Seeking Health Care at Emergency Departments

Access issues affecting Aboriginal people

Annette J. Browne, PhD, RN

Reprinted from "Aboriginal People" issue of Visions Journal, 2008, 5 (1), pp. 24-25

Many Aboriginal people have difficulty accessing health care services. I am a member of a team of university and community-based researchers1 who want to see people’s access to primary health care services improved. We have been conducting a study2 to help us understand more fully the social and health factors that make accessing health services difficult for many Aboriginal people in inner city areas. As we discuss below, many of the people in this study were affected by mental health and substance use issues.

Overview of our study

Access to health care is heavily influenced by social, economic and political factors. For Aboriginal people who are living in inner city neighbourhoods, many experience high rates of poverty, unemployment and lack of access to adequate housing. Many people have also been affected by intergenerational trauma from residential schools. Together, these issues can result in higher rates of mental health problems such as anxiety or depression, or in some cases, addictions. Many people also experience discrimination on the basis of their status as Aboriginal people, poor people or people living with mental health and addictions. All these factors can make it difficult for some Aboriginal people to get the help they need.

The problem of accessing services is made worse because many physicians’ offices do not accept new patients; this is partly because their practices are full. There are also some physicians who choose not to work with people who have complex health problems, particularly when these include mental health or addictions issues.

In the inner city neighbourhood where the study was conducted, there are many clinics and doctors’ offices. However, a relatively high number of Aboriginal people seek help, at a particular inner city emergency department (ED), for “walk-in” types of health issues ranging from sprains, mild fractures and abdominal problems, to requests for medications to relieve chronic pain. Once people started to explain their situation, however, it became clear that many were also living with addictions issues and/or mental health issues, and dealing with the effects of poverty.

The focus of this study was not on emergency visits for acute or life-threatening health problems. We interviewed (in depth) 34 people who self-identified as Aboriginal and who were, for the most part, “walk-in” patients seeking help at a non-urgent division of a large ED. The majority lived in an inner city neighbourhood recognized as one of the poorest in Canada. Many lived in very poor conditions, in rooming houses or in shelters. Some were homeless. Many had experienced trauma and violence as children and young adults, and now lived with chronic pain, anxiety and depression. Many lived with addictions to illicit drugs, alcohol or prescription drugs.

Highlights from the research findings

A major issue for many of the participants in this study was the challenge of getting help for chronic pain and related health issues. We know that people who have serious drug or alcohol addictions often live with chronic pain, and that people with chronic pain often have experienced severe emotional trauma or violence in their life. There are also links between people’s mental health problems, experiences of chronic pain and histories of trauma.

What we learned from the patients in this study is that their chronic pain was not only physical in nature, but reflected the pain of “social suffering.” Social suffering refers to mental, social and emotional pain people experience because of economic, historical, political and institutional power inequities.3 In the case of the Aboriginal people in this study, these health issues were the end result of personal and intergenerational traumas, marginalization, stigma and discrimination that are part and parcel of the history of colonization of Aboriginal people in Canada.

In terms of getting temporary relief for their chronic pain, for some participants, the ED was viewed as the “best bet.” That was because of their experiences trying to get health care in other places in the community. As the patients described, they often felt dismissed or not taken seriously when they went to doctors’ offices, community clinics or walk-in offices. They felt uncomfortable going to those places because they thought they would be negatively judged as drug seeking or not having real health concerns.

In some cases, people were concerned about how they would be judged by health care providers in community or walk-in clinics because of their “rough appearance” (rough because they were living on the street, were barely housed, or were living with severe addictions). As one man who lives with addiction, chronic pain and anxiety expressed about his experience at a walk-in clinic, “I don’t know if it was because I didn’t shave that day. I was all scruffy and I came in and just sat there . . . So, um, nothing against street people or that, I used to be one, but you know, if that was his [the health care provider’s] impression, he didn’t tell me. He didn’t say anything, but he just told me to go home. But the pain is bad and it’s been happening for quite a few months now.”

At the ED, they knew that they would be seen and treated—eventually—even if it meant waiting a long time. For some people, this was better than risking the chance of being sent home without being seen, or without having their needs addressed at community or walk-in clinics.

A 59-year-old woman in our study who lived with major anxiety and chronic pain told us how she repeatedly sought help at two EDs in her downtown neighbourhood—because she didn’t know what else to do to get help. At walk-in clinics or community clinics, she was often told there was nothing they could do for her. This only served to worsen her anxiety, and made her question whether she was, in fact, having pain. This process of second-guessing herself resulted in delays getting the help she really needed. Because she ended up waiting until she was very ill before coming to the ED, the nurses there questioned her decision to wait for so long before coming in. This, too, fed her anxiety.

This woman also spoke openly about how her experiences in residential school, and the anxiety and pain she attributed to those experiences, made it hard for her to relate to people in authority positions—including doctors or nurses. This also created anxiety for her about where to go for health care. As a result, she repeatedly came to the inner city ED.

The ED, however, was not always a good place for this woman to be. She, and many other people in the study, had mixed feelings about EDs. For example, she described the frustrations expressed toward her by some ED staff, who couldn’t relate to why she kept coming in. As she described, “He [an ED staff person at one of the hospitals] said, ‘You know how many times you have been here?’ I said, ‘No.’ He said, ‘Thirty-three times.’ And I said, ‘Well, this is a hospital, right?’” She went on to say, “I didn’t really need to hear it, because I was really having a lot of problems with myself. And I didn’t understand it, because being raised in the residential school, you’re always told to shut up and we didn’t have any opinion about anything. So it was really hard for me to converse with doctors.”

This woman’s example, and others, help us to understand how challenging it can be for some Aboriginal people to get help with health or mental health problems they feel are legitimate. Although many of the people in this study did get the help they needed at this inner city ED, many also described the worry they experienced about how they would be treated the next time—not just at this ED, but in the wider system of health care.

Conclusions

Our study showed that people’s reasons for coming to the ED for walk-in issues are shaped by complex social, economic and personal factors. In the case of the Aboriginal people who participated in this study, these factors include:

  • past experiences at various health care settings

  • patients’ own assumptions about how they’ll be treated in walk-in clinics, doctors’ offices and community clinics, given their identity as Aboriginal people, their low socio-economic status, their appearance because of living on or near the street, and their mental health or addictions issues

  • worries that their health concerns will be dismissed because of assumptions made about them by health providers in walk-in clinics, doctors’ offices and community clinics

  • difficulty relating to authority figures as a result of residential school experiences or other traumatic issues in their lives

For the people in this study, these factors created an underlying anxiety about seeking health care in general—at EDs and at other settings. Until there are significant improvements in the availability of other responsive, welcoming and effective services, EDs may need to continue as non-emergency health access sites for many people.

 
About the author

Annette is an Associate Professor in the School of Nursing at the University of British Columbia. She holds a New Investigator Award from the Canadian Institutes of Health Research and a Scholar Award from the Michael Smith Foundation for Health Research

Acknowledgements:

Funding for this study was provided by the Canadian Institutes of Health Research (CIHR).

We are very grateful to the many patients who generously shared their experiences with us.

 

Footnotes:
  1. The research team includes, in alphabetical order: Annette J. Browne, Betty Calam, Nadine Caplette, Lou Demerais, Tanu Gamble, Jane McCall, Rod McCormick, Bill Mussell, John O’Neil, Patricia Rodney, Vicki Smye, Sannie Tang, and the members of our Community Advisory Committee.

  2. This article is based on findings from a study that has recently been completed. Contact Annette.Browne@nursing.ubc.ca for copies of the research summary report or articles published from this study.

  3. Kleinman, A., Das, V. & Lock, M. (Eds.). (1996). Social suffering. Berkeley: University of California Press.