods Social factors Access to care Health care utilisation Social exclusion
Paths leading to social exclusion are often accompanied by declining health status, regardless of whether this morbidity is the cause or the consequence of exclusion  . Considerable research, especially in Anglophone countries, has dealt with the relationships among socio-economic factors, life conditions and the health status of individuals  ,  . It shows clearly that social precariousness is associated with an increased risk of morbidity, especially in the areas of mental health, infectious diseases such as tuberculosis or sexually transmitted diseases, as well as increased dependency on various substances (alcohol, drugs, tranquilizers…)  . In France, studies carried out since the 1990s  ,  ,  indicate that, while there are no illnesses specific to poverty, persons who are socially marginalised accumulate risk factors and morbid states, and present with pathologies at more advanced stages than do others  . A recent publication has addressed current thinking on the impact of the process of social exclusion on both health risks and health care, including self-care and care provided by the existing health system  .
Beginning in the mid 1980s, the “exclusion from health care” of different socially disadvantaged populations (without health insurance or of modest financial means) was brought to light and criticized in public debates. In order to deal with this situation, measures were taken (essentially in urban areas) to furnish these people with free care, initially through humanitarian associations, then
in hospital settings  . Apart from the diversity in their ways of functioning, the care they give and their institutional environment (hospitals, associations, communities, etc.), these facilities generally share the common attribute of having been created through the initiative and commitment of health care professionals. Their “success” has been based on the nearly systematic juxtaposition of two characteristics: a programme which combines free medical care and attention to social issues, in particular for those people whose social and health problems often seem inseparable; and the principle of immediate treatment regardless of means, of proof of health insurance, of identity papers or of visa status. These free clinics — “easy access consultations” or “transitional care
facilities”, depending on the terms used and the principles declared by their founders — have, up to
the end of the 1990s, treated an increasing number of persons, revealing at the same time the extent of the difficulties faced in gaining access to health care in our country. (The rising growth curve of attendance did not slow down until the creation of Universal Health Coverage in 2000, that is, subsequent to this research project.) The professionals establishing the first facilities of this type were often engaged simultaneously in running programmes, denouncing problems and bearing witness to situations of exclusion from the conventional health care system.
The impetus for this research project came from a request, made by these professionals to researchers in the areas of sociology and epidemiology, to find answers to some of their questions: Who are the patients who come to free clinics? What are their problems, medically speaking or otherwise? In what way do such centres meet, or not meet, their expectations? In line with this request, our task was to carry out multidisciplinary research among patients of free clinics in order to describe and understand their social and health situations. Our research problem involved us more generally in the determinants of health and health seeking behaviour of socially vulnerable populations. Our main hypothesis was that recourse to these centres did not depend solely on the financial situation and social protection coverage of these individuals. It was thus necessary to study a larger array of factors linked to their social condition (including looking at the processes and life events leading up to these conditions), as well as any use they may have made of other medical facilities. Moreover, we hypothesised that free health care centres were not necessarily the only kind of medical facility used by people in difficult circumstances, nor the kind used by them after their having attempted to consult in all other available facilities. It was thus necessary to analyse the strategies of individuals within the health care system, including, but also going beyond, the choice “to consult or not to consult”. From the sociological perspective of the project in particular, we tried to understand what happens in a free health care centre, beyond just medical care, and how that may influence health-seeking behaviours of persons in difficult circumstances. We were especially interested in the social relationships that are formed in the centres, and the way patients experience their consultation.
In order to encompass the diversity of populations using such centres, we wished to carry out a study in several different facilities, ones where patient recruitment, even when it is of people in difficult circumstances, is dissimilar from the point of view of health problems, life conditions and utilisation of health services.
For this article, we have chosen to present, in turn, the methods used, then some examples of health seeking behaviour of the study populations and links existing between their social characteristics (socio-economic situation, social isolation, social support, etc.) and their health seeking behaviours, and finally to discuss the limits and future directions of this kind of multidisciplinary and multi-centric research.
MATERIALS AND METHODS
The research team brought together for this project decided from the beginning to combine both sociological and epidemiological approaches, as well as qualitative and statistical methods. Initially,
a sociological study was carried out using a series of informal observations and interviews in four free clinics: three dispensaries run by Médecins du Monde (MDM) and one out-patient consultation (PASS) in a Parisian hospital (APHP). In all, nearly one hundred people consulting in these centres (30 at the hospital and 60 at Médecins du Monde centres) were given in-depth interviews, which covered basically their experiences in the centres attended, as well as their attitudes about assistance programmes and the health system in general. At the same time, fifty people working in these facilities were interviewed, recruited from among both volunteers and salaried employees. Nearly all these interviews were tape-recorded and integrally transcribed. In order to characterise the relationship patients developed with health care facilities they attended, a comprehensive approach was adopted: the discourse of people interviewed, as well as the way this discourse was organised, form the basis of analysis, which takes into account both the modality of service use and the meaning patients give to their experiences.
Secondly (and as an extension of the epidemiological research we carried out beforehand in some of the facilities studied  ,  ,  ), a quantitative socio-epidemiological study was done in a sample of clients from five free clinics in the Paris area (three of which were investigated in the qualitative study): Médecins du Monde's centres in the 11 th Arrondissement of Paris, and at Gennevilliers; the Baudelaire facility (PASS of the Saint-Antoine hospital, APHP, in the 12 th Arrondissement of Paris); the Verlaine facility (PASS of Saint-Louis hospital, APHP, in the 10 th Arrondissement of Paris); and the CHAPSA at Nanterre (a reception and care centre for Parisian homeless picked up during rounds made by the Police Prefecture, the RATP (metropolitain underground) and the Samu social (emergency medical and social aid units)). The sociologists, the epidemiologists and the clinicians associated with the project, prepared a questionnaire. It's final version has 121 questions and covers the following topics: a detailed description of the social circumstances of the individual on the day of the study (and how long these have existed); a description of the person's attitudes, expectations and perceptions concerning the health care system in general, and more particularly concerning the facility in which he or she was being interviewed; the person's own evaluation of his or her felt state of health, medical antecedents, symptoms and reasons for consulting; as well as a description of his or her health seeking behaviours, especially during the past month (care itineraries, facilities visited and detailed reasons for consulting), during the past trimester (hospitalisations), and during the past six months (all contacts taken together). Using this approach, 500 persons were interviewed (100 persons chosen at random from each site) who fulfilled the following inclusion criteria: aged 18 years or older, coming to consult a physician at the free health facility, able to understand and speak French. The statistical analysis of data used the following methods: Chi2 test for the comparison of qualitative data, non parametric rank test (Wilcoxon) for comparison of quantitative variables, multiple correspondence analysis and ascending hierarchical classification (cluster analysis using the Ward method) for statistical quantification of the typology prepared from the interviews, and a logistic regression model for the multivariate analyses. All statistical analyses were done using SAS/STAT ?, version 6.12 (SAS Institute Inc., Cary, NC, 1996). The observations and interviews were carried out between 1996 and 1998 and the statistical sample interviewed in 1998.
Description of the population using these facilities
In the free hospital and association-based health centres, a majority of consultants are males, between 25 and 35 years of age. Eighty percent are of foreign nationality, 70% to 80% have a home (depending on the centres), and 62% are educated beyond the age of 15 years. However, around 55% are unemployed and the majority are without health insurance (62% at Saint-Antoine hospital and up to 83% at MDM centres). The CHAPSA at Nanterre is different from the other study sites in that its recruitment is 90% male, 78% French and 95% homeless. Also, half of the patients have
health insurance, so this is a population similar to the Parisian homeless population  ,  . In all sites, the majority of people interviewed were unmarried (58%) or separated, widowed or divorced (17%). A quarter comes from rural areas, with the French twice as likely to come from there (41%) than are foreigners (19%, p =0.001). It would appear that, in our study population, there is a phenomenon of urban migration, in addition to that of international immigration.
On the day of the interview, a third of people interviewed said they worked (except at CHAPSA where only 8% said they did). There were important differences between foreign nationals and the French: respectively 39% and 16% worked (p =0.001). Among those that work, the large majority (79%) have undeclared employment, more frequently among foreigners (83%) than among the French (56%, p =0.001). Finally, 36% of people said they had no means of support. In addition, many patients in free health care centres face social and affective isolation. For example, when they were asked about social support, 12% of respondents said they could count on no one for any of the depicted situations (in case of illness, for finding lodgings, financial support, moral support, etc.). For each situation taken separately, between 40% and 60% of respondents have no one to help them.
As concerns health, 50% of people interviewed described four or more symptoms, and 20% described at least eight symptoms. A history of back and joint pain (all causes taken together) is the most frequent problem found among those interviewed (40% of people interviewed, twice that found in the general population  ). Mood and sleep problems are especially frequent, and, depending on the way questions were formulated (a combination of anxiety-depression symptoms, a diagnosis of “depression” or a “depressive condition”), between 30% and 57% of people were affected, a figure 4 to 6 times greater than for the general population. As concerns addictive behaviours, use of tobacco among males is higher (49%) than that estimated for the general population  . The proportion of those drinking to excess (defined by a score >=2 on the CAGE test  ) reaches 25% for the study population as a whole. Multivariate analysis shows that male sex, age over 40 years, homelessness and French nationality are all associated with a 2 to 4 times higher risk (statistically significant) of consuming excessive quantities of alcohol. Finally, it should be noted that a third of consultants had previously attended the centre where they were interviewed 1 to 2 times, 40% had come 3 to 9 times and a quarter of them were consulting for the first time. Types of relationships established with free clinics
From a sociological perspective, in order to understand modes of health seeking behaviour it is necessary to go beyond the specific question of medical needs as defined by health professionals, as well as by patients themselves, in order to focus on other types of logic which influence the relationship with the health system  . In addition, in free clinics, the helping dimension of care interferes with the medical dimension and the social work undertaken. Analysis of interviews carried out in the hospital setting and in humanitarian centres shows that attitudes towards these dimensions, and thus the way use of facilities is experienced, differs according to the patient, and evolves over time for the same patient as well. Individuals'expectations towards the centre and their use of available services are in fact transformed as a function of changes in their health status and social situation, of changes in the way they view their situation, and over the course of a number of visits because of their interactions with personnel and the internalisation of norms in force at the centre. It has thus been possible to formally describe a “moral career”  ,  for the vulnerable patient, corresponding to an institutional trajectory during which the relationship to the free care centre is transformed  . Initial recourse generally corresponds to isolated cases of using the centres: patients do not invest in a long-term relationship of medical or social follow-up. When patients are unable to obtain health insurance as a result of these first consultations, or when they do not wish to consult elsewhere, most patients become regular clients of the centre. Others continue using centres, but on an erratic basis. Analysis of the interviews has also led us to distinguish three types of relationships to the centre being frequented: distancing, settling in, and discrepancy.
This typology was subsequently identified and quantified by the socio-epidemiological study, in which fifteen questions on the relationships with care centres and assistance were administered to the study population. Only those who had already consulted in the centre prior to the day of the study answered all of these questions, that is to say 372 persons. The search for 3 clusters by ascending hierarchical classification (AHC) identifies three groups of modes of response, which are also identified by analysis of multiple correspondence (AMC), and which agree with the three types found during the analysis of the interviews: distancing, settling in and discrepancy (fig. 1) . In order to classify each individual in one or the other of the three types, we calculated 3 cumulative scores from the AHC (each one corresponding to the number of modalities concerning an individual, out of the list of the modalities of variables characteristic of the group), then classified the individual in the group for which his or her score was the highest. A similar method of classification was undertaken using the AMC. These two classifications were found to be in complete agreement and only 2 individuals could not be classified, because of the equivalence of some of their scores.
The distancing relationship is characterised by strategies setting limits on the consultation in a free clinic, through detached interaction — or at least experienced as temporary — with members of the
personnel, and by the desire that care should be limited to the problem at hand. These are generally people whose health status does not require middle or long-term follow-up, or who have only recently begun using the free clinic. The distance these people maintain in relation to the centre and its personnel is often the result of the humiliation they feel when they have recourse to assistance  . Being obliged to ask for free health care represents, in their eyes, a deterioration of their status and self-image. The comments of a 41-year-old woman clearly summarise this feeling: “I'm
really not used to this and I'm really… embarrassed. (…) We've never arrived at this kind of a situation, you know, its… its tough! I think. It feels like we're asking for charity.” Of 500 patients interviewed by questionnaire, more than one out of two said they were embarrassed to ask for free care — and this was so regardless of sex, age, nationality, housing situation, employment status or social coverage. It will be noted as well that this feeling of embarrassment is found in each of the facilities studied, thus in both conventional centres (PASS at hospital) and in centres expressly intended for the poor. In reality, more than the nature of the centres they use, it is the necessity of having to depend on institutional assistance, which constitutes a humiliating ordeal for these patients. This is reflected in their consulting behaviour. Indeed, determined to preserve their dignity, they refuse to be seen in the eyes of others, or in their own eyes, as “living on benefits”. As a result, they often limit the number and frequency of their consultations. Thus, 43% of persons given a questionnaire at hospital and MDM said they would consult a physician more often if they had health insurance. And several patients questioned during interviews say they wait longer before consulting after appearance of symptoms than they did when they were better off financially, or even say they won't consult in the same centre for several health problems at the same time. According to the AMC and the AHC, the distancing relationship is characterised by the following modalities: would prefer consulting elsewhere if he or she had a choice; especially appreciates the professional qualities of the physicians at the centre; is neither very comfortable nor uncomfortable in the centre; finds the reception quite good; only consults when he or she cannot do otherwise (fig. 1) . This relationship applies to 40% of those interviewed (and having already consulted).
Conversely, the settling in relationship is characterised by a frequency of use which is not limited by any feeling of humiliation, and by a relationship that includes follow-up care. Regular attendance at free clinics presupposes learning how the centre functions and its norms, but also an adaptation, which is both symbolic and of one's identity, to the implications of regular use of such a facility. In a settling in relationship, patients transform the meaning of care received. It is no longer
experienced as demeaning assistance, but is referred to more as a right to care and help, to which everyone is entitled. This enables them to continue their recourse without feeling embarrassment. They consult as though they had health insurance. Relationships with personnel are similarly transformed and are no longer limited to just technical and professional activities. Personal and