Access to care: who are these patients who give up, and why?

Article 25 of the Universal Declaration of Human Rights of 1948 guarantees the right of access to healthcare for all. In fact, he states that:

“Everyone has the right to a standard of living sufficient to ensure his health and well-being and that of his family, in particular for food, clothing, housing, medical care […]”

However, even though the French population is aging, this right of access to care is increasingly difficult to guarantee, in a context of hospital crisis and insufficient staff in city medicine.

The media and political figures are already echoing the problems encountered by certain citizens in seeking treatment. In such a situation, it happens that individuals give up care. In what exactly do these renunciations of care consist? Who do they concern? Research is helping to shed light on these questions.

Do not confuse “renouncing care” and “not consenting to care”

First of all, it should be emphasized that renunciation in the sense in which we refer to it here does not concern situations where one refuses to consent to the recommended care (for reasons, for example, of distrust of the medical world).

The first idea that comes to mind when we think of “forgoing care” concerns the impossibility of consulting a doctor when a need for care arises. This is how this concept is envisaged by the Institute for Research and Documentation in Health Economics (IRDES), since its introduction in the 1990s. We consider in this context that there is a renunciation of care when a person considers that he would need care, but that he cannot obtain it because of the circumstances.

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This impossibility of consulting a doctor is not always due to a lack of care. Thus, a person in a precarious situation who does not have the means to pay for complementary health insurance (and therefore anticipates that a consultation will only be partially reimbursed) may consider that he does not have the means to spend money at a doctor and refrain from consulting, even when she feels in poor health. She therefore forgoes treatment. People who are very busy with their professional or family life can also give up treatment for lack of time, especially if the specialists closest to their home are too far away.

In such situations, the renunciation of care is more of the order of frustration, of regret. To give up is in a way not being able to follow the adage “when you want, you can”.

The limits of declarative surveys

We must be aware that the fact of "forgoing care" can not have the same meaning according to the people considered. The analysis of the phenomenon of renouncing treatment is in fact based on declarative surveys: it is the individuals questioned who affirm that they have – or not – renounced treatment. There is therefore an element of subjectivity which should encourage caution when analyzing this phenomenon.

This situation also leads to difficulties in comparing the surveys with each other, as the answers to the questions on the renunciation of care are sensitive to the formulation of these.

According to the samples, the prevalence of renunciation of care in the adult population in France can be evaluated at 3% like a more than 20%.

Why do we give up treatment?

Many factors can prevent individuals from seeking care: complicated personal situation, socio-economic status, cultural reasons, etc. But the refusal of care does not depend solely on such constraints.

Above all, these indicate why individuals cannot seek care. But as mentioned earlier, it is the question of an unfulfillable “wish” that is at the heart of this notion. Understanding renunciation therefore presupposes both knowing why individuals consider, in the first instance, seeking care, and why, in the end, they cannot.

Wanting real access to care presupposes above all identifying a health problem or issue and, secondly, estimating that it must be answered by contact with the medical world. For this it is necessary take care of your health, know where to turn et have sufficient confidence in health professionals and the healthcare system.

We may not want to seek care because we do not perceive a health problem or issue, either because there is none, or because we do not understand it, or because we don't give it any importance. In extreme cases, there may also be a complete mistrust of the medical world (the refusal by some of the vaccination against Covid-19 was a salient illustration of this situation).

Crossing barriers to access care

Access to care then implies being able to overcome various barriers. The first, and probably the best known, is the financial barrier. Faced with care, depending on his health coverage, an individual may have to personally bear the costs. This is called the “out-of-pocket payment”. The poorer one is, the more obviously it is difficult to cope with it.

In France, this barrier mainly corresponds to the absence of complementary cover. Having complementary coverage largely protects against foregoing care. It has also been shown that the Universal-Complementary Health Coverage (CMU-C) could make it possible to give up care less than by having a classic complementary.

A second barrier, also well known, is geographical. Obtaining care implies physical access to an available healthcare professional. It is therefore necessary that the care are not too far from the patients potentials. It is also necessary that the number of doctors present in a territory is sufficient to meet the needs of the population.

On this subject, it should be emphasized that "medical deserts" are not only found in remote countryside: if, in a populated district of a large city, the local medical office has only one doctor, the situation is not is no different from that of a sparsely populated rural area without a doctor. To understand this, the indicator ofLocalized potential accessibility was developed by the Department of Research, Studies, Evaluation and Statistics (DREES) and IRDES. The objective is to succeed in measuring the tensions existing between supply and demand for care in the territories of France.

Municipalities with poor access tend to be rural municipalities located outside the influence of major urban centers. Already in 2013, more than 20% of people living in rural areas or outside the influence of urban centers lived in places where access to general practitioners was very poor. These “medical deserts” where general practitioners are lacking tend to concern municipalities in central France, or those located around the Paris region and in the overseas territories. Ten years later, the situation has probably not improved.

Beyond these two obvious barriers, others, less known, exist. For example, some healthcare professionals may discriminate against certain patients for various reasons (gender, Ethnicity, social status…). Whether it happens voluntarily or not, this discriminatory barrier sometimes influences access to care.

Finally, another organizational barrier can stand in the way of access to care. It corresponds to the fact that the material or human resources of a care unit do not meet the needs of the patients. This is for example the case when a service has set up a system for making appointments exclusively via the Internet, thereby excluding many older people. The lack of a professional with a command of sign language is also a barrier for some people with hearing disabilities.

The examples could be multiplied, but it is simply a question of understanding that, when the healthcare system does not adapt to the specific needs of certain patients, then the latter may end up giving up.

Better target populations at risk of foregoing care

It is difficult to truly assess the extent of the phenomenon of renunciation of care in France. Indeed, as mentioned above, since renunciation is subjective, the answers vary a lot according to the way in which the individuals are questioned.

Generally, the surveys introduce questions on the renunciation of care without specifying the reasons, or by focusing them specifically on the financial reasons. We usually observe questions of the type

“During the past 12 months, have you given up treatment for financial reasons? If so, what care? As a result, data on other forms of renunciation are unfortunately very patchy, or even non-existent.

Although the measures differ, we generally find similarities between the profiles of the individuals who forego care. This work has also made it possible to identify the characteristics that increase the risk of giving up and those that, on the contrary, protect.

We know, for example, that the women forego care more than men. This could be due to differences in relationships to health and care between men and women, which encourage women to be more aware of their care needs: unlike men, who are less attentive to their health, they are more likely to realize that they cannot access the necessary care.

We also know that it is during working life that we give up the most, potentially due to lack of time to devote to their health. Smoking is also associated with more renunciation.

Likewise, the healthier you are physical et mental and the more we give up. However, it is difficult to determine what is in the order of cause and consequence: do we forego care because we are in poor health, or are we in poor health because we give up?

With regard to the renunciation of care for financial reasons, the scientific literature logically raises the role of income (the richer you are, the less you give up) and precariousness. Also, the fact of have supplementary health cover reduces the risk of giving up, a fortiori if this cover is of good quality.

Ultimately, this work therefore makes it possible to identify which populations should be particularly targeted in the fight against quitting. To be effective, policies aimed at ensuring adequate access to healthcare for all must mobilize tools adapted to these groups. This involves achieving a comprehensive understanding of the determinants of quitting and how they affect the decisions made by members of different social groups.

Inaki Blanco-Cazeaux, PhD student in public health, University of Bordeaux

This article is republished from The Conversation under Creative Commons license. Read theoriginal article.