A systematic review of health status, health seeking behaviour and healthcare utilisation of low socioeconomic status populations in urban Singapore

Singapore is an urbanised Asian society with high cost of living. In a world-wide survey on the cost of living, Singapore emerged as the most expensive city to live in [1]. The affordability of housing is a major area of concern. In a survey of voters, cost of living and affordability of housing was among the top 3 issues that people worry about most. Income disparity in the country is high with a GINI Co-efficient of 0.458 in 2016 [2]. Even then, this was the lowest level in a decade after concerted government efforts to reverse a widening trend. At the same time, Singapore’s population is ageing rapidly, and 1 in 5 persons will be over 65 years old by the year 2030 [3]. Increased healthcare spending is anticipated and Singapore’s healthcare costs is expected to rise nearly tenfold over the next 15 years. With high levels of income disparity, increasing healthcare cost and a decreasing old-age support ratio, elderly persons with poor social support are at the highest risk of having poor health outcomes. These at-risk seniors are most likely to reside in public rental housing which are heavily subsidised by the Singapore government.

It is well-established that low socioeconomic status (SES) influences one’s health, rate of morbidity and mortality [4‐6]. SES influence health via the interaction between the individual’s socioeconomic characteristics as well as their area’s socioeconomic conditions [7, 8].

Educational level, income status, employment status, financial assistance requirement are examples of individual-level measures of SES. Unfortunately, such information are not routinely collected during healthcare encounters. Hence, using such measures to identify at risk population may not be practical. On the other hand, housing information such as residency in public rental housings are readily available and has been used as an area-level measure of SES. This information is collected in almost all healthcare encounters and the unique postal codes correspond to individual houses and apartment blocks.

Housing has been known to be an important social determinant of health [9, 10]. In Singapore, housing is not geographically segregated according to SES, instead there is a mixture of public rental housing together with owner-occupied public housing within each residential precinct. The home ownership rate of resident households in Singapore is among the highest in the world at 90.9% [11]. Households that cannot afford to purchase their own homes and have no other housing options are offered heavily subsidized rental housings under the Public Rental Scheme [12]. Such rental housings form clusters within residential precincts and studying residents in these micro-communities may provide useful insights on the impact of low socioeconomic status on health, within a relatively affluent society.

Using residency in public rental housing as a marker of low SES, our aim is to review studies on the association between staying in public rental housing in Singapore (as a low SES community) and health (health status, health seeking behaviour and healthcare utilisation).

As shown in Figs. 1, 26 and 24 potentially relevant articles were retrieved through the PubMed and Scopus searches respectively. The abstracts of these articles were evaluated for relevance to the aims of this review. Articles that were not related to health, or not done specifically on public rental housing or not based in Singapore were excluded. Another 2 articles were identified from hand search of bibliographic references of the shortlisted articles. A total of 14 articles which includes 4 prospective studies [13‐16], 8 cross-sectional studies [17‐24] and 2 retrospective cohort studies [25, 26] were obtained for the review. Among these studies, 4 of the articles included qualitative interviews [14, 20, 23, 24]. Effect of a community interventional program on outcomes was also studied in 4 of the articles [13, 15, 16, 22]. Most of the prospective studies were done with the comparison of outcomes between the rental housing and owner-occupied housing community. Tables 1 and 2 summarised the description and results of the 14 articles reviewed.

Socio-demographic characteristics of the population were collected in all the articles. There was a larger proportion of elderly living in the rental housing. More than half of them were single and not married. There was an almost equal distribution of both genders. Most of them had no formal education or only primary school education [17]. Singapore is a multi-ethnic urbanised Asian society, there is an ethnic integration policy in place to maintain a good ethnic mix in our public housing estate (Housing Development board, HDB), thereby helping to promote racial integration and harmony. However, there was a slightly higher percentage of non-Chinese staying in the rental housing as compared to owner-occupied housings [17‐19]. Rental housing are heavily subsidised housing for those who have low or no household income and have no assets. They were mainly elderly, unemployed and on financial aid for healthcare or daily living.

Among the 14 articles, seven of them mainly covered the outcome related to one’s health status, five articles on their health seeking behaviour and the last two were on the healthcare utilization.

While there has been numerous studies evaluating the association between staying in public rental housing and health, this is the first review to summarise these relationships with health (health status, health seeking behaviour and healthcare utilisation).

Singapore is a small, multi-ethnic Asian country undergoing rapid urbanisation. Urban planning in Singapore takes into consideration the need to prevent development of disadvantaged neighbourhoods [27]. The Urban Redevelopment Authority of the country is well known for its meticulous planning with regards to population distribution and the allocation of public amenities. This includes ensuring that all residents have ready access to healthcare facilities. Notwithstanding that, in this review, it was found that residents of public rental housings have poorer health status and outcome. These residents had lower participation in health screening, preferred alternative medicine practitioners to western-trained doctors in primary care. Lastly, hospital utilisation was increased among them. Traditionally, studies had found that different individual markers of SES such as employment status, educational level and housing type are associated with poorer health [28, 29]. Compared to markers such as employment status and educational level, housing type is part of the patient’s address and is easily retrievable from the electronic health record. In Singapore, residents in the same apartment block share the same postal code. In the on-going effort to improve health and living conditions of the economically disadvantaged, policy makers can use this as a proxy marker of SES [30, 31] to identify high-risk populations and direct intervention programs to where it is most needed.

This findings in this review provides good insights into possible reasons for poorer health of residents of public rental housings in Singapore. We had developed a mechanism map to explained the association between living in public rental housing with poorer health (Fig. 2). Firstly, perceptions and health literacy have a major impact on health. The elderly staying in the rental housing tend not to be highly educated [18] and had poor health literacy. For example, many had low awareness and misperceptions about cognitive impairment or dementia, accepting it as part of normal ageing. Studies that intervened to increase participation rate in health screening were unsuccessful despite making it free of charge and providing it at the residents’ doorstep at a time of their choice. A possible reason may be that such elderly persons are averse to discovering additional health problems when they are already having difficulties coping with existing problems of living. A different approach such as reassuring the participants of the availability of additional support for them when health issues are discovered may prove to be more effective.

Secondly, the juxtaposition of low SES apartment blocks within communities of higher SES may increase perception of inequality, a lack of social support and social distance. Local social inequality [7] may have negative impact on the health status of residents of public rental housings. Wide disparities in income may result in diminished trust in the community that could lead to social withdrawal. Such social isolation may have negative effects on health especially on cognition and depression. The sense of community would be low when one stay in a high-rise apartment where communal interaction are limited to immediate neighbours due to the shortage of community space. This is exacerbated in elderly staying in rental housing, who had smaller social network and are mostly living alone. One study found that elderly persons with a weak social network are more likely to suffer from pain and the progression of chronic pain [32]. For cancer patients and those with disabilities, access to amenities in the community and to public transport is critical especially when they have to commute regularly for visits or treatment at healthcare facilities. Consideration to these areas should be given when developing policies or services for patients of low SES. Effort must be made to create opportunities for social interaction between residents in high rise apartment blocks. Another example of social distance hindering health status was the lack of trust between the doctor and the patient when the latter felt that doctors are not in touch with the reality of staying in the public rental housing. This could be improved but it requires investment in building a good doctor-patient relationship and ensuring continuity of care [33].

Thirdly, the anxiety over the affordability of medical care among residents of public rental housings deter many of them from seeking medical help especially in the screening of chronic disease. In Singapore, one of the recent new interventions to improve access to healthcare for such patients was the Community Health Assist Scheme (CHAS). It provides additional subsidy to Singaporeans with lower household income for primary care. Recipients of this assistance scheme can seek treatment from private General Practitioners (GP) who are often located within communities where such rental housings are found. At the time of writing there were about 1650 GPs in private practice who have signed up for the CHAS since its inception in 2012. About 1.3 million Singaporeans are eligible for this scheme [34]. More of such targeted subsidy schemes may give elderly persons with low SES the confidence to take up health screening programs and adhere to the management plans of their chronic diseases.