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“For the three health outcomes, we find highly significant, positive relationships between financial security and health, a finding widely supported by literature. We also find that being Spanish relative to being Dutch worsens health outcomes. There is ample evidence of countries with different welfare systems having different health outcomes. For instance, Eikemo et al. [14] found that Southern European countries (including Spain) had among the worst health inequalities in Europe, second to Eastern Europe. Southern European countries also had the highest prevalence of poor/fair self-rated health [14]. In contrast, the ‘Bismarkian’ countries, including the Netherlands, had the lowest health inequalities, although average prevalence rates of poor/fair self-rated health.

“However, contrary to our expectation, being Spanish weakens the relationship between financial security and physical health and, to a lesser extent, social health. We find no moderating effect of nationality for the relationship between financial security and mental health. Again, because of the weaker social security system in Spain relative to the Netherlands, as well as the greater income inequality in Spain relative to the Netherlands, we initially expected that financial security would play a larger role in determining health outcomes in Spain than in the Netherlands. We find several possible explanations for our somewhat surprising findings.

“First, we explore the possibility that we have found a true effect. Unemployment and underemployment are much more democratic in Spain than in the Netherlands. In 2014, the overall unemployment rate in Spain was 24.6%. For young people, the unemployment rate was 57.6%. In addition to these already-high unemployment figures, Spain in 2014 had an extremely precarious labor market, with a high number of temporary job contracts and depressed wages [44]. A lack of financial security is clearly more widespread in Spain than in the Netherlands. Given that many more people are financially precarious in Spain than in the Netherlands, it may be that nationality itself, rather than financial security, explains the differences in health outcomes.

“Second, the ESS7 was undertaken only a few years after the Great Recession’s apex in 2011. Therefore, this survey may have not registered the effects of more pronounced financial insecurity on health. It may be that financial security has or will become a more important predictor of Spanish research persons’ health outcomes in the future, but this had not yet become evident. We see some evidence for this explanation with mental health, which stands out as the only health outcome that does not have a weaker effect in Spain than in the Netherlands. Mental health has been found to be one of the first aspects of health to change in response to unemployment, as opposed to measures of physical health such as mortality [45]. It may be that, as time passes, the relationships between financial security and health outcomes become stronger.

“It is also worth emphasizing that the health outcomes we study likely have important similarities regarding their aetiologies. For instance, social health has been shown to be a protective factor against ill health. In a literature review, Kawachi & Berkman [46] demonstrated that social ties often helped to maintain psychological well-being (although there are some exceptions to this, especially among lower SES women, for whom social networks may be stressors). Social networks have also been identified as important agents in physical health behavior change [47]. This is perhaps why social health is less well-explained (based on the models’ adjusted R2s) by financial security than mental health and physical health. Further, mental health and physical health may also be related. There is some evidence that mental health is on the causal pathway between lifestyle and behavior on the one hand, and physical health on the other [48]. Instead, it may be that these three types of health interact with and impact one another. Indeed, this interrelatedness is in line with Huber et al.’s definition of health as a dynamic process [23].”

Source: Thompson, K., Wagemakers, A. & van Ophem, J. Assessing health outcomes in the aftermath of the great recession: a comparison of Spain and the Netherlands. Int J Equity Health 19, 84 (2020). https://doi.org/10.1186/s12939-020-01203-6.

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“The results of this study demonstrate that homeless individuals cannot access public healthcare services in conditions of equality, which constitutes an important inequity for this population group. The healthcare system in Spain is configured for a “standard patient” and does not easily adapt to those who present special characteristics. Homeless individuals encounter serious difficulties in making use of public healthcare services in conditions of equality. This generates important inequities in the system, which have been documented in the relevant literature [33].

“One finding of the present study is that homeless patients often complained about the treatment they received from healthcare professionals. This can negatively affect future visits to healthcare centers, so it seems vital that a homeless individual’s first visit to a healthcare center, whether primary care or hospital emergency care, be a positive experience [34].

“The target group also provided information about abandoning prescribed treatments due to the difficulties associated with follow-through in the absence of a home and adequate living conditions. This has been reported in other studies [35] and is something the patients associate with their way of life.

“The present study corroborates recent research [36] in revealing that despite their diminished health –especially in pathologies such as chronic obstructive pulmonary disease, musculoskeletal disorders, tuberculosis, and skin and foot problems [37]– homeless individuals make less use of public assistance services and have lower life expectancy than the rest of the population. Sub-optimal use of healthcare services is related to various obstacles to access. These may stem from the homeless population itself, who may lack identification documents, maintain biases about the deficient attention they expect to receive, or indicate little regard for their own health. In other cases, barriers correspond mainly to lack of medical coverage in countries without universal access to healthcare services [38]. There may also be administrative and bureaucratic barriers related to contact personnel, or cultural and ethnic barriers derived from the behavior of healthcare workers [39].

“One relevant result of this study has been to verify the persistence of aspects linked to the use of healthcare services, which for the patient are perceived as –and act as– important barriers to access that seriously affect equity of access and use of the system. These aspects are broadly supported by prior studies that have detected similar situations in other countries [40] and recognized by relevant professionals [41]. Along with barriers to access, the studies also refer to unsatisfactory use. This generates disaffection with the system among homeless individuals, who think they are not treated adequately, accorded sufficient respect or given sufficient attention [42]. Along the same lines, another recent study in Alabama (USA) reported de-humanized attention along with a lack of commitment and professionalism on the part of medical staff. This contributed to diminishing confidence in the medical system among homeless individuals [39, 43].”

Source: Cernadas, A., Fernández, Á. Healthcare inequities and barriers to access for homeless individuals: a qualitative study in Barcelona (Spain). Int J Equity Health 20, 84 (2021). https://doi.org/10.1186/s12939-021-01409-2.

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Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and several other nations.

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Page last updated Sept. 21, 2021 by Doug McVay, Editor.