Family Practice Advance Access originally published online on February 14, 2005
Family Practice 2005 22(2):177-183; doi:10.1093/fampra/cmh724
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The GP's perception of poverty: a qualitative study
Department of General Practice and Primary Healthcare, Ghent University, Belgium
Correspondence to Sara Willems, Ghent University, Department of General Practice and Primary Healthcare, UZ–1K3, De Pintelaan 185, B-9000 Ghent, Belgium; Email: Sara.Willems{at}ugent.be
Received 1 July 2004; Accepted 27 September 2004.
Willems SJ, Swinnen W and De Maeseneer JM. The GP's perception of poverty: a qualitative study. Family Practice 2005; 22: 177–183.
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Abstract |
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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. 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.
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Introduction |
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Despite marked health improvements in the overall population, evidence of systematic differences in health between people from lower and higher social classes has been accumulating rapidly in recent years. The explanations for this are frequently explored but remain largely unclear.1,2 These multiple and complex causes include individual factors such as personal history (e.g. childhood socio-economic status and living conditions) and education, structural factors such as income, housing facilities, the unequal distribution of risk factors in the population and barriers to the accessibility of the healthcare system, all of which lead to differences in usage of healthcare.1–8
Numerous studies have identified different barriers to the process of obtaining adequate and timely medical care, particularly for patients from disadvantaged groups. In the categorization of these barriers, a distinction can be made between those on the user's side and those on the provider's side. On the user's side, there is documentary evidence of socio-demographic barriers, psychological barriers, barriers related to the patient's knowledge, attitude towards illness and towards the healthcare system, and barriers created by the characteristics of the patient's social and environmental background. However, one explanation for the inequalities in healthcare usage that is considered to be much more significant and which receives considerably more attention from those concerned with improving the health of the poor concerns the barriers on the provider's side.9 That is to say, the barriers related to the characteristics of the healthcare system and those related to the personal attributes of the healthcare providers. In this context, the concept of attributes refers to the GP's perceptions and attitudes, such as his/her conceptualization of poverty and his/her attitude towards deprived patients. It is reasonable to assume that these attributes have an impact on the doctor's consultation style and the relationship with the patient and can act as a barrier for deprived patients.
Poverty studies distinguish three dimensions in the conceptualization of poverty: economic well-being, social exclusion and capability. Economic well-being stems from the issue of whether someone has sufficient income to acquire a basic level of consumption or human welfare. Secondly, the social isolation of the poor from the rest of society can be perceived as a cause of poverty. Finally, poverty can be regarded as a function of the lack of the individual skills, such as education or health, needed to attain a basic level of human well-being.10
Little is known about how GPs define poverty, their attitudes towards deprived patients and their perception of the attitude of those patients towards health and the healthcare system. The aim of this study is to explore these perceptions and attitudes, thereby obtaining an insight into the ways GPs deal with the problem of poverty and their proposals for improving healthcare for the poor.
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Subjects and setting
The study took place in the city of Ghent (population 200 000) in Belgium. In view of the exploratory hypothesis-generating nature of this research, a qualitative method based on semi-structured interviews was used. Qualitative research enables us to access an area that does not lend itself to quantitative research and has the added advantage of uncovering issues or concerns that had not been anticipated or considered by the researcher, a restriction implicit in the use of closed-ended questions.11–13 The choice of semi-structured face-to-face interviews was made based on prior negative experiences of gathering 6 to 8 GPs at one time. After the interviews, some of the respondents reported that they had appreciated this technique on account of the somewhat sensitive nature of the subject. We used a purposive sampling strategy to select 25 participants, aiming for maximum variation in the type of practice (single-handed practices, practices with a patient list and capitation, community health centres with a patient list and without capitation), the GP's district of work (the different deprived areas of Ghent), his/her number of years of experience and gender. The deprived areas were identified according to the "Atlas of poverty", which uses the following indices: the concentration of migrants, the number of inhabitants with low incomes, long-term unemployed, receipt of financial support from the government and the number of candidates on the waiting list for social housing.14 All 25 GPs (8 female and 17 male, making up 33% of the doctors working in the deprived areas of Ghent) were contacted by phone and 21 agreed to participate in the study (84%).
Interviews
Data was collected using a loose structured interview guide consisting of open-ended questions. The questions defined the area to be explored and formed the basis from which the interviewer or the interviewee could diverge in order to pursue an idea in more detail.13 The advantage of the use of an interview guide is that it increases the comprehensiveness of the data and makes the data collection process more systematic for each respondent. Furthermore, logical gaps in data can be anticipated and closed. It also keeps the interviews fairly conversational and situational.15 The interview guide used in this study was developed from literature covering the topic of questioning one's attitude and beliefs towards a certain topic and through discussions with experts in qualitative research.14 One pilot interview was conducted to test whether the questions in the interview guide met the basic principles of good questions for qualitative research of open-endedness, 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 during the course of the research interviews.
The interview guide consisted of the following core questions defining the area to be covered:
How would you define the concept of ‘poverty’?How do you perceive the attitude of deprived people towards health and illness?
How do you deal with deprived patients?
What would you suggest to improve healthcare for deprived patients?
WS, a GP and research fellow at the Department of General Practice and Primary Healthcare, conducted the interviews. He adopted a non-directive approach to encourage the physicians to develop and elaborate their own perspectives. Interviews lasted from 40 to 90 minutes and were conducted in the GPs' surgeries. They were tape-recorded and fully transcribed.
Analysis
The individual transcripts were analysed using Framework Analysis techniques. This approach employs sifting, charting and sorting the material in a systematic manner in order to allow key issues and themes to emerge. A priori issues are integrated into the data analysis.16 The interview transcripts were read repeatedly and were first coded independently by two researchers (WS and SW) to capture the range and the diversity of the GPs' perceptions and to compare them across transcripts. Recurrent themes reflect a shared understanding among GPs of the phenomena under investigation. Furthermore, ideas on emerging themes were compared and modified until agreement was reached. This was a dynamic process, with each transcript informing both the collection of further data and their subsequent analysis. The entire process was supervised by a senior researcher (JDM). The criteria of credibility, transferability, dependability and confirmability outlined by Lincon and Guba (1999) were adopted as tests of thoroughness and trustworthiness.16 As is usual in qualitative research, the data is presented in the form of general concepts illustrated with quotations.
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Results |
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All respondents were Caucasian; 14 (70%) were doctors working in a single-handed practice; 1 worked in a practice with a patient list and capitation and 2 worked in a community health centre; for 3 of the GPs, the type of practice is not known. Their workload varies between 5–15 hours/day and consultation times vary between 10–20 minutes per patient. The average time in practice was 15.7 years (range: 1–36 years).
GPs' conceptual model for poverty: causes and effects (Box 1)
In the conceptual model for poverty described by GPs, socio-economic aspects, patients' psychological and individual characteristics, and socio-cultural aspects can be identified. Almost all respondents refer to socio-economic aspects (Box 1) as being significant factors in poverty. Specifically, the physicians refer to low income, poor education, unemployment and bad housing as significant factors.
| BOX 1 GPs' conceptual model for poverty: causes and effects Socio-economic aspects Low income Low education Unemployment Bad housing Psychological aspects and patient's individual characteristics Lack of ambition and motivation to improve the situation Lack of skills to manage the household budget Limited intellectual capacity Lack of social and relational skills Limited communication skills Addiction-related problems Laziness Fear of what might happen in the future Lower health status Socio-cultural aspects Negative influence of the social group Social isolation Passed on from one generation to the following generation: impossible to break this vicious circle Consumerism (overspending) Large family sizes Impact of society: inadequate reaction to poverty
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Patients' psychological and individual characteristics (e.g. attitudes and coping skills) (Box 1) are also considered important in the definition of poverty, although the stipulation of this aspect is less homogeneous. The most commonly cited feature in this context is lack of ambition and motivation to improve the situation.
"They don't want to change their situation ...; they are used to it. They no longer have the courage to change it."Furthermore, a lack of the skills needed to manage their budget, limited intellectual capacity and a lack of social and relational skills are mentioned. Finally, the GPs identify limited communication skills, addiction, laziness, fear of what might happen in the future and lower health status as individual determining factors in poverty.
The definition of poverty also identifies socio-cultural aspects (Box 1), the most important of which is the negative influence of the social group, or more specifically, the negative influence of parents on their children. The social isolation of the deprived patient is also a significant factor. On this subject, some respondents refer to the fact that poverty is structurally transmitted from one generation to another and consider it almost impossible to break this vicious circle.
"If the father is a workman, the son is a workman, etc. Children who want to study have to be very intelligent and need to have a very strong personality. They have to distance themselves from their family. Otherwise it is not possible."A minority of the GPs refer to the role of society and inadequate reaction to poverty.
"If there were stricter laws on payment on credit, the problems caused by buying large amounts of goods on account would not be possible anymore."Finally, consumerism (overspending) and large family sizes are mentioned as factors behind poverty.
GPs' perceptions about deprived persons' views of the health services (Box 2)
On the one hand, GPs sometimes have a rather negative idea of the patients' attitude, referring to the limited knowledge and insight of deprived patients into health and illness and their limited interest and motivation to change their health-related behaviour.
"They are not interested in their health. They don't see the advantage of, for example, healthy food."GPs also point out the inadequate use of medical services by deprived patients, such as use of the emergency services for primary healthcare problems. In relation to preventive care for the deprived, the GPs report lower usage, partly because of financial restrictions but also because of limited knowledge, the short-term outlook of patients and their lack of motivation and "stability".
"People from this patient group are more focused on the present. They come to the practice when they have an acute problem, but you need a lot of persuasive qualities to make them come for the monitoring of chronic conditions or for prevention."Deprived patients are sometimes considered as the more "floating patient group", i.e. not consulting the same doctor each time. This could be related to the availability of the GP and the nature and the content of the healthcare provided (does the doctor meet the patient's expectations?). On this subject, the respondents refer to this patient group as very focused on getting sick-leave certification and on short-term symptom relief. The respondents have the feeling that people living in poverty expect the doctor to take all the responsibility for their health (doctor-oriented locus of control).
"They never say, ‘I'll solve that problem’. They say, ‘You must solve the problem’."On the other hand, the respondents also show an understanding and empathy towards the predicaments faced by the poor. They try to identify the underlying mechanisms for the patient's risk-related behaviour or his/her ‘inadequate’ use of healthcare services, such as penurious living conditions leading to high levels of psycho-social stress, the lack of a social network to appeal to when in the need of help, and the fear of being considered a bad parent or of having their children taken away from them by social services.
"They rarely postpone healthcare for their children; they really want the best care for their children. I think they consider them as one of the few good things they have left and they don't want to be considered as a bad parent."
| BOX 2 GPs' perceptions about deprived persons' views of the health services Limited knowledge and insight in own health and illness Limited interest and motivation to change health-related behaviour Inadequate use of medical services "Floating patient group" possibly related to the availability of the GP and the nature and content of the healthcare provided Short term symptom relief Doctor-oriented locus of control Trying to identify the underlying mechanisms for the patient's risk-related behaviour, inadequate use of healthcare ... Penurious living conditions leading to high levels of psycho-social stress Fear of having their children taken away or to be considered a bad parent Lack of help from social network
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GPs' strategies for dealing with deprived patients in primary care (Box 3)
Most of the GPs feel they play an important role in the patient's life, monitoring their physical, psychological and social health and well-being and enjoying their trust. They generally have a positive attitude towards working with deprived patients and regard contact with them as warm, spontaneous and rewarding. This results in attempts to lower the primary healthcare threshold for deprived patients.
| BOX 3 GPs' strategies for dealing with deprived patients in primary care Change in modes of communication: Different language use (easier wording, etc.) Trying to get an insight into and show empathy for the living conditions of the patient Cost reduction: Free medication samples Prescribing the cheapest product Critically analysing and adjusting the medication scheme Reducing or waiving fee Asking for one fee in stead of two when examining two persons from the same family Postponing payment Taking on increased responsibility: Managing the patient's problem as long as possible at primary healthcare level More co-ordinated referrals to specialists Requesting help from other medical or social caregivers
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A first approach concerns doctor–patient communication. Some mention that they speak differently (using simpler words, etc.), while others state that they try to get an insight into and show empathy for the living conditions of the patient.
"When someone is in the middle of a difficult period in his life and he comes to see me about bronchitis, I don't tell him to quit smoking. Smoking is the only 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 if he can cut down his smoking by half."A second area of intervention concerns the financial threshold. Most doctors regard the cost of medication as an important barrier. They try to reduce these costs by giving the patient free medication samples, prescribing the cheapest product or by critically analysing and adjusting the patient's medication scheme. As far as payment for the consultation is concerned, the GPs try to 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 payment.
"I also ask my colleagues to reduce their fees, and they generally do."A third course of action concerns referral to specialists and other healthcare professionals. On the one hand, the respondents report that patients' financial problems don't necessarily delay referral to a specialist. However, they do try to manage the patient's problem themselves for as long as possible at primary healthcare level.
A patient's financial status has particular bearing upon the extent of the "co-ordination of the referral to a specialist". For deprived patients, the GP regularly makes the appointment with the specialist, helps set treatment priorities in the light of the patient's priorities in daily life, and refers the patient to a specialist who does not demand large out-of-pocket payments. The GP often checks the feasibility of the medical strategy proposed by the specialist, taking into account the specific living conditions of the patient.
The GPs also report that they ask for the help of other medical or social caregivers to monitor the patient's situation and to advise the patient in administrative and financial matters. GPs participating in a multidisciplinary team consider this to be a very effective way of managing the patient's care, although there is some concern about the efficiency of multidisciplinary meetings.
However, some doctors have a rather negative perception due to the poor outcome, demanding attitude and medical shopping practised by the deprived, resulting in reduced motivation to expend energy on this patient group.
"I have the feeling that when one works with the deprived, one gets into a vicious circle: I have the feeling that I work a lot but don't get any results and that takes away my motivation to expend more energy in this area."
GPs' suggestions for improvements to the healthcare system (Box 4)
The GPs offer suggestions for improving the accessibility of primary healthcare for the deprived as well as suggestions at community level. Concerning the accessibility of primary healthcare, the GPs suggest the implementation of an income-related cost-share, especially for medication and the consultation fee. The GPs also advocate specialised training in (communication) skills and knowledge in order to tailor the content and the style of the consultation to the needs of the deprived.
"We should be better informed, as doctors. There was a lack of information in my training on how to work with those people. We should talk more with people who work daily with them and know them better."Some physicians suggest improving the accessibility of the healthcare system by creating more multidisciplinary teams. They also want the social services available for the deprived to be more transparent.
"There is an enormous range of social services for the deprived. Sometimes, I don't know which centre to contact for which problem."Another suggestion is to stimulate patient education and prevention.
"It is very important to put energy into prevention. Primary prevention, secondary prevention, ... it's very important to make them realise that they should live healthier lifestyles .... It should be someone from their peer group who tells them that."At community level, the GPs emphasize the important role of schools and teachers. Moreover, they point to the need to improve the working conditions of the less educated and to ‘supervise’ the unemployed when giving them unemployment benefits. They also feel that community projects focusing on restoring social networks and improving the social skills, communication skills and coping skills of the deprived should be encouraged.
"I think we should have more social contact in the neighbourhood. In this respect, the creation of community centres is very positive. And there should be more benches in the neighbourhood so that people can sit together and have a talk."Furthermore, the GPs refer to the credit agencies and the poor regulation of these institutions, having observed that credit and over-spending can be a significant factor in the poverty of the patient.
| BOX 4 GPs' suggestions for improvements to the healthcare system Cost-sharing Education and training of caregivers Teamwork Transparency in the social services available Prevention Patient education
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Discussion |
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All of the GPs interviewed for this project report being confronted with the problem of accessibility of primary healthcare for the deprived in their practice and show a varying level of commitment towards these patients.
In their definition of poverty, the doctors interviewed mention socio-economic aspects, psychological and personality characteristics and socio-cultural aspects as being important. This conceptualization corresponds relatively well with the three dimensions of poverty defined in the literature on this subject, namely economic well-being, capability and social exclusion.10 However, the respondents in this study seem to place greater emphasis on personality characteristics than the literature. Nevertheless, we can conclude that the doctors are mostly aware of the broader social and structural context of poverty, facilitating a more comprehensive approach to the problem.
Concerning the way GPs perceive the attitude of deprived people towards health and illness, evidence of both paternalism and empathy was found. Some doctors adopt a ‘blaming the victim attitude’, but others take a more emancipatory viewpoint, respecting the autonomy of the patient and stressing the importance of ‘empowerment’. When looking at how the GPs deal with deprived patients, we can conclude that the GPs' perceptions often lead to altruistic behaviour, as the interviewed physicians show a high level of creativity and commitment in the search for individual solutions. Three types of actions aimed at reducing the barriers can be identified: action concerning communication, action in respect of the financial burden and action regarding referral to specialists and other caregivers, with some considering multidisciplinary teams to be a very useful tool. However, negative perceptions can sometimes lead to more negative consequences such as doctors lowering their expectations of deprived patients, a perceived lack of results leading to reduced motivation to invest energy, etc.
When asking for suggestions for improving primary healthcare for the deprived, the GPs refer to actions to improve financial accessibility and suggest solutions at community level. Finally, the GPs refer to the structural aspects of poverty such as the need for suitable employment opportunities and improved regulation of credit agencies.
This study is the first on this topic and the results provide a new and valuable insight in this research area. No similar study investigating the physician's definition of poverty and his/her beliefs and attitudes concerning deprived patients was found in the literature. The extent to which the GP acts as a barrier to healthcare for the deprived may have been overlooked in the existing research because most previous work has been quantitative in nature, whereas hypothesis-generating qualitative methods are perhaps more appropriate for this area of research.9
Care should be taken in when interpreting the results of this study, as the interviews with the GPs preclude the possibility of making definitive statements about the nature of the relationship between doctors and deprived patients, since consultations were not directly observed. However, despite the potential for discrepancies between reported attitudes and actual behaviour, it does increasingly appear that measurements of prejudicial attitudes correlate well with measurements of behaviour in a wide variety of situations, suggesting that doctors' expressed attitudes may be reflected in their actions.9
This study has several limitations. Although interviews are an effective way of identifying and exploring perceptions, results can be biased and may not represent all doctors' perceptions and attitudes. For example, the fact that the interviewer is also a fellow doctor could have influenced the answers of the respondents. The challenge facing the interviewer was to obtain sufficient distance from the topic being investigated and to adopt an open attitude. This was achieved by collaborating with a social scientist to analyse the data.18 The use of a semi-structured interview guide also has some weaknesses, as important and salient topics may be inadvertently omitted. Interviewer flexibility in sequencing and wording can result in substantially different responses, thereby reducing the comparability of responses.15 Where the number of respondents is concerned, we can conclude that although the sample size of 21 GPs was set before starting the interviewing process and could therefore have limited the scope of the analysis, saturation was almost reached. That is to say, practically no new aspects were found. One further limitation is that all the doctors work in a deprived area of one Belgian city (Ghent), whereas interviewing GPs working in more affluent areas could possibly have added interesting findings to the results. Specific features of the Belgian healthcare system, such as direct access to GPs and specialists at any time for any reason, fee-for-service with 33% cost-share by the patients and the fact that the majority of the doctors work in single-handed practices, could have influenced the answers of the respondents. However, this impact could be assumed to be rather small, due to the universal nature of the concepts researched in this study, and is limited to topics concerning the financial threshold. Finally, it would be interesting to integrate the results of this study into a multi-method approach where quantitative methods are also used.19
The findings of this study may contribute to the underpinning of medical student undergraduate training and in-service training, the planning of accessible healthcare services for all patients and the strengthening of social cohesion in the community. We found that although the doctors are aware of the broader social and structural context of poverty, they sometimes have a rather negative image of the patient's attitude towards health and illness and act within a rather ‘paternalistic’ framework. Previous research showed that if doctors fail to provide a positive, patient-centred approach, including aspects such as approaching the patient as a whole person and trying to find common ground, patients will be less satisfied, less enabled, and may have greater symptom burdens and higher rates of referral.20
Including the issue of poverty in the medical student curriculum and in-service training for practicing doctors could have a positive impact on their attitude towards this patient group. The growing importance of communication skills training in many medical school curricula should also provide opportunities to challenge stereotypes, enabling each student to reflect on their consulting styles and to actively consider behaviour that encourages patient participation rather than medical paternalism.9,21
With regard to the planning of accessible healthcare services, further research is needed into the barriers to the accessibility of the healthcare system for the deprived. As part of this, it is important not only to quantitatively analyse variables such as consumption patterns and out-of-pocket payments but also to qualitatively explore the experiences and living conditions of deprived patients and the perception of healthcare providers. This bi-axial approach could contribute to the development of a healthcare system that meets the expectations of the target group. The short-term perspective of the target group and the long-term perspective of the providers need to coincide.
Finally, the fundamental solution for reducing socio-economic inequalities in health is to tackle poverty and to pursue equity in income, education and social participation. Community projects that focus on the restoration and development of social networks and social cohesion and on the improvement of the social, communication and coping skills of the deprived, should be encouraged.22 Multidisciplinary primary healthcare teams can play an important role in these projects because, very often, they are the only link left between the patient and society.
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Declaration |
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Funding: this research has been carried out with a grant from the Ministry of Employment and Social Affairs of the Flemish Community.
Ethical approval: The study has been subject to ethical review by the Ethics Committee of the Ghent University Hospital (ref: 2004/261).
Conflicts of interest: none.
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Acknowledgments |
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We would like to thank all our colleagues for their editorial comments on earlier versions of the manuscript. We are also grateful to the GPs for participating in this study.
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1 Mackenbach J, Van De Mheen H, Stronks K. A prospective cohort study investigating the explanation of socio-economic inequalities in health in the Netherlands. Soc Sci Med 1994; 38: 299–308.[CrossRef][ISI][Medline]
2 Power C, Matthews S. Origins of health inequalities in a national population sample. Lancet 1997; 350: 1584–1589.[CrossRef][ISI][Medline]
3 Benzeval M, Judge K, Whitehead M. Tackling inequalities in health. London: King's Fund; 1995.
4 Van de Mheen H, Stronks K, Looman CWN, Mackenbach JP. Does childhood socioeconomic status influence adult health through behavioural factors? Int J Epidemiol 1998; 27: 431–437.
5 Lundberg O. The impact of childhood living conditions on illness and mortality in adulthood. Soc Sci Med 1993; 36: 1047–1052.[CrossRef][ISI][Medline]
6 Sturm R, Gresenz CR. Relations of income inequalities and family income to chronic medical conditions and mental health disorders: national survey. Br Med J 2002; 324: 1–5.
7 Field K, Cart FB, Briggs J. Socio-economic and locational determinants of accessibility and utilization of primary health-care. Health Soc Care Community 2001; 9: 294–308.[CrossRef][ISI][Medline]
8 Alter DA, Naylor CD, Austin P, Tu JV. Effects of Socioeconomic Status on Access to Invasive Cardiac Procedures and on Mortality after Acute Myocardial Infarction. N Engl J Med 1999; 341: 1359–1367.
9 Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed Access to Health Care: Risk Factors, Reasons, and Consequences. Annals of Internal Medicine 1991; 114: 325–331.[CrossRef][ISI][Medline]
10 Udaya Wagle. Rethinking poverty: definition and measurement. Int Soc Sci J 2002; 54: 155–165.[CrossRef]
11 Morse M, Field P. Qualitative Research Methods for Health Professionals. Thousand Oaks: Sage Publications; 1995.
12 Kitzinger J. The methodology of focus groups: The importance of interaction between research participants. Social Health Illn 1994; 16: 103–121.
13 Pope C, Mays N. Qualitative Research: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Br Med J 1995; 311: 42–45.
14 Dienst Economische Expansie en Tewerkstelling. Socio-economisch profiel van de stad Gent en zijn Stadsgewest. In Buyse L. Atlas Kansarmoede. Brussel: Mens en Ruimte; 1992. (http://www.gent.be)
15 Patton MQ. How to use qualitative methods in evaluation. London: Sage; 1987, 108–143.
16 Bryman A, Burgess G (ed.). Analysing qualitative data. London: Routledge; 1994, 173–194.
17 Lester H, Bradley C. Barriers to primary healthcare for the homeless. The general practitioner's perspective. Eur J Gen Pract 2001; 7: 6–12.
18 Britten N, Jones R, Murphy E, Stacy R. Qualitative research methods in general practice and primary care. Fam Pract 1995; 12: 104–114.
19 Pope C, Mays N. Qualitative Research: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Br Med J 1995; 311: 42–45.
20 Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S. Observational study of effect of patient-centredness and positive approach on outcomes of general practice consultations. Br Med J 2001; 323: 908–911.
21 Kelly ME, Fenlon NP, Murphy AW. An approach to education about, and assessment of, attitude in undergraduate medical education. Ir J Med Sci 2002; 171: 206–210.[ISI][Medline]
22 De Maeseneer J, Derese A. Community-oriented primary care. Eur J Gen Prac 1998; 4: 49–50.
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