The issue of accessible veterinary care has been growing in the veterinary professional discourse. Currently, there is considerable interest in addressing the barriers to accessible veterinary care. Broad categories of barriers to accessible veterinary care include socioeconomic, geographic, and knowledge-based barriers. These are not mutually exclusive of one another and contribute to the complexity of accessible veterinary care. The financial or socioeconomic barriers to care often create the most tension both in daily veterinary practice and within the broader profession, while geographic barriers pose both logistical and sociocultural challenges. Barriers to accessible care not only impact animal welfare, but also the experiences of those who care for them, animal owners and veterinarians alike. It should be noted that the veterinary profession, animal welfare agencies and animal health industries have been highly successful in reducing knowledge-based barriers to care through active public engagement, communications and education on issues such as preventive medicine, population control (spay/neuter) and care for cats. The purpose of this presentation is not to provide an exhaustive examination of this challenging issue, but rather to engage with veterinary professionals in an open dialogue on multi-level barriers to care in order to further our understanding.

Research on the issues of accessible veterinary care is being conducted by several groups including but not limited to the Access to Veterinary Care Coalition (AVCC) out of The University of Tennessee Knoxville,¹ Shelter and Community Medicine at Tufts University,^2,3 the Access to Care Initiative of the American Veterinary Medical Association,⁴ and the Strategy and Research Department of the American Society for the Prevention of Cruelty to Animals⁵. In terms of barriers to accessible care, the recent AVCC report identified challenges to providing care from perspectives of both animal owners and veterinarians. Among veterinarians, factors impacting the provision of accessible care include personal finances (e.g., student debt), concerns about standard of care, workplace policies, and devaluing professional services. This report also identified how veterinarian’s attitudes on pet ownership may impact the provision of accessible care: “the majority of respondents do not think everyone is entitled to own a pet…However, veterinarians in urban areas were more likely to believe that everyone is entitled to a pet and that society bears some responsibility to help care for all pets.”¹

Among pet owners, socioeconomic and financial factors are, not surprisingly, significant barriers to accessing veterinary care along with transportation challenges, not having appropriate equipment (e.g., carrier), geographic barriers and not knowing where to get care.¹

As previously mentioned, the issue of accessible veterinary care is complex. Therefore, in order to examine this issue in a structured approach, I have chosen a One Health framework. Using a One Health model ensures that other sectors and stakeholders are considered, as well as the interactions between sectors. Additionally, it supports the examination of complex issues from multiple levels, including individual, institutional and systemic, and structural levels. For the purposes of this presentation, exploring the barriers to accessible care, the human sector of the One Health model will include both individual and institutional or systemic barriers, whereas structural barriers and influences will be considered within the broader environment sector. I have chosen to use a nested One Health model to do this (Figure 1). Similar to social determinants of health frameworks,⁶ a nested model appropriately describes how larger structures influence both systems and individual experiences in the context of accessible care.

Figure 1. Nested One Health model to explore barriers to accessible veterinary care

Naturally, the sector that has been most explored in terms of accessible care is the human sector. As mentioned previously, the individual care-providing stakeholders include both animal owners and veterinarians. Socioeconomic and/or financial factors are obvious barriers for animal owners to access veterinary care in terms of available disposable income and affordability. However, financial factors may also be barriers for veterinarians in providing care. For example, financial factors for veterinarians including operational costs and remuneration models based on production may influence provision of care.

Education level influences access to care for animal owners both directly through an awareness of the health needs of animals and indirectly through the effect on education level on employability, socioeconomic and financial status. Similarly, for veterinarians, education creates significant debt load such that when remuneration is tied to production, financial barriers once again arise. Geographical factors for animal owners may be tied to socioeconomic status for those living in impoverished areas, but also for rural or remote areas which may be ‘care deserts’ where there are few to no veterinary services available. Such geographical issues impact care provision for veterinarians as well, creating logistical, operational and financial challenges in serving large geographical areas with smaller populations, as well as challenges in attracting veterinarians to rural and remote areas. The issue of serving rural and remote populations is not unique to veterinary medicine and is tied to several larger systems and structures.

The role of demographics and culture on barriers to care further add to the complexity of this issue. Among animal owners, cultural roles of animals, expectations of care, and individual experiences contribute to accessing veterinary care. For example, self-sufficiency, stoicism and trust are cultural issues that have been identified as barriers to accessing care among rural Canadian farmers.⁷ Among veterinarians, similar factors of role of animal, expectation of care and individual experience impact where, how, when and to whom care is provided. As mentioned above, attitudes and perceptions on the right to pet ownership, the value of veterinary care, as well as risk and liability, and appropriate standards of care contribute to the provision of care.

Systems within the human sector include human health systems, education, and regulations, legislations, and policies. The human health system is relevant to the discussion on accessible veterinary care, as there are still considerable barriers to accessible and equitable human health care even within a Canadian universal health care system. Therefore, it may be unreasonable to expect that equitable animal health care access is achieved before human health access. In the One Health model, human health is tied to animal health, and therefore by extension it could be argued that where there is inequitable access to human health care there will be inequitable access to animal health care. Education is also identified as a system within the human sector as veterinary education influences our approaches to the practice of medicine including standards of care. Veterinary regulations and legislations that influence standards of practice and therefore liability, as well as workplace rules and policies, further impact the provision of care.

In this One Health model the animal sector is nested within the human sector as humans are overall responsible for their care and management. With respect to accessible care, animal-based factors influence the amount and kind of care including species, breed, age, and reproductive status. Individual variation within any given population further impacts care, as well as the condition of the animal and/or disease process. Systems within the animal sector include the human manipulation of genetics through breeding, as the impacts of the systematic selection (and public demand) for unhealthy traits in animals on accessible veterinary care cannot be ignored.⁸ Further, human-derived intensive animal (food) management and production systems influence all three One Health sectors.⁹

Lastly, we will discuss the larger and broader environmental and structural factors that influence accessibility of veterinary care. Throughout the previous discussions, one can see the web of interconnections between both factors and sectors; however, large structural factors are often ignored. Much like the social determinants of human health, broad socioeconomic, cultural and environmental conditions in which we live and work have a powerful influence on both human and animal health.¹⁰ Environmental conditions including climate change, urbanization, and globalization impact the daily lives and experiences of individuals, families, communities, and the animals that we live with and work with. If we look at climate change as an example, the effects of climate change disproportionately affect the poor and vulnerable, humans and animals alike. Environmental inequalities and injustices include speciesism via wildlife extinction and endangerment but is also experienced in urban populations. One well-known example is Hurricane Katrina, in which environmental injustice and human (and animal) neglect were shown to be tied to race, education and class¹¹ and further prompted the 2006 U.S. Pet Evacuation and Transport Standards (PETS) Act¹². This environmental disaster highlighted the impacts of structural inequalities on both people and animals.

It is in this way that political socioeconomic factors are important to consider when discussing the issues of accessible veterinary care, as these large factors are also tied to deeper issues of race, class, and gender inequalities. As veterinary care is fee-for-service, to exclude discussion of these issues would be to ignore the reality of people’s lived experiences in current political socioeconomic times. As previously stated, the issue of accessible care is complex, and while exploring these barriers through lenses of One Health and structural influences may uncomfortably increase its complexity, our social discourse and actions must include ways to acknowledge and address these multi-level barriers to accessible care.

References

1.  Access to Veterinary Care [Internet]. The University of Tennessee Knoxville; 2018 [cited 2019Mar27]. Available from: http://avcc.utk.edu/avcc-report.pdf.

2.  Lavallee E, Mueller MK, McCobb E. A systematic review of the literature addressing veterinary care for underserved communities. J Appl Anim Welf Sci. 2017;20(4):381–94.

3.  Benka VA, McCobb E. Characteristics of cats sterilized through a subsidized, reduced-cost spay-neuter program in Massachusetts and of owners who had cats sterilized through this program. J Am Vet Med Assoc. 2016;249(5):490–498.

4.  Houlihan K. Access to Care Initiative of the American Veterinary Medical Association. Email to Michelle Lem (michell. lem@vetoutreach.org) 2019 Apr 11 [cited 2019 Apr 12].

5.  Slater M. Strategy and Research Department of the American Society for the Prevention of Cruelty to Animals. Email to Michelle Lem (michell.lem@vetoutreach.org) 2019 Apr 9 [cited 2019 Apr 12].

6.  Mikkonen J, Raphael D. Social determinants of health: The Canadian facts. York University, School of Health Policy and Management; 2010.

7.  Wasson E, Wieman A. Mental health during environmental crisis and mass incident disasters. Vet Clin North Am Food Anim Pract. 2018;34(2):375–388.

8.  Valliant S, Fagan JM. Healthcare Costs Associated with Specific Dog Breeds. Rutgers University; 2014 [cited 2019 Apr12] Available from: https://rucore.libraries.rutgers.edu/rutgers-lib/48043/PDF/1

9.  McMichael AJ, Powles JW, Butler CD, Uauy R. Food, livestock production, energy, climate change, and health. The Lancet. 2007;370(9594):1253–1263.

10.  Card C, Epp T, Lem M. Exploring the social determinants of animal health. J Vet Med Educ. 2018:1–11.

11.  Adeola FO, Picou JS. Hurricane Katrina-linked environmental injustice: race, class, and place differentials in attitudes. Disasters. 2017;41(2):228–257.

12.  PETS Act (FAQ) [Internet]. The American Veterinary Medical Association [cited 2019Apr12]. Available from: www.avma.org/KB/Resources/Reference/disaster/Pages/PETS-Act-FAQ.aspx.