Abstract
BackgroundIn Singapore, subsidized primary care is provided by centralized polyclinics; since 2000, policies have allowed lower-income Singaporeans to utilize subsidies at private general-practitioner (GP) clinics. We sought to determine whether proximity to primary care, subsidised primary care, or having regular primary care associated with health screening participation in a low socioeconomic-status public rental-flat community in Singapore.MethodsFrom 2009–2014, residents in five public rental-flat enclaves (N = 936) and neighboring owner-occupied precincts (N = 1060) were assessed for participation in cardiovascular and cancer screening. We then evaluated whether proximity to primary care, subsidised primary care, or having regular primary care associated with improved adherence to health screening. We also investigated attitudes to health screening using qualitative methodology.ResultsIn the rental flat population, for cardiovascular screening, regular primary care was independently associated with regular diabetes screening (adjusted odds ratio, aOR = 1.59, CI = 1.12–2.26, p = 0.009) and hyperlipidemia screening (aOR = 1.82, CI = 1.10–3.04, p = 0.023). In the owner-occupied flats, regular primary care was independently associated with regular hypertension screening (aOR = 9.34 (1.82–47.85, p = 0.007), while subsidized primary care was associated with regular diabetes screening (aOR = 2.94, CI = 1.04–8.31, p = 0.042). For cancer screening, in the rental flat population, proximity to primary care was associated with less participation in regular colorectal cancer screening (aOR = 0.42, CI = 0.17–0.99, p = 0.049) and breast cancer screening (aOR = 0.29, CI = 0.10–0.84, p = 0.023). In the owner-occupied flat population, for gynecological cancer screening, usage of subsidized primary care and proximity to primary care was associated with higher rates of breast cancer and cervical cancer screening; however, being on regular primary care followup was associated with lower rates of mammography (aOR = 0.10, CI = 0.01–0.75, p = 0.025). On qualitative analysis, patients were discouraged from screening by distrust in the doctor-patient relationship; for cancer screening in particular, patients were discouraged by potential embarrassment.ConclusionsRegular primary care was independently associated with regular participation in cardiovascular screening in both low-SES and higher-SES communities. However, for cancer screening, in the low-SES community, proximity to primary care was associated with less participation in regular screening, while in the higher-SES community, regular primary care was associated with lower screening participation; possibly due to embarrassment regarding screening modalities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0411-5) contains supplementary material, which is available to authorized users.
Highlights
In Singapore, subsidized primary care is provided by centralized polyclinics; since 2000, policies have allowed lower-income Singaporeans to utilize subsidies at private general-practitioner (GP) clinics
As the type of practice setting can influence doctors’ empathy and patients’ enablement [7] and the patient-physician interaction is important in encouraging screening participation in low-income populations [8], we were interested in determining whether the physical characteristics of primary care and the doctor-patient relationship influenced screening participation in a low-income Asian community, Singapore is an example of an urbanized, multi-ethnic Asian society
Definitions Primary care characteristics We looked at the association between regular cancer/cardiovascular screening participation and the following aspects of primary care: 1) proximity to primary care; 2) Receiving subsidised primary care, via the Community Health Assist (CHAS) programme; 3) Having regular follow-up with a primary care physician, instead of ad-hoc visits to primary care
Summary
In Singapore, subsidized primary care is provided by centralized polyclinics; since 2000, policies have allowed lower-income Singaporeans to utilize subsidies at private general-practitioner (GP) clinics. Accessibility of primary care and preventive health services is related to geographic distance, especially in rural areas [4, 5]. Those living in deprived areas are more dependent on health services within their neighborhoods, because of reduced mobility and resources [6]. These studies are mainly focused on Western urbanized populations; within the literature, few studies have examined the relationship between primary care characteristics and primary care utilisation in Asian societies. While our previous local studies identified various barriers to screening access (cost, knowledge, attitudes, convenience, the doctor-patient relationship), we did not determine which of these barriers were most significant in the low-SES population
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