Access to Health Services

The final category presented to identify people at heightened risk during pandemic is access to health services. This refers to whether an individual has access to vaccination or treatment for influenza or other health issues during an influenza pandemic. Access to health services is a critical issue during pandemic and requires an ethical framework based on equity [48]. It is predicted that health care resources may be depleted within just a few weeks of managing the increased demands for care during an influenza pandemic [48]. Since the duration of a pandemic is often long and a second wave, which presents additional demands on an already exhausted health care system, is likely [49-50], the impacts on the health care system could be significant.

Vaccination and treatment-seeking behavior are important factors determining risk during an influenza pandemic, particularly for people who have chronic medical conditions who may require ongoing access to health professionals [14, 83]. It was estimated by Statistics Canada that during the H1N1 pandemic, 41% of Canadians over age 12 received the pandemic vaccine. This estimate excludes vaccination given to military personnel and Aboriginal Peoples living on reserves, who receive health services directly from the federal government [105]. In the survey, the main reasons people provided to explain why they hadn’t been vaccinated were a) their belief it was not necessary and b) their perception that the media had exaggerated the threat. Vaccine uptake rates among health care professionals were higher in Canada than other countries; 66% of health care workers in Canada received the vaccination. The U.S. reported 37% of health care workers had been vaccinated [105].

In Canada, during the H1N1 pandemic, immigrants and refugees were less likely to be vaccinated (38%) [105]. As discussed in a previous section on culture, ethnicity and language, vaccination uptake rates are influenced by many factors, including limited access to transportation, geographic location, health beliefs, and possession of health insurance and legal documentation, and language barriers [11, 17, 22, 58, 106, 117]. Income and income security intersect with all of these factors, particularly in relation to health insurance, availability of health professionals, and convenience for accessing services [7, 13, 17, 72].

Access to transportation is an important factor influencing people’s ability to seek treatment or preventive health services, therefore Santibanez et al. [46] included those who are “transportation disadvantaged” to be part of a high risk group. Hebert et al. [85] found that people were more likely to receive a vaccine if it was being given in a location that was accessible for them. Certain marginalized groups, particularly low income residents in city centers, and Aboriginal populations in rural and remote communities have difficulty in accessing health services and education programs [11, 18, 72]. To address this issue, Coady et al. [63] conducted an intervention study which involved dissemination of educational information to hard-to-reach groups, employing door-to-door canvassing as a strategy to reach the community. This strategy improved accessibility by reaching populations not typically influenced by other communication campaigns. Vlahov et al. [64] concluded that interventions which utilized door-to-door strategies were more successful in targeting hard-to-reach populations, if planned in advance.

Many people who have limited financial resources and certain ethnic groups (non-Hispanic black and Hispanic) do not have a regular primary health care provider. Therefore, they are more likely to delay seeking treatment and to seek primary care through emergency departments in hospitals, which affects the timeliness of their treatment. Given the potential delays in being assessed, effective treatment with antivirals during an influenza pandemic may be impacted as they are designed for early treatment [17]. Crighton et al. [57] also observed that in Ontario, there was an overrepresentation of influenza and pneumonia hospitalizations in the elderly, Aboriginals, and those with lower levels of education.

Certain groups who are already reliant on the health care system may be at an increased risk if the system became stressed due to an influenza pandemic. Individuals with conditions such as HIV/AIDS, hepatitis A and B, and tuberculosis may not be able to receive the sufficient and appropriate care they need if all of the health care providers are managing a pandemic. With immune systems that are already weaker than usual, these patients are especially susceptible and reliant on access to services during a pandemic [83].

Health care seeking behavior can be negatively affected by language and cultural barriers for ethnic and cultural minorities. For health care information to be accessible and effective, cultural sensitivity is needed; including the need for translation [88]. The quality of treatment and understanding of risks can be negatively impacted by these social barriers. For people who lack health insurance or do not have citizenship documents, paying for health care services can be a problem and often influences when or if they seek treatment.