A decade on the mean streets: A new typology for understanding health choices of those living in poverty's grasp

Social determinants of health are widely described but few researchers have more than cursory contact with those whose lives fall into the most impoverished epidemiological categories. Framing the problems as inappropriate emergency room visits and non-compliance with treatment regimens sheds little light on the choices driving such behaviors. Drawing on 11 years of working continually among residents of a highly diverse and grindingly poor urban neighborhood, this paper examines the meanings people assign to their health behaviors. It presents a new ‘care seeking typology' based on a content analysis of accounts shared in nearly 400 in-depth neighborhood interviews. When combined with close observations of patients in a small university affiliated, community based safety-net clinic, 10 health seeker types emerge. Each type is illustrated with authentic stories rarely surfaced by traditional scientific methods and validated through reviews by community participants. While several resulting composites mirror frequently cited stereotypes of downtrodden lives, others challenge prevailing beliefs about why and how the poor make health care decisions. Not surprisingly, money plays a central role in care seeking among the population studied. However, the connection is frequently misunderstood by health providers and policymakers, with frustratingly predictable results. Opportunities for more successful therapeutic engagement emerge from this new mapping of social perceptions.