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The GP's perception of poverty: A qualitative study

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DOI: 10.1093/fampra/cmh724 · Source: PubMed

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 Family Practice Advance Access published February 14, 2005

© The Author (2005). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
doi:10.1093/fampra/cmh724

The GP’s perception of poverty: a qualitative study

Sara J Willems, Wilfried Swinnen and Jan M De Maeseneer

Willems SJ, Swinnen W and De Maeseneer JM. The GP’s perception of poverty: a qualitative
study. Family Practice 2005; Pages 1–7 of 7.
Background. Health differences between people from lower and higher social classes
increase. The accessibility of the health care system is one of the multiple and complex causes.
The Physician’s perceptions, beliefs and attitudes towards the patient are in this context
important determinants.
Objectives. To explore the general practitioners’ definition of poverty and their perception of
the deprived patients’ attitude towards health and health care, to get insight into the ways
general practitioners deal with the problem of poverty and to present the proposals general
practitioners make to improve health care for the deprived.
Method. The study involved qualitative methodology using 21 semi-structured interviews.

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The interviews were recorded and transcribed verbatim. The transcripts were coded using
Framework Analysis techniques. Interviews were undertaken with general practitioners in
primary care, working in a deprived area in the city of Ghent.
Results. In the definition of poverty, three concepts can be identified: socioeconomic aspects,
psychological and individual characteristics, and socio-cultural concepts. General practitioners
adopt different types of approaches to deal with deprived patients in practice: adaptation of the
doctor-patient communication, lowering of the financial threshold, referral to specialists and
other health care professionals.
Conclusion. Including the issue of poverty and poverty in the curriculum of the medical
students and in the in-service training for practicing doctors could have a positive impact on
their attitude towards this patient group. Further research is needed into the barriers in the
accessibility of the health care system for the deprived, exploring qualitatively and quantitavely
the experiences and the living conditions of deprived patients and the perceptions of health care
providers.
Keywords. General practitioners, Poverty, Physician-Patient relations, Accessibility of Health
Services

Introduction population and barriers to the accessibility of the

healthcare system, all of which lead to differences in
Despite marked health improvements in the overall usage of healthcare.1–8
population, evidence of systematic differences in health Numerous studies have identified different barriers to
between people from lower and higher social classes has the process of obtaining adequate and timely medical
been accumulating rapidly in recent years. The care, particularly for patients from disadvantaged
explanations for this are frequently explored but remain groups. In the categorization of these barriers, a distinc-
largely unclear.1,2 These multiple and complex causes tion can be made between those on the user’s side and
include individual factors such as personal history (e.g. those on the provider’s side. On the user’s side, there is
childhood socio-economic status and living conditions) documentary evidence of socio-demographic barriers,
and education, structural factors such as income, housing psychological barriers, barriers related to the patient’s
facilities, the unequal distribution of risk factors in the knowledge, attitude towards illness and towards the
healthcare system, and barriers created by the
characteristics of the patient’s social and environmental
Received 1 July 2004; Accepted 27 September 2004. background. However, one explanation for the inequali-
Department of General Practice and Primary Healthcare, ties in healthcare usage that is considered to be much
Ghent University, Belgium. Correspondence to Sara Willems,
Ghent University, Department of General Practice and more significant and which receives considerably
Primary Healthcare, UZ–1K3, De Pintelaan 185, B-9000 more attention from those concerned with improving
Ghent, Belgium; Email: Sara.Willems@ugent.be the health of the poor concerns the barriers on the

Page 1 of 7
Page 2 of 7 Family Practice—an international journal

provider’s side.9 That is to say, the barriers related to the number of inhabitants with low incomes, long-term
the characteristics of the healthcare system and those unemployed, receipt of financial support from the
related to the personal attributes of the healthcare government and the number of candidates on the
providers. In this context, the concept of attributes waiting list for social housing.14 All 25 GPs (8 female and
refers to the GP’s perceptions and attitudes, such as 17 male, making up 33% of the doctors working in the
his/her conceptualization of poverty and his/her attitude deprived areas of Ghent) were contacted by phone and
towards deprived patients. It is reasonable to assume 21 agreed to participate in the study (84%).
that these attributes have an impact on the doctor’s
consultation style and the relationship with the patient Interviews
and can act as a barrier for deprived patients. Data was collected using a loose structured interview
Poverty studies distinguish three dimensions in the guide consisting of open-ended questions. The questions
conceptualization of poverty: economic well-being, defined the area to be explored and formed the basis
social exclusion and capability. Economic well-being from which the interviewer or the interviewee could
stems from the issue of whether someone has sufficient diverge in order to pursue an idea in more detail.13 The
income to acquire a basic level of consumption or human advantage of the use of an interview guide is that it
welfare. Secondly, the social isolation of the poor from increases the comprehensiveness of the data and makes
the rest of society can be perceived as a cause of poverty. the data collection process more systematic for each
Finally, poverty can be regarded as a function of the lack respondent. Furthermore, logical gaps in data can be

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of the individual skills, such as education or health, anticipated and closed. It also keeps the interviews fairly
needed to attain a basic level of human well-being.10 conversational and situational.15 The interview guide
Little is known about how GPs define poverty, their used in this study was developed from literature
attitudes towards deprived patients and their perception covering the topic of questioning one’s attitude and
of the attitude of those patients towards health and the beliefs towards a certain topic and through discussions
healthcare system. The aim of this study is to explore with experts in qualitative research.14 One pilot
these perceptions and attitudes, thereby obtaining an interview was conducted to test whether the questions in
insight into the ways GPs deal with the problem of the interview guide met the basic principles of good
poverty and their proposals for improving healthcare questions for qualitative research of open-endedness,
for the poor. neutrality, sensitivity and clarity to the interviewee.15
Only a few minor textual changes were subsequently
made to the interview guide, which also remained stable
Methods during the course of the research interviews.
The interview guide consisted of the following core
Subjects and setting questions defining the area to be covered:
The study took place in the city of Ghent (population
How would you define the concept of ‘poverty’?
200 000) in Belgium. In view of the exploratory
How do you perceive the attitude of deprived
hypothesis-generating nature of this research, a
people towards health and illness?
qualitative method based on semi-structured interviews
was used. Qualitative research enables us to access an
How do you deal with deprived patients?
area that does not lend itself to quantitative research and
What would you suggest to improve healthcare for
has the added advantage of uncovering issues or
deprived patients?
concerns that had not been anticipated or considered by
the researcher, a restriction implicit in the use of closed- WS, a GP and research fellow at the Department
ended questions.11–13 The choice of semi-structured face- of General Practice and Primary Healthcare, con-
to-face interviews was made based on prior negative ducted the interviews. He adopted a non-directive
experiences of gathering 6 to 8 GPs at one time. After approach to encourage the physicians to develop and
the interviews, some of the respondents reported that elaborate their own perspectives. Interviews lasted
they had appreciated this technique on account of the from 40 to 90 minutes and were conducted in the
somewhat sensitive nature of the subject. We used a GPs’ surgeries. They were tape-recorded and fully
purposive sampling strategy to select 25 participants, transcribed.
aiming for maximum variation in the type of practice
(single-handed practices, practices with a patient list and Analysis
capitation, community health centres with a patient list The individual transcripts were analysed using
and without capitation), the GP’s district of work (the Framework Analysis techniques. This approach employs
different deprived areas of Ghent), his/her number of sifting, charting and sorting the material in a systematic
years of experience and gender. The deprived areas were manner in order to allow key issues and themes to
identified according to the “Atlas of poverty”, which emerge. A priori issues are integrated into the data
uses the following indices: the concentration of migrants, analysis.16 The interview transcripts were read repeatedly
 “Tell me about poverty” Page 3 of 7
and were first coded independently by two researchers
(WS and SW) to capture the range and the diversity of BOX 1 GPs’ conceptual model for poverty: causes and effects
the GPs’ perceptions and to compare them across
Socio-economic aspects
transcripts. Recurrent themes reflect a shared under-
standing among GPs of the phenomena under investi- Low income
gation. Furthermore, ideas on emerging themes were Low education
compared and modified until agreement was reached. Unemployment
This was a dynamic process, with each transcript infor- Bad housing
ming both the collection of further data and their
Psychological aspects and patient’s individual characteristics
subsequent analysis. The entire process was supervised
Lack of ambition and motivation to improve the situation
by a senior researcher (JDM). The criteria of credibility,
transferability, dependability and confirmability outlined Lack of skills to manage the household budget
by Lincon and Guba (1999) were adopted as tests of Limited intellectual capacity
thoroughness and trustworthiness.16 As is usual in Lack of social and relational skills
qualitative research, the data is presented in the form of Limited communication skills
general concepts illustrated with quotations.
Addiction-related problems
Laziness

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Results Fear of what might happen in the future
Lower health status
All respondents were Caucasian; 14 (70%) were doctors Socio-cultural aspects
working in a single-handed practice; 1 worked in a
Negative influence of the social group
practice with a patient list and capitation and 2 worked
in a community health centre; for 3 of the GPs, the type Social isolation
of practice is not known. Their workload varies between Passed on from one generation to the following generation:
impossible to break this vicious circle
5–15 hours/day and consultation times vary between
10–20 minutes per patient. The average time in practice Consumerism (overspending)
was 15.7 years (range: 1–36 years). Large family sizes
Impact of society: inadequate reaction to poverty
GPs’ conceptual model for poverty: causes and
effects (Box 1)
In the conceptual model for poverty described by GPs, negative influence of the social group, or more
socio-economic aspects, patients’ psychological and specifically, the negative influence of parents on their
individual characteristics, and socio-cultural aspects children. The social isolation of the deprived patient
can be identified. Almost all respondents refer to is also a significant factor. On this subject, some
socio-economic aspects (Box 1) as being significant respondents refer to the fact that poverty is structurally
factors in poverty. Specifically, the physicians refer to transmitted from one generation to another and
low income, poor education, unemployment and bad consider it almost impossible to break this vicious circle.
housing as significant factors.
Patients’ psychological and individual characteristics “If the father is a workman, the son is a workman,
(e.g. attitudes and coping skills) (Box 1) are also consid- etc. Children who want to study have to be very
ered important in the definition of poverty, although the intelligent and need to have a very strong
stipulation of this aspect is less homogeneous. The most personality. They have to distance themselves from
commonly cited feature in this context is lack of their family. Otherwise it is not possible.”
ambition and motivation to improve the situation. A minority of the GPs refer to the role of society and
“They don’t want to change their situation . . .; they inadequate reaction to poverty.
are used to it. They no longer have the courage to “If there were stricter laws on payment on credit,
change it.” the problems caused by buying large amounts of
goods on account would not be possible anymore.”
Furthermore, a lack of the skills needed to manage their
budget, limited intellectual capacity and a lack of social Finally, consumerism (overspending) and large family
and relational skills are mentioned. Finally, the GPs sizes are mentioned as factors behind poverty.
identify limited communication skills, addiction, laziness,
fear of what might happen in the future and lower health GPs’ perceptions about deprived persons’ views of the
status as individual determining factors in poverty. health services (Box 2)
The definition of poverty also identifies socio-cultural On the one hand, GPs sometimes have a rather negative
aspects (Box 1), the most important of which is the idea of the patients’ attitude, referring to the limited
Page 4 of 7 Family Practice—an international journal

BOX 2 GPs’ perceptions about deprived persons’ views of the BOX 3 GPs’ strategies for dealing with deprived patients in
health services primary care

Limited knowledge and insight in own health and illness Change in modes of communication:
Limited interest and motivation to change health-related Different language use (easier wording, etc.)
behaviour
Trying to get an insight into and show empathy for the living
Inadequate use of medical services conditions of the patient
“Floating patient group” possibly related to the availability of Cost reduction:
the GP and the nature and content of the healthcare provided
Free medication samples
Short term symptom relief
Prescribing the cheapest product
Doctor-oriented locus of control
Critically analysing and adjusting the medication scheme
Trying to identify the underlying mechanisms for the patient’s
Reducing or waiving fee
risk-related behaviour, inadequate use of healthcare . . .
Asking for one fee in stead of two when examining two persons
Penurious living conditions leading to high levels of psycho-
from the same family
social stress
Postponing payment
Fear of having their children taken away or to be considered a
bad parent Taking on increased responsibility:

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Lack of help from social network Managing the patient’s problem as long as possible at primary
healthcare level
More co-ordinated referrals to specialists

knowledge and insight of deprived patients into health Requesting help from other medical or social caregivers
and illness and their limited interest and motivation to
change their health-related behaviour.
“They are not interested in their health. They don’t
mechanisms for the patient’s risk-related behaviour or
see the advantage of, for example, healthy food.”
his/her ‘inadequate’ use of healthcare services, such as
GPs also point out the inadequate use of medical services penurious living conditions leading to high levels of
by deprived patients, such as use of the emergency psycho-social stress, the lack of a social network to
services for primary healthcare problems. In relation to appeal to when in the need of help, and the fear of being
preventive care for the deprived, the GPs report lower considered a bad parent or of having their children taken
usage, partly because of financial restrictions but also away from them by social services.
because of limited knowledge, the short-term outlook of
“They rarely postpone healthcare for their children;
patients and their lack of motivation and “stability”.
they really want the best care for their children.
“People from this patient group are more focused on I think they consider them as one of the few good
the present. They come to the practice when they things they have left and they don’t want to be
have an acute problem, but you need a lot of considered as a bad parent.”
persuasive qualities to make them come for the
monitoring of chronic conditions or for prevention.” GPs’ strategies for dealing with deprived patients in
primary care (Box 3)
Deprived patients are sometimes considered as the more
Most of the GPs feel they play an important role in the
“floating patient group”, i.e. not consulting the same
patient’s life, monitoring their physical, psychological
doctor each time. This could be related to the availability
and social health and well-being and enjoying their trust.
of the GP and the nature and the content of the
They generally have a positive attitude towards working
healthcare provided (does the doctor meet the patient’s
with deprived patients and regard contact with them as
expectations?). On this subject, the respondents refer to
warm, spontaneous and rewarding. This results in
this patient group as very focused on getting sick-leave
attempts to lower the primary healthcare threshold for
certification and on short-term symptom relief. The
deprived patients.
respondents have the feeling that people living in
A first approach concerns doctor–patient communi-
poverty expect the doctor to take all the responsibility
cation. Some mention that they speak differently (using
for their health (doctor-oriented locus of control).
simpler words, etc.), while others state that they try to
“They never say, ‘I’ll solve that problem’. They say, get an insight into and show empathy for the living
‘You must solve the problem’.” conditions of the patient.
On the other hand, the respondents also show an “When someone is in the middle of a difficult period
understanding and empathy towards the predicaments in his life and he comes to see me about bronchitis,
faced by the poor. They try to identify the underlying I don’t tell him to quit smoking. Smoking is the only
 “Tell me about poverty” Page 5 of 7
thing he has left and it reduces his stress in a difficult
period. I tell him that it is a step in the right direction BOX 4 GPs’ suggestions for improvements to the healthcare
system
if he can cut down his smoking by half.”
A second area of intervention concerns the financial Cost-sharing
threshold. Most doctors regard the cost of medication as Education and training of caregivers
an important barrier. They try to reduce these costs by Teamwork
giving the patient free medication samples, prescribing Transparency in the social services available
the cheapest product or by critically analysing and
Prevention
adjusting the patient’s medication scheme. As far as
payment for the consultation is concerned, the GPs try to Patient education
reduce the burden for the patient by lowering or waiving
the fee, charging for one instead of two when examining
two persons from the same family, or by postponing the
accessibility of primary healthcare, the GPs suggest the
payment.
implementation of an income-related cost-share,
“I also ask my colleagues to reduce their fees, and especially for medication and the consultation fee. The
they generally do.” GPs also advocate specialised training in (communi-
cation) skills and knowledge in order to tailor the
A third course of action concerns referral to specialists

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content and the style of the consultation to the needs of
and other healthcare professionals. On the one hand, the
the deprived.
respondents report that patients’ financial problems
don’t necessarily delay referral to a specialist. However, “We should be better informed, as doctors. There was
they do try to manage the patient’s problem themselves a lack of information in my training on how to work
for as long as possible at primary healthcare level. with those people. We should talk more with people
A patient’s financial status has particular bearing who work daily with them and know them better.”
upon the extent of the “co-ordination of the referral to
Some physicians suggest improving the accessibility of
a specialist”. For deprived patients, the GP regularly
the healthcare system by creating more multidisciplinary
makes the appointment with the specialist, helps set
teams. They also want the social services available for
treatment priorities in the light of the patient’s priorities
the deprived to be more transparent.
in daily life, and refers the patient to a specialist who
does not demand large out-of-pocket payments. The GP “There is an enormous range of social services for
often checks the feasibility of the medical strategy the deprived. Sometimes, I don’t know which centre
proposed by the specialist, taking into account the to contact for which problem.”
specific living conditions of the patient.
Another suggestion is to stimulate patient education and
The GPs also report that they ask for the help of other
prevention.
medical or social caregivers to monitor the patient’s
situation and to advise the patient in administrative and “It is very important to put energy into prevention.
financial matters. GPs participating in a multidisciplinary Primary prevention, secondary prevention, . . . it’s
team consider this to be a very effective way of managing very important to make them realise that they
the patient’s care, although there is some concern about should live healthier lifestyles . . . . It should be
the efficiency of multidisciplinary meetings. someone from their peer group who tells them that.”
However, some doctors have a rather negative perce-
At community level, the GPs emphasize the important
ption due to the poor outcome, demanding attitude and
role of schools and teachers. Moreover, they point to the
medical shopping practised by the deprived, resulting in
need to improve the working conditions of the less
reduced motivation to expend energy on this patient
educated and to ‘supervise’ the unemployed when giving
group.
them unemployment benefits. They also feel that
“I have the feeling that when one works with the community projects focusing on restoring social networks
deprived, one gets into a vicious circle: I have the and improving the social skills, communication skills and
feeling that I work a lot but don’t get any results and coping skills of the deprived should be encouraged.
that takes away my motivation to expend more
“I think we should have more social contact in the
energy in this area.”
neighbourhood. In this respect, the creation of
community centres is very positive. And there
GPs’ suggestions for improvements to the healthcare
should be more benches in the neighbourhood so
system (Box 4)
that people can sit together and have a talk.”
The GPs offer suggestions for improving the accessibility
of primary healthcare for the deprived as well as Furthermore, the GPs refer to the credit agencies and the
suggestions at community level. Concerning the poor regulation of these institutions, having observed
Page 6 of 7 Family Practice—an international journal

that credit and over-spending can be a significant factor the deprived may have been overlooked in the
in the poverty of the patient. existing research because most previous work has been
quantitative in nature, whereas hypothesis-generating
qualitative methods are perhaps more appropriate for
Discussion this area of research.9
Care should be taken in when interpreting the results
All of the GPs interviewed for this project report being of this study, as the interviews with the GPs preclude the
confronted with the problem of accessibility of primary possibility of making definitive statements about the
healthcare for the deprived in their practice and show a nature of the relationship between doctors and deprived
varying level of commitment towards these patients. patients, since consultations were not directly observed.
In their definition of poverty, the doctors interviewed However, despite the potential for discrepancies
mention socio-economic aspects, psychological and between reported attitudes and actual behaviour, it does
personality characteristics and socio-cultural aspects as increasingly appear that measurements of prejudicial
being important. This conceptualization corresponds attitudes correlate well with measurements of behaviour
relatively well with the three dimensions of poverty in a wide variety of situations, suggesting that doctors’
defined in the literature on this subject, namely expressed attitudes may be reflected in their actions.9
economic well-being, capability and social exclusion.10 This study has several limitations. Although inter-
However, the respondents in this study seem to place views are an effective way of identifying and explor-

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greater emphasis on personality characteristics than ing perceptions, results can be biased and may not
the literature. Nevertheless, we can conclude that the represent all doctors’ perceptions and attitudes. For
doctors are mostly aware of the broader social and example, the fact that the interviewer is also a fellow
structural context of poverty, facilitating a more doctor could have influenced the answers of the
comprehensive approach to the problem. respondents. The challenge facing the interviewer was
Concerning the way GPs perceive the attitude of to obtain sufficient distance from the topic being
deprived people towards health and illness, evidence of investigated and to adopt an open attitude. This was
both paternalism and empathy was found. Some doctors achieved by collaborating with a social scientist to
adopt a ‘blaming the victim attitude’, but others take analyse the data.18 The use of a semi-structured inter-
a more emancipatory viewpoint, respecting the view guide also has some weaknesses, as important and
autonomy of the patient and stressing the importance of salient topics may be inadvertently omitted. Interviewer
‘empowerment’. When looking at how the GPs deal flexibility in sequencing and wording can result in
with deprived patients, we can conclude that the GPs’ substantially different responses, thereby reducing the
perceptions often lead to altruistic behaviour, as the comparability of responses.15 Where the number of
interviewed physicians show a high level of creativity respondents is concerned, we can conclude that
and commitment in the search for individual solutions. although the sample size of 21 GPs was set before
Three types of actions aimed at reducing the barriers starting the interviewing process and could therefore
can be identified: action concerning communication, have limited the scope of the analysis, saturation was
action in respect of the financial burden and action almost reached. That is to say, practically no new aspects
regarding referral to specialists and other caregivers, were found. One further limitation is that all the doctors
with some considering multidisciplinary teams to be a work in a deprived area of one Belgian city (Ghent),
very useful tool. However, negative perceptions can whereas interviewing GPs working in more affluent
sometimes lead to more negative consequences such as areas could possibly have added interesting findings to
doctors lowering their expectations of deprived patients, the results. Specific features of the Belgian healthcare
a perceived lack of results leading to reduced motiva- system, such as direct access to GPs and specialists at
tion to invest energy, etc. any time for any reason, fee-for-service with 33% cost-
When asking for suggestions for improving primary share by the patients and the fact that the majority of the
healthcare for the deprived, the GPs refer to actions to doctors work in single-handed practices, could have
improve financial accessibility and suggest solutions at influenced the answers of the respondents. However,
community level. Finally, the GPs refer to the structural this impact could be assumed to be rather small, due to
aspects of poverty such as the need for suitable employ- the universal nature of the concepts researched in this
ment opportunities and improved regulation of credit study, and is limited to topics concerning the financial
agencies. threshold. Finally, it would be interesting to integrate
This study is the first on this topic and the results the results of this study into a multi-method approach
provide a new and valuable insight in this research area. where quantitative methods are also used.19
No similar study investigating the physician’s definition The findings of this study may contribute to the
of poverty and his/her beliefs and attitudes concerning underpinning of medical student undergraduate training
deprived patients was found in the literature. The extent and in-service training, the planning of accessible
to which the GP acts as a barrier to healthcare for healthcare services for all patients and the strengthening
 “Tell me about poverty” Page 7 of 7
of social cohesion in the community. We found that Ethical approval: The study has been subject to ethical
although the doctors are aware of the broader social and review by the Ethics Committee of the Ghent University
structural context of poverty, they sometimes have a Hospital (ref: 2004/261).
rather negative image of the patient’s attitude towards Conflicts of interest: none.
health and illness and act within a rather ‘paternalistic’
framework. Previous research showed that if doctors fail
to provide a positive, patient-centred approach, References
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