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International Journal for Quality in Health Care 15:495-500 (2003)
© 2003 International Society for Quality in Health Care

Soup kitchen consumer perspectives on the quality and frequency of health service interactions

L. J. Trevena1,2, J. M. Simpson1 and D. Nutbeam1

1 School of Public Health, The University of Sydney,
2 The Exodus Foundation, Australia

Objective. Whilst previous research has repeatedly documented premature mortality and high morbidity among seriously disadvantaged and homeless populations, far less is known of the extent and nature of their interactions with health services.

Design and setting. This cross-sectional case study describes health service utilization patterns and explores participant-reported difficulties in accessing health care, adhering to prescribed treatment and maintaining continuity of care amongst 100 users of a charity-run soup kitchen in urban Sydney.

Participants and results. The study describes a largely welfare-dependent population sample with poor health who are frequent users of the health system (85% had seen a general practitioner in the preceding 6 months). The homeless were more likely to report difficulties accessing health care when needed [odds-ratio 3.15; 95% confidence interval (CI) 1.04–9.62]. One in three respondents reported difficulty adhering to prescribed treatment following their last health care visit. Affordability (P < 0.0001), not understanding instructions (P = 0.007), and not agreeing with advice (P < 0.0001) were the main factors associated with adherence difficulties. One in four failed to return for follow-up visits as advised, largely associated with attitudinal barriers such as a history of not believing problems would be addressed (P = 0.05), not trusting health professionals (P = 0.04), and not knowing where to get help in the past (P = 0.05).

Conclusion. These results reinforce the important role of free primary care in reducing access barriers for the disadvantaged, but also highlight possible reasons for service interactions being ineffective in a substantial proportion of cases.

Keywords: continuity of patient care, health services accessibility, homeless persons, patient compliance

Accepted for publication June 3, 2003.

A considerable volume of recent research has described the nature and size of the disparities in health between the rich and the poor [1,2]. Whilst the existence and nature of this problem is being more clearly defined, finding potential solutions represents a major challenge. The nature and quality of interactions between the poor and the health system remains sparsely documented and largely anecdotal, particularly for the homeless and seriously disadvantaged. Such interactions will vary from country to country, and often depend on the type of health system. Emergency departments often claim that they carry the health care burden of many transient and marginalized people [3,4] asserting, for example, in the US that a lack of free health care might be the main reason for this. In the UK, where free health care is available to patients registered with a general practitioner (GP), lack of registration among the indigent has been cited as problematic [5]. Similarly, deinstitutionalization of the mentally ill, with a lack of community-based mental health services, has been implicated in contributing to health problems and health service-access issues among the seriously disadvantaged [6].

While descriptive studies of local homeless and poor populations in several countries reveal demographically heterogeneous communities [7–11], they consistently document premature mortality [12–14] and poor health [7,15,16], with high rates of hospitalization [17]. In addition, countries providing free access to primary and ambulatory health care have high utilization rates of these services by the seriously disadvantaged, indicating the importance of affordability for equity of access to community-based services. A large survey of 2974 homeless people in the USA [17] recently demonstrated additional difficulties in adhering to prescribed treatment in 32% of those for whom it was prescribed. However, despite documenting the proportion of those citing access and adherence problems and examining possible determinants of these, few studies have directly recorded the participant-identified reasons for such difficulties.

This cross-sectional study of users of a soup kitchen in urban Sydney examines the health service utilization patterns of a seriously disadvantaged population and documents the participants’ points of view on difficulties in accessing health care when needed, in adhering to prescribed treatment, and in maintaining continuity of care in follow-up.


   Subjects and methods
Top
 Subjects and methods
Results
 Discussion
 Conclusion
 References
 
Between 4 May and 7 December 1998, 100 face-to-face interviews were conducted amongst a representative sample of users of a charity-run soup kitchen at the Exodus Foundation in urban Sydney. One hundred and forty subjects aged >=15 years were approached according to the seat they chose during the lunchtime period on Monday to Friday. Sampling seat numbers were randomly generated from a seating plan of the soup kitchen and subjects were excluded if they were under the age of 15 years, spoke little English, or if they failed a cognitive assessment instrument designed to exclude those who were psychotic, intoxicated, intellectually impaired, or suffering from memory problems [18]. This instrument was administered by a qualified medical practitioner who conducted all interviews. Data obtained by self-report from those who passed this test was believed to be reasonably reliable, since reliability of self-report from such individuals is supported in the literature [19]. For the purpose of analysis, participants of low accommodation status were grouped according to the Australian definition of ‘homeless’ as defined by Chamberlain and MacKenzie [20], which includes boarding house residents.

The size of the population using the Exodus Foundation meals service is unknown. Nevertheless, it was estimated that a sample size of 100 would allow us to estimate the percentage of the population reporting access problems with a 95% confidence error of no more than 10%. It would also give 80% power to detect as significant, at the two-sided 5% level, associations between barriers to health care and reported access difficulty with an odds ratio of ~3.5 or an absolute difference in percentages of 25–30%.

Subjects agreed to answer a set of semi-structured questions on a range of demographic, health, and health service issues. They were asked about the frequency of health service interactions, the types of providers accessed, the presenting problem for their most recent visit, when their last hospitalization had occurred, and the reason for admission. The presence and type of their nominated regular source of health care was also noted.

Barriers to accessing health care were identified by asking whether the participant had ever had difficulty obtaining health care when sick and, if so, the reasons for this difficulty. Initially, participants identified their own reasons for access difficulties, but were also asked whether they had experienced each of a checklist of potential barriers derived from preliminary pilot and provider discussions. These potential barriers were: a bad previous experience with a health service, not trusting health professionals, being too embarrassed to seek help, not believing problems will be addressed, lack of transport, lack of Medicare card, not wanting help, not knowing where to find help, inability to afford care required, and having to wait too long for an appointment.

Adherence problems were identified by asking whether treatment had been prescribed at the last health care visit and, if so, whether this had been implemented by them. Reasons for being unable to adhere to treatment advice were identified by participants and recorded. Similarly, participants were asked whether they had been advised to return for follow-up with either the same or a different provider. If follow-up was advised but not attained, the reasons preventing this were also recorded.

Unstructured answers were usually short phrases only, and were analyzed for content based on categories that were predetermined using the literature and the pilot project. All unstructured responses fitted within these broad categories. All interviews were conducted by a single researcher and answers noted in situ. Data were stored and analyzed using Minitab and SAS version 8 for Windows software. Significance tests of association between predictive and outcome variables were performed using Fisher’s exact test, given the size of the sample. Separate analyses were performed for the three outcome variables: access barriers, adherence difficulties, and failed follow-up. Predictive variables included key demographic, general health, and health system factors. Multivariate analysis was not possible due to low frequencies and dependencies between predictive variables.


   Results
Top
 Subjects and methods
 Results
Discussion
 Conclusion
 References
 
Of the 140 people approached directly, 13 (9%) were ineligible and 100 of the remaining 127 (79%) consented to participate and answer questions about demographics, health status, and health service utilization. Ninety seven (76%) responded to questions about accessing health care, but only 85 (67%) agreed to discuss adherence and follow-up from their most recent health care visit.

The mean age of the sample was 49.4 years and the ratio of males to females was 4:1, with 93% reporting that they were single. Thirty nine percent of the population were homeless or living in boarding house accommodation, and the remainder lived in either government-assisted housing or private rental accommodation. Fifty seven percent stated that they had left school at age <16 years. Thirty six percent were receiving unemployment benefits, 42% were smokers, and almost half (48%) reported their health status as ‘fair’ or ‘poor’.

As Table 1 shows, users of the soup kitchen at the Exodus Foundation are frequent users of the health system. Eighty nine percent of those interviewed had visited a doctor in the preceding 6 months, with a third of these having their most recent visit in the preceding fortnight. Eighty five percent of these visits were with a general practitioner and half were related to a chronic illness. A high proportion (40%) had been admitted to hospital in the preceding 12 months, mainly for acute illnesses and trauma, and two-thirds of the sample reported having their own general practitioner whom they would see if unwell. Eighteen percent had visited a doctor three times in the past 6 months, 19% had visited twice, and 13% only once.


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  		Table 1 Health service utilization patterns for 100 soup kitchen users

 

While this community appears to use health services frequently, 16 out of 97 reported that there had been occasions when they needed to see a doctor but could not get help. Table 2 shows that such access difficulties were associated with homelessness (including boarding house residents), lack of transport, fair–poor self-reported health, a history of mental illness or cancer, lack of knowledge about available health services, participant embarrassment about seeking health care, and not believing that their problem would be addressed.


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  		Table 2 Factors associated with difficulty accessing health care for soup kitchen users (n = 97)1

 

In addition to obtaining information about the patterns of health service utilization and perceived barriers to accessing health care, further information was obtained about the outcomes of participants’ most recent health care interaction. From Table 3 it can be seen that 85 people responded to this question, and that 26 of these (31%) reported having difficulty adhering to the treatment prescribed during their last visit. Adherence difficulties were significantly associated with failure to present for follow-up, lack of transport, inability to afford treatment, lack of understanding about instructions for treatment, and a lack of agreement with advice given.


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  		Table 3 Factors associated with treatment adherence difficulties at last consultation for soup kitchen users (n = 85)1

 

Similarly, almost one in four people failed to present for follow-up after their last visit as advised. This included 16 people who had required follow-up but did not seek it, three who required follow-up but were unable to obtain this anywhere, and two who were unable to see the same doctor but sought follow-up with a different provider. This lack of continuity of care was most significantly associated with communication issues within the previous consultation. Patients were more likely to fail to present for follow-up if they also reported embarrassment about seeking advice (10%; P = 0.05), a belief that their problems would not be addressed (19%; P = 0.05), a reported lack of trust in health professionals (14%; P = 0.04), and a history of not knowing where to seek help when required (24%; P = 0.05). Demographic, material, and specific health factors were not significantly associated with failed follow-up in this sample.


   Discussion
Top
 Subjects and methods
 Results
 Discussion
Conclusion
 References
 
The sampling methods of this study have enabled a representative, albeit small, sample of the Exodus community to be interviewed about the nature of their interactions with the health system. In this respect the results need to be treated with some caution, particularly in generalizing to other disadvantaged communities. Nonetheless, several strong themes emerge from the findings, which are of importance in planning to meet the profound needs of this underserved population.

The reported levels of health care access amongst the seriously disadvantaged participants of this study were comparable to those of the general Australian population, but less than some overseas studies indicate [15,17,21,22]. Thirty percent of Exodus clients consulted a doctor in the preceding fortnight, compared with 29% of the general Australian population [23], but Exodus clients were more likely to have been seen at Accident and Emergency or hospital outpatient clinics (9% of the Exodus population compared with 3% of the general Australian population). Examining a 6 month period, 89% of Exodus clients had seen a doctor compared with 72% of the general Australian population. While data were not available to enable age–sex standardization on these comparative figures, a trend towards equitable access to doctors and frequent health service utilization through Australia’s universal free health system is apparent. In contrast, a recent US study [17] reported that one in four homeless persons (24.6%) reported that they had been unable to obtain medical care when needed over the preceding year. The proportion amongst the Exodus soup kitchen users was lower, at one in six (16%), but still more likely to persist among the homeless.

A lack of information for marginalized patients about available health services was a significant yet modifiable barrier to quality health care identified by participants in this study. It was linked to other barriers such as not believing that problems would be addressed, not trusting health professionals, and being too embarrassed to seek help. Such beliefs deserve closer examination amongst the seriously disadvantaged, both to clarify the extent to which they reflect an individual’s real experiences, and to seek potential remedies to them [24]. It was not possible to tell from this study how informed practitioners were about available resources for the homeless, and there is some evidence to suggest that professional development in this area may be of benefit [25]. Useful resources and strategies for general practitioners to improve health outcomes for marginalized patients are not widely available in many areas and, if so, have not been formally evaluated. Providing such resources and evaluating their effectiveness, particularly in geographic areas known to have many homeless or very disadvantaged patients, is needed urgently.

Health care provider attitudes and beliefs about homelessness may also, in part, contribute to some of the attitudinal barriers noted in this study [25,27,28]. Further study of these factors is required to understand the nature of these suboptimal health service interactions better.

Even with an increased awareness of the special health care needs of seriously disadvantaged, homeless, or marginalized clients, substantial challenges remain with health care providers in improving the quality of health care for such patients. It is often very difficult to identify seriously disadvantaged clients, many of whom are too ashamed to raise their social circumstances as an issue within the consultation. Some studies have suggested that socioeconomic data should be collected routinely within the consultation [26], but the acceptability of this has yet to be assessed. Primary care service infrastructure and systems, such as appointments and fee-for-service, may reduce the time available to build up rapport with socially marginalized patients, many of whom have complex health and social problems. Within the Australian system there are strong financial disincentives for doctors to afford long consultation times to such patients.

Some positive work in this field has recently come from the McKinney projects in the USA, mainly working with the homeless who suffer mental illness [29,30]. Good evidence now exists as to the effectiveness of assertive outreach models in the community with such populations [31]. The findings of our small case study concur with these models, which allow for better engagement with marginalized groups, the provision of appropriate information and skills over a defined period of time, and a greater integration with mainstream services, as self-efficacy health and social circumstances improve. Such models are worthy of further evaluation amongst seriously disadvantaged communities, particularly to see if they overcome some of the barriers to health care quality that the participants in this study identified.


   Conclusion
Top
 Subjects and methods
 Results
 Discussion
 Conclusion
References
 
This cross-sectional case study among a soup kitchen population in urban Sydney describes a population who are frequent, but not excessive, users of the Australian health system. It highlights the importance of free primary health care in such communities and shows that disadvantaged individuals will access such services if available. In addition, an exploration of the outcomes of the most recent of these frequent health care interactions showed that a substantial proportion of consultations may be ineffective. One in three clients reported difficulty carrying out their prescribed treatment, and one in four failed to attend follow-up as advised. Unlike previous research in this area, this case study also documents participants’ reasons for poor adherence to treatment advice and failed follow-ups. It suggests that affordability of treatment, access to transport, and most importantly effective communication of relevant health information and engagement with disadvantaged patients are critical to the improvement of consultation outcomes. It is also suggested that effective elements of assertive outreach models should be tested on groups such as these, with particular attention to the development and evaluation of tailored health care information and strategies, or guidelines for general practitioners and emergency department staff working in disadvantaged areas.

The authors wish to acknowledge Reverend Bill Crews, staff, and clients of the Exodus Foundation who participated in this research, and Ms Petra Macaskill (School of Public Health) for advice on sampling methods. Funding was provided by a seeding grant from the Royal Australian College of General Practitioners Foundation, and a University of Sydney Postgraduate Association Scholarship.


   Footnotes
 
Address reprint requests to Dr Lyndal Trevena, Room 322, Edward Ford Building (A27), The University of Sydney, NSW 2006, Australia. E-mail: lyndalt{at}health.usyd.edu.au Back


   References
Top
 Subjects and methods
 Results
 Discussion
 Conclusion
 References
 

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