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The complex self perceptions and relationships of patients who attended free clinics affected their attendance and ability to benefit from care
  1. Patricia Larson, RN (EC), MN
  1. Sherbourne Health Centre, Toronto, Ontario, Canada

    Statistics from

 Q What are the lived experiences of patients attending free clinics? How do their evolving relationships with the clinic and staff affect their identities and self presentation?


    Qualitative study using a grounded theory method.


    4 national governmental organisation’s and public hospital’s free clinics in the Paris area and a large provincial city in France.


    94 patients (mean age 37 y, 60% men, 50% immigrants to France) living in precarious housing conditions. One third lived in their own homes, one third lived temporarily with friends or family, and the others were homeless or lived in a hotel, shelter, or squat. Health status varied among patients. Some visited the clinics for occasional benign disorders, whereas others had chronic diseases (eg, HIV or cancer). Some patients attended the clinic to visit social workers or to simply spend some time in a heated, friendly venue.


    94 face to face interviews (lasting an average of 45 min) were done. 37 staff members were interviewed individually and in groups. Almost all interviews were audiotaped and transcribed. The interviews discussed patients’ relationships with the free clinic, their use of healthcare and social services, their health perceptions and experiences, and their social situations. Data were analysed using a grounded theory approach.


    3 modes of attendance were identified. (1) Occasional attendance. People with health problems that did not require long term medical follow up visited free clinics for specific medical problems. These patients appreciated the assistance they received but did not expect complete management of their problems because they either did not think they needed it or were afraid to ask. These patients felt humiliation from the shame of having to ask for free care. Their inability to pay for private clinics was seen as a marker of marginalisation. Often they resorted to asking for free care because they feared the problem worsening or they attached great importance to feeling healthy. Other patients experienced pragmatism, which enabled them to attend the clinic without feeling demeaned. They valued their health and felt that the aid was temporary. (2) Regular attendance. These patients settled into regular attendance when health insurance was still not available after several visits and when they felt well cared for and comfortable in the clinics. They attended the clinics for all of their health problems, not just the serious ones. 3 phases were seen. The initiation phase consisted of internalising the operating rules and standards of the clinic. When staff emphasised that every patient had a right to care, patients could begin to view themselves as being entitled and not as welfare recipients. Patients worked on establishing good relationships with physicians and other staff members. They appreciated the staff’s professional dedication and welcoming manner. The settling in phase consisted of patients’ regular relationships with medical and social care management. The free clinic became a meaningful place in their lives for social as well as health reasons. Patients recognised that the provided service was not only medical but a combination of social, psychological, and medical support. A few patients had what the author labelled a demanding approach to care. This group focused on their personal needs and rights and had trouble adjusting to the constraints of the clinics. They dictated the type of care they expected and how it should be provided. Often these patients had serious medical or social problems and generally mistrusted institutions. They assumed they were being denied access to the latest medical advances and could be abusive to staff. (3) Inconsistent attendance. A small proportion of people attended clinics sporadically. They usually were marginalised people who had trouble settling into a clinic, paying attention to bodily symptoms, complying with treatments, or attaching importance to behaviours necessary for hygiene, health, and care. Their marginalisation contributed to a decline in self image and a gradual detachment from their bodies. This made it difficult for these patients to benefit as fully as providers might expect from the care they received, which was distressing not only to patients but also to staff, whose actions were less likely to be successful.


    In patients who attended free clinics, relationships with staff and self perceptions about asking for free care influenced not only how often they attended the clinics but also how well they were able to benefit from the care they received.


    The grounded theory analysis by Parizot et al examined the perceptions and relationships of clients who attended “clinics for the poor” in France and their ability to “fully benefit” from care received in these situations. The study provides an intriguing insight into aspects of health care in France and the sociopolitical context of the western world in which homelessness and marginalisation have become taken for granted. The study encourages reflection on the importance of maintaining relationships with clients in contexts in which health care, although seen as a “right,” is delivered in a segregated fashion. I am left wondering whether these findings have relevance in other countries, especially in those where health care is delivered in a system with universal and equal access.

    As a nurse practitioner with more than 2 decades of experience working with marginalised people and communities, I find the study by Parizot et al somewhat troubling. The authors focus on the characteristics of individual clients rather than on the systemic healthcare features and the sociopolitical failures that lead to poverty and social exclusion in the first place. Parizot’s loaded language—“inconsistent” attendance, “demanding” approach—is as suggestive of artefacts of translation as it is of negative moral judgements. My stance as a nurse who comes from a critically analytic perspective is a different one. I prefer to focus on the right to health care and overcoming the barriers to acceptable health care, as well as recognising the difficulties of accessing a system designed to “work” for the affluent rather than for people who have to prioritise what the rest of us take for granted.

    View Abstract


    • For correspondence: Dr I Parizot, Inserm, Research Team on the Social Determinants of Health and Healthcare, Paris, France. parizot{at}

    • Sources of funding: Programme Sciences biomédicales, santé et société (Inserm, CNRS, MiRe).

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