Participants identified two types of barriers to good relationships between HCPs and PLPs: difficult communication and social distance. These barriers are intimately connected to living conditions, since HCPs often misunderstand the realities of PLPs.
Social distance
PLPs and HCPs live in different social contexts and do not face the same realities. These differences create
social distance, which manifests as: 1) prejudice and labels; 2) different choices and logics, but similar values; and 3) social inequalities and unequal rights.
All participants agreed that HCPs may hold prejudices toward PLPs. In this regard, one PLP participant said: There is the barrier of the ‘welfare’ label. ‘Poor women’ equals stupid and lazy. There are prejudices that are a real barrier between PLPs and HCPs. PLPs also thought that professionals held them to be responsible for their own health problems, and said this was because HCPs were not aware of their circumstances. Of all categories of HCPs, the PLPs identified physicians’ prejudices as the most harmful, as diagnosing from a position of prejudice could create much suffering.
The HCP participants also recognized that professionals sometimes held prejudices toward PLPs, attributing these prejudices to their own limitations, either in terms of their personal boundaries (e.g. they feel uncomfortable dealing with PLPs) or of the system (e.g. they are ill-equipped to deal with PLPs’ complex situations). Although HCP participants recognized that certain professionals may hold prejudices, few admitted to having negative preconceptions about PLPs themselves.
2)
Different choices and logics, but similar values
In the merging of knowledge and practice meetings, it emerged that the PLP and HCP participants held the same values, despite their different choices founded on different logics. A striking example of the contrast in their two logics was their discussion about new mothers’ choice between breastfeeding or using infant formula. HCPs noted that PLPs would rather use formula than breastfeed, even though, in the HCPs’ opinion, breast milk is the best choice for babies’ health and also more economical. One HCP expressed her view of the behaviour of mothers living in poverty who choose not to breastfeed and instead spend money on formula, which is very expensive:
As I see it, breastfeeding is easy, the milk is always warm and available, and it allows the baby to be very close to his mother, to establish a good contact. Several experts say breast milk is good, it has antibodies, lots of things; and then when patients tell me they’re not going to breastfeed, and they’ll buy formula, well, I see that as a barrier. Especially for someone living in poverty, I think it's a shame because we see the price here on the sign, formula is very expensive, whereas breast milk is free.
In contrast, a PLP participant explained that the choice to use formula may be based on the fear of not being able to give babies everything they need in breast milk. Mothers may believe their milk is not good enough because they were often told they were bad and a failure, so they devalue themselves:
Yes, because the choice she makes is: If I’m not eating enough, will my milk be good? Will it have everything it needs? It’s very doubtful, when you eat once a day, and then you eat bread and butter, no matter the menu, it’s not much. You know? You say to yourself that formula, even at $20, at least it’ll have everything [the baby] needs.
Hence, the choices are based on different priorities, which lead to misunderstanding and judgment on both sides. As one HCP participant said:
I couldn’t possibly have known that in the office. I would have asked the woman whether she’s breastfeeding or giving formula. She’d say she’s giving formula. I’m not sure I’d ask her why, and I’m also not sure that it would come out, ‘Well, I give formula because I’m afraid my child won’t get everything he needs in my breast milk, because I don’t eat enough.’ Maybe she’d never tell me she was eating only once a day and that this made her worried about her baby. So I go out of there thinking she’s buying formula, which is super expensive, and that’s not a good choice. And she has the impression I don’t understand her.
Thus, the different choices are based on different logics, as one PLP participant noted:
It’s sad, because everyone wants to be a good mother. But for this woman, being a good mother means breastfeeding. And for another woman, being a good mother means feeding your baby formula. So we have the same values: we want to be good mothers to our children.
Overall, PLPs and HCPs, given their different backgrounds and life experiences, have different logics. PLPs are often trapped in the ‘
logic of no choice’, seeing themselves confined to only one solution because of their life conditions (e.g. low income, marital status, unaffordable housing), while perceiving that HCPs have strong opinions about what choices they should make. As one PLP participant noted:
To realize that your opinion of someone who has more money is different from [your opinion of] someone with less; [the former] has a choice. When something is imposed, you have no choice. You have just one option. And that’s what you have to do, because if you don’t, you’re not a good poor person, you don’t do the right things, you’ve missed the boat a little’. That irritates me!
In addition, when PLPs make a choice in their daily lives, they often feel judged. One PLP participant said: Do we have the right to buy a beer without being judged? Without being judged by society? Are we allowed to have fun, to make choices?
In this ‘logic of no choice’, PLPs feel guilty when they are not able to follow the recommendations of HCPs (e.g. regarding nutrition, breastfeeding, etc.). They feel they have the know-how and the intelligence to follow them, but their living conditions are major obstacles that may lead them to make different choices.
Our participants discovered they lived under a ‘
logic of no choice’ and realized that HCPs’ actions towards them were guided by a
‘logic of diagnosis’. According to all participants, the
‘logic of diagnosis’ is central to HCPs’ work. With limited resources and time, physicians may reach a diagnosis before completely understanding the patients, including their psychosocial situation. They feel this is the way things should be done, even though they accept that this approach might not work for all patients. As one HCP participant noted:
You know, it takes a diagnosis to treat a patient. And maybe there’s a flaw there and it doesn’t work for all types of people. Then there’s also the fact that we’re expected, with our limited resources, to analyze this patient in half an hour and decide what we’re going to do with him, because the next time we see him may be in six months.
PLPs felt that this situation could have serious consequences, because without taking the time to see the whole situation the HCP could be making a diagnosis based on prejudice. One PLP participant reported that a friend was misdiagnosed with intellectual disability after one consultation of only 15 to 20 minutes:
The physician makes an instantaneous reading, like a Polaroid. You wait a couple of seconds, and then you have the picture. He doesn’t see the overall situation, the stress or the violence you live with. It’s a fragmented vision. Then we’re locked into this diagnosis that the social workers and other health professionals rely on. It follows us our whole life.
Participants spoke about the need to find a meeting point between the contrasting logics of these different worlds. For example, an HCP participant explained her photograph:
What this represented for me, is also the gaps between what we expect of the patient—you’ve talked about it a little: the food guide, what should be done, what’s good—we know, but we can’t do it with what the patient can afford. So what we need to do, in teaching, is to consider people’s purchasing power, so that we can meet in the middle and work together.
However, one PLP challenged the HCP by saying that, although it is a good thing to want to ensure these two different worlds meet, the power imbalance makes it difficult:
Individually, PLPs have very little power over their own lives, but those who try to improve the social situation, it must be said, are totally excluded, they’re not listened to by governments. Those of you who live in the other world as doctors or who rub shoulders with people in power, what can you do…?
3)
Social inequalities and unequal rights
Some participants recognized that PLPs have little social, economic, and political power and social recognition compared to HCPs, who typically come from a higher socioeconomic class. PLP participants were aware of their position and wished that HCPs would offer more help and support. Conversely, HCPs (especially family physicians) thought they were too often perceived as having more power than they actually have. As one noted:
We’re ready to work to change things, but at this point we’re in the same position. We don’t know the ropes, we don’t know where to go…. I’m only a physician, and I’m not pretending to be anything else. So I don’t have any more pull to play the system, I don’t have any more pull to be heard. What I say is not going to be heard any more than what you say.
Some HCP participants initially had the impression that PLPs were accusing them of being the cause of their problems. Then, during the discussion, both groups came to agree that it is the system that produces the barriers and perpetuates social inequality. One HCP participant concluded:
I think the communication between PLPs and physicians is probably not so bad. Maybe it’s the entire system, and everything around it, that really needs to be reviewed in depth.
In the end though, participants agreed that, while the system is partly responsible for some of the barriers, everybody has an individual responsibility to break them down.