Domande e riposte di cura : Il ruolo della vulnerabilità nell’accesso alla cura : un vero discorso di salute

Access to care and vulnerability: a real health issue Aim. To study the relationship between vulnerability and the health care system in the urban context, investigating the variables that generate access inequality and complexity in the relationship between healthcare personnel and patients. To create a tool to define and recognize vulnerability, to be used by healthcare services, since we believe that the health system is a social system that defines health and equity, as the WHO-Commission on social determinants of health declared. Methods. This study applies the quanti-qualitative intersection method, as in the "here and now" of a medical examination, combining narrative and numbers. The study focuses on the vulnerable population identified through the application of a filter comprising 4 elements: being a migrant, not having a job/income, and being homeless and uneducated. The study focuses mainly on patients' awareness of health services and these patients' strategies and abilities in accessing health care, both during the preceding year and their intentions for doing so in the future. This study's urban context involves two research fields: the emergency room (ER) at the Sacco Hospital and the social pharmacy at the San Fedele Center (SF) in Milan. Results. A total of 282 patients, all adults, were recruited during the 8 week study period for each field (2014-2015): 49 (51% men) in the ER with white and green codes at triage, 233 at the SF (52% men). The health care paths reported involve three levels: patient, practice, and policy. The filter tool shows that vulnerability has a high level of complexity: 75% ofER patients, and 49% of the SF population, have a co-presence of three elements. In summary, the patients' health care requests/needs highlight: the desire to be listened to, the need for care addressing basic needs, and a suffering often not understood by the health care system, but also a willingness to change. In Italy, the general practitioner (GP) is a key service even though it remains marginal among the services: 52% of the ER and 73% of SF populations, while the most used service is the emergency room (83% in ER, 52% at SF). Overall, the paths of care are driven by someone else's support: 59% of the ER population received someone else's help, and 49% of the SF population received help from multiple sources. Conclusions. Vulnerable people are a real challenge to the public health system, a fact that underlines that matching requests with delivery of care is difficult. Demand does not reach the public health system autonomously, both because it is not completely grasped and because of its complexity. An active health system capable of identifying the vulnerable population through the use of a filter-tool and of addressing the needs of the vulnerable is essential in a global health vision, enforcing patients' access to health in the different levels of care (patient-practice-policy).