“It Shouldn’t Be This Hard”: Women’s Experiences Accessing Health Care While Living With a Low Income

Abstract

A key standard of the Canadian health care system is reasonable access to health services for all—yet, this remains unfulfilled for many women facing financial hardships. Women living on a low income are more likely to experience anxiety, depression, and harmful health behaviors. While researchers have explored access among equity-deserving women, few have used a narrative approach and none have applied dialogic or performative analysis—a method that examines the interactive nature of storytelling and how narratives function as actions that shape identity and social reality—in a qualitative secondary data analysis about women living in Canada. Interview/focus group transcripts from a primary study about five women were revisited to address the new question: What stories do women living on a low income have about accessing health care services in Kingston, Canada? Participants’ accounts were framed as theatrical scenes, portraying structural and emotional dynamics shaping their health care experiences. Core scenes emerged: rejection and exclusion—when access is denied or limited; health care information—when directions fail; and the need for reassurance and trust in relationships with health care providers. Limitations in social determinants (e.g., housing, food access, and transportation) were a through line regarding access, and despite which, participants persisted and adapted. Their stories evidence the pressing need for re-designed systems prioritizing equity, compassion, and clear communication. This study shows the realities of those often overlooked in policy discussions and demonstrates the depth of a narrative approach for revealing how care is lived.

In Canada, access to health care services is meant to be universal (Government of Canada, 2016), but for women living on a low income, that promise often falls short (Camargo-Plazas et al., 2022; Duhn et al., 2024; Khullar & Chokshi, 2018; Socías et al., 2016; Waite et al., 2022). In particular, low income as a social determinant of health intersects with other social determinants of health (SDHs), such as health care access, housing, food security, education, and employment, resulting in cumulative disadvantages on overall health and well-being (Camargo-Plazas et al., 2022; Duhn et al., 2024; Khullar & Chokshi, 2018; Socías et al., 2016; Waite et al., 2022). Low income is linked to higher rates of smoking, unhealthy diets, physical inactivity, and substance use disorder, reinforcing the need for equitable access to health services (Khullar & Chokshi, 2018).

Women with low incomes experience additional barriers to financial stability due to historical societal roles and systemic barriers, including gender pay gaps, unpaid work, familial responsibilities, and limited access to secure, well-paid employment (Canadian Women’s Foundation, 2018). Furthermore, a majority of “invisible” unpaid workers are women, whose roles include caregiving, household work, and volunteer work (Gladu, 2021). The economic realities many women face contribute to challenges in accessing health care, particularly for services not covered by provincial insurance, such as prescription medications (Longo et al., 2021; Turin et al., 2020), physiotherapy (Turin et al., 2020), and assistive devices like hearing aids and glasses (Berardi et al., 2021). Beyond financial barriers, women with low incomes may encounter psychosocial hardships when seeking care, including stigma and discrimination. Women from equity-deserving groups, such as those who experience homelessness, have a substance use disorder, or are racialized, have shared experiences of judgment, stigma, and provider dismissal in health care settings (Majebi et al., 2024; Monchalin et al., 2020; Thomas et al., 2022). For some women, especially newcomers or those living in rural areas, language and provider shortages add yet another layer of difficulty (Moffitt et al., 2022). Past negative incidents can discourage individuals from seeking medical care, sometimes leading to delayed or forgone treatment (Duhn et al., 2024; Waite et al., 2022; Walcott et al., 2016).

Despite growing awareness, little is known about how women living on a low income narrate and make sense of their experiences accessing health care in Canada. Using qualitative secondary data analysis (QSDA), our study centers on the voices of women living on a low income to explore how they engage with and make meaning of their experiences in the Canadian health care system. Using a critical narrative approach, we explored how income and its intersection with other SDHs shape how women experience access to health care.

Reflexivity Statement

The first author’s interest in women’s health and health care access began while participating in mobile medical clinics in remote communities in Peru. During this time, she observed stark health inequities between rural and urban populations, particularly among women. Many women in these rural areas had preventable health issues, such as urinary tract infections, postpartum complications, and limited access to gynecological care, which were deeply rooted in systemic barriers to health care access. Witnessing how access shaped health outcomes ignited her interest in health equity, women’s health, and structural determinants of health. The experience shaped her academic trajectory and her pursuit of graduate education focused on public and global health. Her interest in qualitative research lies in the ability to capture the richness of people’s lived experiences and the contexts by which they are shaped, with the potential to inform meaningful social and health system change.

To understand her positionality, the first author used the three-tiered social identity map developed by Jacobson and Mustafa (2019) as a guideline for reflection. As a white, heterosexual, middle-class, able-bodied woman living in Canada, and undertaking this work as a graduate student, she acknowledged the power imbalances inherent in interpreting the narratives of women living on a low income. This positionality required ongoing attention to how assumptions, expectations, and interpretive tendencies could shape analysis. Significant care was taken to remain open to narratives beyond the researcher’s own ways of knowing, with a deliberate focus on centering participants’ voices rather than seeking personal identification with their experiences. The goal of this reflexive practice was to develop a deeper understanding of participants’ accounts and to promote social awareness of how SDHs influence access to health care services.

They were challenged to identify and question personal perspectives, reframing their mind to be open to any and all narratives. Significant personal reflection and recognition of pre-conceived notions helped sustain an approach focused on uplifting the voices of the women. While participating in this research, the first author did not seek to relate to participants; rather, the goal was to develop a deeper understanding of their experiences and to promote social awareness of how various SDHs influence their access to health care services.

Reflexivity was enacted as an ongoing analytic practice throughout the research process. Field notes and reflexive journaling supported awareness of positionality and power differentials during data analysis, particularly when engaging with emotionally complex or distressing narratives (Holmes, 2020). Recording and revisiting reflections allowed the first author to interrogate emerging interpretations and to distinguish researcher responses from participants’ accounts. This process was critical in ensuring that analytic decisions remained grounded in the stories shared by the women and that interpretations reflected participants’ meanings, values, and suggested changes rather than researcher assumptions. Continuation of this reflexive practice throughout analysis and manuscript preparation supported attention to voice, power, and representation, helping to ensure that findings remained faithful to the lived experiences described by participants.

Methods

The Primary Study

The primary study, conducted as a participatory project although adapted due to the COVID-19 pandemic, focused on how gender and income, as SDHs, influence access to health and social services for women with low incomes. Study participation invitations were extended to those who accessed St. Vincent de Paul Society of Kingston (SVDP), a non-profit organization operating in Kingston since 1969 in support of basic living essentials for individuals and families and with a mission centered on compassion, respect, and upholding the dignity of all (St. Vincent de Paul Society of Kingston [SVDP], 2020). Ethical approval for it was obtained from Queen’s University, General Research Ethics Board (TRAQ# 6024959).

Participants were selected purposively to ensure maximum variation in demographic characteristics, such as age, education, income, and relationship to SVDP. Five women participated, and the data were collected through semi-structured 60-minute interviews, photovoice, and a focus group activity (Duhn et al., 2024). Thematic analysis of data was guided by the conceptual framework developed by Loppie-Reading and Wien (2013), which categorizes SDHs into three levels: proximal (e.g., health behaviors, physical environments, employment, and income), intermediate (e.g., community infrastructure, resources, and capacities), and distal (e.g., historical, political, social, and economic contexts). Methodological details and findings from that study are published (Camargo-Plazas et al., 2022; Waite et al., 2022).

Qualitative Secondary Data Analysis (QSDA)

QSDA can be conducted through three main modes: (1) formal data sharing, in which researchers analyze archived data they did not collect and are not affiliated with the primary study; (2) informal data sharing, where secondary analysts collaborate with the original research team to re-analyze data with added contextual insight; and (3) re-use of self-collected data, where researchers analyze data they themselves collected to explore new questions or perspectives (Boris, 2015; Ruggiano & Perry, 2019; Tarrant, 2017). In this study, the same research team that conducted the primary study undertook a secondary qualitative data analysis, re-using self-collected data to address a new research question, consistent with Heaton’s (2008) conceptualization of secondary analysis.

Although the same research team conducted both the primary study and this QSDA, the secondary analysis qualifies under the self-collected data model. The current study applied a new analytic framework, dialogic/performative narrative analysis, and focused on a distinct research question concerning health care access, which was not the emphasis of the original project. This approach aligns with established definitions of QSDA involving self-collected data (Heaton, 2008), and the researchers’ prior involvement strengthened the contextual sensitivity of the analysis (Heaton, 2008; Tarrant, 2017).

Re-used qualitative data can include a range of materials such as interview transcripts, surveys, journals, field notes, photographs, and focus group transcripts (Kim, 2020; Wickham, 2019). In this case, our team drew on interview and focus group data collected during the original participatory study. While we were also involved in the primary study, our deep familiarity with the dataset and context strengthened the quality and trustworthiness of the analysis by providing insight into participant perspectives and research conditions (Wickham, 2019).

To ensure ethical integrity, we obtained ethics clearance for the QSDA from Queen’s University, General Research Ethics Board (TRAQ# 6035720). As part of that process, the first author re-contacted all original participants to request additional consent for the secondary use of their data, and all participants voluntarily agreed. Although they did not review the QSDA findings, we view their renewed consent as an indication of their continued willingness to share their stories in the interest of promoting understanding, with respect for context and voice.

Our goal within this QSDA was to gain deeper insight into how women living on a low income experience access to health care by asking a research question that differed meaningfully from the original study. Grounded in a critical theory framework, the analysis focused on how participants’ narratives reflected and resisted broader systems of social struggle, domination, and marginalization, with a focus on empowering individuals to challenge systemic constraints related to class and gender (Creswell & Poth, 2025). The guiding research question was: What stories do women living on a low income have about accessing health care services in Kingston, Canada?

Narrative Inquiry Approach

Narrative inquiry (NI) is a qualitative approach focused on collecting stories from individuals to inform an understanding of their experiences (Creswell & Poth, 2025; Ison et al., 2014). Through observing stories, researchers develop an interpretation of how others create meaning from their experiences, and how external factors contribute to the creation of a narrative (Riessman, 2008). As NI is interpretive by nature (Creswell & Poth, 2025), the understanding developed through analysis may be different depending on who reads the stories. Comparing one’s understanding of an experience to existing interpretations in previous literature, therefore, gives increased value to findings, allowing consistencies and irregularities in interpretations to be revealed (Riessman, 2008).

Sorting Versus Sampling

In primary qualitative research, sampling strategies such as purposive or snowball sampling are used to recruit participants (Creswell & Poth, 2025). In contrast, when conducting secondary qualitative data analysis, researchers use a “sorting” technique to reshape existing datasets to align with a new analytic purpose (Boris, 2015). Sorting involves assessing the relevance, richness, and completeness of existing data to determine its suitability for addressing a new research question (Ruggiano & Perry, 2019; Tarrant, 2017). For this QSDA, the five anonymized interview and focus group transcripts were sorted to determine suitability for analysis. To determine the suitability of the primary study data with the proposed narrative approach, we established (a) the appropriateness of the data to answer the research question, (b) whether the quality of data would permit analysis, and (c) the accessibility of data. Regarding this, our primary study purpose aligned closely with the research question for this QSDA. Alignment of primary and secondary research questions is important to ensure that available data are appropriate for secondary analysis (Boris, 2015; Ruggiano & Perry, 2019; Tarrant, 2017). Additionally, the quality of data was explored by assessing the completeness of data and the quality of interviewing (Ruggiano & Perry, 2019). Only high-quality (rich description; relevance to the secondary research question) transcripts from the primary study’s individual interviews were included. After reviewing all transcripts, both the individual interviews and the focus group transcript were included in this QSDA. Finally, all data were accessible and available to us.

Notably, the inclusion criteria for this QSDA were consistent with those of the primary study: adults 18 years of age or older who identified as women, lived on a low income, and were able to understand and speak English. Participants were considered to be living on a low income if they self-identified as such and accessed services from a community-based organization that supports individuals facing financial hardship. The organization does not require formal income verification or proof of government assistance to access services such as food, clothing, or other basic needs. However, its services are specifically designed for and accessed by individuals experiencing material deprivation, which aligned with the study’s focus on income-related barriers to health care. We define “equity-deserving” participants as those who experience systemic barriers to health due to economic, social, and institutional inequalities (Queen’s University – Human Rights and Equity Office, n.d.). This term aligns with Canadian health equity discourse and is used alongside “underserved” and “marginalized” to reflect the structural constraints faced by the population studied.

Data Management

The proper data storage and management allows for responsible sharing and re-use of research data (Government of Canada, 2021). For this QSDA, we used a copy of the transcripts and audio recordings from the primary study. A OneDrive© folder was created to store them, with access restricted to the first author MS (student and research fellow), second author LD (member of student’s thesis committee and co-applicant in the primary study), and last author PC-P (student’s supervisor and principal applicant of the primary study). Each file was named by a participant indicator (participants 1, 2, 3, etc.) and interview number (interviews 1, 2, 3, etc.) to maintain organization and confidentiality. We assigned different participant pseudonyms to those used in the primary study. This information will be kept securely for 5 years as per Queen’s University policy. After this time, the de-identified data will be deposited in the Queen’s University Repository as per the Social Sciences and Humanities Research Council’s (SSHRC) research data archiving policy (SSHRC, 2016).

Data Analysis

A dialogic/performative narrative method of analysis was selected for this QSDA over other narrative methods due to the opportunity to explore the co-produced, multi-voiced nature of participants’ stories (Boris, 2015; Green, 2017). Grounded in the work of Goffman and Bakhtin, this approach enables analysis of not only what participants say but also how they construct meaning through tone, delivery, and social interaction (Green, 2017). Our analytic approach draws from Goffman’s (1959) concept of performance, Bakhtin’s (1981) notion of dialogism, and Riessman’s (2008) emphasis on the co-construction of narrative meaning. Together, these theoretical anchors enable attention to how women narrate their experiences in interaction with broader social forces. By focusing on both the content and construction of their stories, dialogic/performative narrative analysis is uniquely suited to uncover how structural inequities are internalized, resisted, and reimagined in the act of storytelling. It is particularly well-suited to this study’s aim of understanding how systemic forces shape lived experience, as it allows deeper insight into identity, power, and context embedded in storytelling.

Following Riessman’s (2008) guidance, we thoughtfully engaged with the interview and focus group transcripts to develop an understanding of the stories shared by the women and the broader forces shaping their experiences. Through repeated readings, we identified how various SDHs influenced participants’ behaviors, access, and interactions with health care. Comparing these interpretations with existing literature allowed for a more layered analysis of women’s experiences. In dialogic/performative analysis, thematic and structural dimensions are considered. Thematic analysis focuses on what is said, highlighting characters, plotlines, and recurring patterns, and structural analysis examines how stories are constructed and conveyed (Boris, 2015; Green, 2017). Together, these methods enabled a deeper interpretation of women’s narratives, using theatrical metaphors to frame their encounters with the health care system.

Trustworthiness

In QSDA, trustworthiness does not follow traditional quality standards (Boris, 2015; Ruggiano & Perry, 2019; Tarrant, 2017). Nevertheless, to guarantee scientific integrity and quality, it does follow some criteria. Using multiple types of analysis, and conducting research that involves multiple methods, types of data, theories, and perspectives, is a strategy that increases the depth of knowledge (Tarrant, 2017). In QSDA, one can triangulate findings of qualitative studies, leading to more trustworthy, meaningful results (Ruggiano & Perry, 2019; Tarrant, 2017). Understanding the original context of the primary study upon which the QSDA is based is also important to ensure the quality and integrity of the data (Boris, 2015; Ruggiano & Perry, 2019; Tarrant, 2017). This knowledge allows influencing factors to be considered during the analysis and interpretation of the data (Boris, 2015). In this QSDA, we analyzed the data in a distinct way from the primary study, adding to the quality and depth of the results. Furthermore, given our knowledge of the primary study, including the processes by which data were obtained, the integrity of this QSDA was enhanced.

Findings

In dialogic/performative narrative analysis, findings can be presented as “scenes” to reflect the dynamic and multi-voiced nature of the stories shared by women. The theatrical metaphor emphasizes researcher positioning as audience members who have observed and developed an understanding of the narratives within the data, presented by women as the “actors.” This framing highlights how stories are told by the participants, as well as how interactions between participants and researchers shape a narration—a highly interpretive, evolving process to develop deeper meaning (Riessman, 2008). Scene 1 explores the restrictiveness of health care services, which leave women feeling disappointed after repeated rejections and rushed interactions. Scene 2 examines the difficulties participants have in receiving clear health information and straightforward health directions. Scene 3 considers how negative interactions with health care providers (HCPs) can deter future help-seeking and underscores the importance of feeling reassured and supported by providers. These findings illustrate how women living on a low income perceive and experience access to health care, and how their ability to “act” in this system is constrained by a range of visible and hidden barriers.

Scene 1: Rejection and Exclusion: When Access Is Denied or Limited

Scene 1 explored the experiences of women living on a low income when they seemingly could not fit within the rigid criteria for certain health care services and when they were denied accessible care. The narratives of the participants showed how a lack of power and patient autonomy led to disappointment and anger at inaccessibility. Women living on a low income felt discouraged by repeated dismissal from service providers. Striving to align with care services also encompassed whether women felt they could navigate the health system, and how well they could make the necessary connections to reach the appropriate services for their needs. Sarah shared her reluctance to seek hospital care, describing long waits followed by rushed interactions that left her feeling dismissed: “I don’t like … to go to the hospital … Then I have to go there and wait for your turn … then you go see the doctor, and it takes only a second for the doctor to see you, they send you home.” Sarah’s experience highlighted how fragmented care could diminish trust in the health system and discourage future care-seeking, even when medical attention was needed.

Like Sarah, Marissa’s frustration was primarily about the multiple providers she and her son saw in her family doctor’s office and how her requests were often not prioritized and became lost when care shifted between providers. She worded the encounters as a “never-ending battle,” making her feel like she was always failing. Marissa shared:

We went from, we went almost two years, a year and a half, little over a year and a half, fighting to get a pediatrician, and they kept saying, the wait lists are long, we don’t have enough and I said well that doesn’t mean we cannot put in the referral. Like, put in that referral.

Marissa had to fight for her health needs on more than one occasion. She explained that many of the alternative care providers working in her family doctor’s office did not hear her and constantly looked for alternative solutions to her health issues. Instead of listening to her needs, Marissa detailed the ongoing rejection and denial of further investigations. Relief came when someone finally listened to her in the following story:

They [providers in family doctor’s office] kept saying, oh, we’ll send you to a sleep clinic. And when I’m saying no, we need to increase my meds. I literally only had to tell my doctor like look, I’m not okay. And he was like, yep, okay, we’ll increase them. Like, you know, that’s listening to me. Versus them telling me no … Yeah, since the increase I seem like, I’m, I’m more stable. I needed that. I knew what my body needed. And to be told no repeatedly. It made no sense.

Like Marissa, Nicole also had situations where she felt her access to care was denied. One of Nicole’s health struggles throughout her life was heavy menstruation, and painful uterine fibroids. She dealt with uterine fibroids until menopause when her symptoms finally subsided. Nicole shared the following story:

I wanted a hysterectomy when I was young and they wouldn’t give it to me and—because I was having some bleeding issues. And I was about 25, and while you, you know, well, we really don’t like to do that at your age because you might have babies. Listen, I’m a lesbian. I don’t want any children. I don’t want them. This was, I want my health …

Nicole’s story showed clear frustration regarding a lack of bodily integrity and body autonomy. Although she knew a hysterectomy would improve her quality of life, HCPs stood in her way, resulting in many years of preventable pain and a sense of denied care.

In another story shared by Nicole about her lung cancer diagnosis, lack of control and patient powerlessness was emphasized. Despite the effort from her doctors, she still lacked control over the situation, describing, “… one machine’s in Ottawa, and the other one’s in Mississauga was a PET scan, but you’ll probably have to wait a few months, you know, and I’m like: Wow, I can’t do anything. While I’ve got this cancerous lump in my body, until this is done.” Knowing she had no choice but to wait for these scans was frightening and stressful for Nicole, and demonstrated how limitations of timely care could worsen quality of life.

Scene 1 highlighted the prominent power imbalances that existed between women living on a low income and their HCPs, who acted as a bridge to accessing timely, holistic health care services. Although women felt strongly about what they needed for their health, barriers arose when HCPs limited accessibility to a wider range of health care services. Issues key to this scene included power imbalances, bodily integrity, body autonomy, and a lack of shared decision-making between patients and providers. HCPs, as co-actors influencing the direction and quality of the women’s performance, must recognize their power to help women feel more in control of their health.

Scene 2: Health Care Information—When Directions Fail (If They’re Even Received)

Participants expressed confusion and irritation when they were not provided with sufficient or consistent information regarding their health. They described situations when they felt lost on their own, with no guidance to independently manage their health. Not being connected to or made aware of available services also caused women to feel like the health care system was failing them when they needed it most. For a successful performance, actors needed to have a well-written, appropriate script for them to study and learn their role. No script—or not being provided with health information—left women feeling bewildered and confused about how to perform health behaviors and optimize their well-being.

Angela’s narrative delved into her experiences of feeling like she was never given enough information to manage her health on a day-to-day basis. She described feeling as though her efforts were always being corrected or scrutinized in health care settings, yet limited direction was provided. One of Angela’s stories focused on her diagnoses of diabetes and fatty liver disease; she described an event when a nurse learned about the new diet Angela had started, followed by a harsh exchange:

I went on a diet. And I had a meeting. And this nurse … found out about my diet. She yelled at me … And because this woman yelled at me, I figured it was dangerous? So, I stopped the diet, and then I gained a few pounds back. Okay. And then I realized when I was on the diet, I realized I had no aches and pains in my legs. I started to feel better. I wasn’t tired.

Although she made independent efforts to improve her health, Angela was criticized and not offered supportive education, causing ongoing confusion about what she should have been doing differently to manage her chronic illnesses.

Marissa described making constant effort to receive health information for her child and herself. In a conversation about her experiences with receiving and understanding health information, Marissa explained she wanted to be met with compassion when seeking to improve her knowledge. She said, “… you should never feel like any question is a burden, like that should never, like, no question’s stupid, every question deserves an answer. Um, that’s just getting knowledge, at least we’re not trying to be ignorant right. Um, we’re asking for that knowledge.” Similarly, Sarah explained she asked questions to make sure she understood the information being given to her, even if it took time: “… but they say to me, cuz I ask too many questions. You have to know what’s going on. If don’t ask how you gonna know? I’m like that.” Foremost, the offering of health information was requested by women when they were in health care environments, with encouragement that they felt capable and safe when asking questions.

As previously referenced, Marissa felt it was problematic when she saw various different providers during appointments at her family doctor’s office. While undergoing investigations for abdominal pain, seeing multiple providers created stress for Marissa because she was continually getting different, inconsistent health information. Consistency in her provider was something Marissa thought would improve her experiences: “… it’d just be nice to see one person, and get you know, the same answer from one person instead of like, three different answers.” Justine’s narrative echoed the frustration Angela, Sarah, and Marissa felt when left to fight for health information. Without giving a specific example, Justine said even a couple of minutes taken by HCPs to explain something would improve her comfort level prior to leaving a health care setting:

Well … it’d be nice that when they go to tell you something, they take the extra couple minutes to explain what they … just said, and to um, say well this is what we want you to do, this is how we want you to do it, and they’ll explain it so you have a better understanding before you leave here.

To confront perceived deficits, Angela was resourceful and learned to use other means, like the Internet, to find the information she unfortunately did not receive from HCPs. Regrettably, in finding alternative sources of information, more confusion arose for Angela when inconsistencies appeared. The following passage from Angela was an example of when she found seemingly important information from the Internet, which was never addressed by her doctor:

It’s like some doctors, doctors are so busy, they don’t have the time to go over things with you. And I got a doctor’s time is very, you know, but the nurses or there should be counselors to go over things like, even the thing with my fatty liver. I wanted more information. Like, I know I did research on the internet. But it would have been nice. Like, when a doctor tells me not to worry about something and then I find out this could lead to liver failure or something. Then in my eye is like, what could I do, you know.

Angela’s story showed the constant effort she made to educate herself about her health, even when she was not provided with information from her designated primary health care resource.

Scene 2 explored how the participants perceived their ability to access information about their health. A main issue women described was feeling lost after leaving health care settings and not knowing how to properly manage or adjust their health behaviors. Participants expressed feeling confused about conflicting and inconsistent information, which decreased the trust they had in health care services. When HCPs took time to discuss and explain things to participants, feelings of comfort and increased confidence were experienced; women felt more capable of going home and managing their health, knowing they were on the right path.

Scene 3: Need for Reassurance and Trust

The third scene encompassed values about feeling reassured and supported by HCPs, while also continually advocating for their health, despite negative past experiences. Participants shared stories of relief during interactions where they knew they would receive the care they desired and felt empowered to access health care whenever they felt it was necessary. Support and reassurance from HCPs were incredibly important to Marissa. Throughout her stories, Marissa explained her child often did not meet certain criteria for most health services meant for children with autism spectrum disorder; she revealed her child was not physically disabled but was also not high functioning, often resulting in their exclusion. She described a time when her child was rushed during an augmentative assessment, causing them to again “fall through the cracks” and be denied developmental services. Despite such negative occurrences, Marissa valued the people involved in her health care who reassured her and encouraged her advocacy:

I have so many other people like my, my actual family doctor, um, the nurse practitioner, they’re not one’s like that. They are there, they make me feel good. They, they let me know that what I’m doing is right. And that I’m good, like … I kept thinking they’re gonna think something’s wrong with me for having [child’s name] there all the time. But you get some that, you know, this is what we’re here for Marissa, no if [child’s name is] not feeling right bring [them] in, we’ll look [them] over, you know …

The ongoing efforts that Marissa made to help her child receive the services they needed, even when faced with ongoing rejection, were a situation that undoubtedly required external support and resilience. As a single mother, having HCPs who gained her trust and provided a safe space to bring her child was critical for Marissa.

For Angela, trust and reassurance from her HCPs were associated with her ability to contact someone when she needed health care. Having nurses and nurse practitioners (NPs) as her first contact point before an appointment with her doctor was a source of reassurance for Angela:

… because if I talked to the nurse practitioner. She can guide me, and she liked, because I knew I was a little down, and I needed a prescription. And I know if I asked her about something. She can contact my doctor much faster than I do. You know like, it’s like something I have learned over the years if I talk to the nurse practitioner, I can get somewhere, you know.

This learned pattern of how to get “results” from the system was comforting for its reliability and consistency, demonstrating the value of ongoing reassurance.

Justine’s narrative also showed the importance she placed on having one person she could trust to help navigate her health and medications. A previous social worker was this person for Justine; they made her feel reassured she could call anytime with questions or concerns about her health care. For example, Justine described a new diabetes medication regimen she did not understand, and it had not been explained to her in a way that made sense. Justine called her social worker to discuss this and felt much more confident after working through how she should take this medication:

It made it so much better in that aspect and then knowing that I wasn’t going off the phone like being confused and being upset and being like, again like a chicken with the head cut off and everything because I didn’t know what she meant. But she was willing, to take that extra couple minutes and explain it.

When her previous social worker moved to a new position, Justine expressed some uncertainty for the future, saying, “I just hope that someday long in the long run that reassurance is going to be there, but I can’t, I don’t know yet.” That little bit of extra time and effort by Justine’s social worker was something that provided her with a clear and calm approach to handling her health at home. This effort was something that helped women feel confident in their health behaviors and ultimately improved their overall health while preventing complications.

Within this scene, participants shared their stories about having needs met through supportive, understanding HCPs. The encouragement for Marissa to bring her child to the doctor whenever she was worried, or for Angela to know her NP would arrange a doctor’s appointment, or for Justine to have a reliable contact person to ask health questions all reflected a key component of health care. For women to feel they could receive the health care they required, a supportive, welcoming environment had to be created by the providers with whom they interacted. Being reassured and supported in their health decisions encouraged future use of health care services and helped women living on a low income feel comfortable accessing care.

Discussion

As the cost of living continues to rise in Canada and globally, the narratives of participants in our study reveal how health care systems perpetuate and reinforce structural inequities rather than alleviating them. Through a critical theory lens, their stories expose health care not as a neutral public service but as an institution deeply embedded in broader systems of power that reproduce social hierarchies (Jenkins et al., 2022). The power dynamics operating within health care encounters extend beyond limiting access; they contribute to the ongoing exclusion of those already disadvantaged by economic systems, reinforcing health care environments where class-based inequities are perpetuated and normalized rather than challenged (Jenkins et al., 2022).

Powerlessness: Institutionalized Disempowerment

A central thread across these narratives was the feeling of powerlessness. When participants described being reduced to passive recipients rather than active partners in care, they illuminated how health care institutions deploy disciplinary power that demands compliance as the price of care (Jenkins et al., 2022). The scrutiny and surveillance documented in previous research (Goldenberg et al., 2023; Hamel-Smith Grasby et al., 2021) function as a form of institutional control where women must continuously prove their “worthiness” for basic health care services.

In our study, this control manifested as a kind of competition in which access depended not on medical need alone but on who could best meet arbitrary thresholds. Whether through provider routines or personal discretion, decisions about access often feel unpredictable and exclusionary. These routine exclusions reflect institutional norms that prioritize procedural efficiency and standardized criteria over individualized, responsive care logics that, while administratively rational, often fail to meet the complex needs of equity-deserving populations. These restrictive criteria reinforce structural power imbalances, limiting women’s ability to pursue meaningful health outcomes even when they actively advocate for themselves. Vital to health care, women need to feel empowered in health environments—they require conversations and education about why certain pathways are restricted, as well as what alternatives can address their health concerns. Without empowerment, women living on a low income cannot escape reduced control over their own health; providers must learn to uplift the voices of these patients to build a trusting, reliable partnership in care that challenges restrictive systems and criteria for care.

The participants also described being dismissed or minimized by HCPs, reinforcing this sense of institutional disempowerment. They shared experiences of being denied referrals, delayed diagnoses, and a general lack of agency in health care interactions. These experiences echoed findings from Darling et al. (2019) and Gibson and Mykitiuk (2012), where care was similarly restricted or gatekept by providers. Across the literature, women with low incomes have long reported struggling to have their concerns heard and taken seriously (Angus et al., 2012; Walcott et al., 2016). In our study, participants repeatedly emphasized how the ability to choose a provider or experience continuity in care enhanced their sense of control. This aligns with growing evidence that patient agency, continuity, and system responsiveness are key to improving care outcomes (Dickins et al., 2021; Kayser et al., 2022; Turin et al., 2020). Critically, it also underscores the need to challenge routine institutional practices that prioritize efficiency over equity and to reimagine care relationships as spaces of shared power.

Discouragement to Return to Care

Through reflection of the stories told by participants, we observed how past experiences—whether of stigma, neglect, or dismissal—shaped participants’ future decisions about engaging with care. Being placed on long waiting lists, denied services, or met with condescending attitudes and rejection discouraged women from returning for care. These deterrents are supported by existing research that links discrimination, long wait times, and unmet health needs with reduced engagement in health services (Dickins et al., 2021; Sanford et al., 2024). The participants in this QSDA described limiting their time in health care settings or avoiding care altogether. This type of withdrawal has been reported in other research, including among pregnant women with substance use disorder who feared stigma or punitive consequences (Stone, 2015), and individuals who perceived care as emotionally uncomfortable, judgmental, or not worth the effort (Taber et al., 2015). In a study by Copeland and Snyder (2011), African American women avoided mental health treatment based on fears of being “committed” and previous experiences of isolating health care environments. The consistency of evidence wherein women report feeling deterred from future health care use represents a preventable health inequity that must be addressed. To reverse this avoidance and prevent worsening health outcomes, intentional and visible action is needed. Women must see real efforts to improve the systems that serve them—efforts that validate their worth and rebuild their trust. Women need people in the system to show they care and to believe that future care experiences can be different from those in the past.

Trust in Health Care Services

Women in this study said that something as basic as having routine physicals, or someone helping them find available services, would signal that their health matters. Reassurance, as indicated by participants, is required to feel safe in health environments, and having a reliable health team builds trust in the system. Small yet meaningful actions were also noted in the work of others as ways to help people feel remembered and cared for by the system (Ingol et al., 2020). This also includes trust, which is foundational to effective health care. Women living on a low income often face intersecting barriers that heighten the importance of building and sustaining trust in the health care system. Ensuring access to safe, reliable, and consistent care is not only essential—it is a matter of equity and justice. Trust should never be eroded by the very systems designed to support well-being. As Baker (2020) notes, strong patient–provider relationships improve outcomes and increase care engagement. Similarly, Kamimura et al. (2020) found people receiving care in under-resourced settings, including many women, reported greater trust and satisfaction when they experienced consistent care and help navigating complex systems. As well, Stanley et al. (2020) found adults living with low income—many of whom were women—associated trust with being listened to, treated with dignity, and cared for consistently over time—all factors that were also voiced by participants of this QSDA. Building trust and respectful, person-centered relationships is essential to ensuring continued access to care. For women navigating poverty and systemic inequities, health care environments must be safe, supportive spaces where they are treated with respect and where their rights to care and wellness are upheld. Although our sample did not include racialized or immigrant participants, the dynamics of exclusion and disempowerment revealed in these narratives are likely amplified for those also navigating systemic racism, xenophobia, or linguistic marginalization (Richter et al., 2020).

Recommendations for Practice, Education, and Research

Drawing from our findings, we offer specific, actionable recommendations to improve practice, education, policy, and research. To address the barriers experienced by the participants in this study, health care systems must actively dismantle the structural barriers that perpetuate inequity by embedding trauma- and equity-informed approaches in everyday practice, policy, and provider education. Providers should be supported to offer consistent, compassionate care, ensure continuity, and provide clear, accessible health information. In education, training programs for health professionals should include content on poverty, systemic discrimination, and the lived realities of underserved populations, with an emphasis on humility, empathy, and shared power in care relationships. Education for HCPs must also expand upon the interconnectedness of the SDH. Poverty can interact with several other determinants—such as race, immigration status, health education, and literacy—to further marginalize vulnerable populations. HCPs must be aware of the multi-faceted nature of the SDH and consider how multiple factors might influence their client’s overall health and health behaviors. Finally, research should continue to elevate the narratives of people from equity-deserving groups, using participatory and narrative methods to inform service design and policy, and to ensure that health systems respond meaningfully to community-identified needs.

Strengths and Challenges of This Study

A primary strength of this study was the use of QSDA. By re-analyzing data collected in the primary study, we were able to identify and explore new findings that extended beyond the original analysis. This approach reduced participant burden, as no new interviews were required, and allowed for a more in-depth and context-rich interpretation of the data. The first author’s prior involvement in the primary study as a research fellow enabled direct access to all transcripts and audio recordings and provided valuable contextual knowledge during data interpretation. This insider perspective strengthened the trustworthiness of the analysis by offering deeper insight into the participants’ narratives.

Another strength was the application of dialogic/performative narrative analysis. Drawing from the work of Riessman (2008), we used a theatrical metaphor to frame participants’ experiences in a creative yet structured way. This approach helped to capture the complexity of women’s health care journeys and highlighted thematic content and narrative structure. This method not only highlighted thematic patterns but also enabled a critical reading of how systemic power operated in participants’ accounts, what was said, how it was said, and what it revealed about broader institutional logics. The metaphor enhanced coherence and depth, making the findings more accessible and meaningful, while emphasizing the interpretive nature of narrative analysis. The study also benefited from the openness and depth of participant contributions. The participants shared detailed, personal accounts of their experiences accessing health care while living on a low income. Their willingness to discuss sensitive topics significantly enriched the data. Furthermore, when contacted for additional consent to conduct the QSDA, all participants responded positively, demonstrating strong engagement and support for the study’s purpose.

We acknowledge study limitations. First, the primary data collection occurred during the COVID-19 pandemic, requiring remote interviews via telephone or video call. While this method ensured it was safe for all, it may have limited rapport and the richness of in-person interaction. Notably, at least one participant did indicate a preference for the privacy of remote interviews. Additionally, the focus group, held in person as restrictions eased, allowed for more spontaneous dialogue, potentially deepening the insights gained.

Second, our participants’ demographic homogeneity represents a critical limitation. All participants identified as white, all but one were Canadian-born, and all except one spoke English as their first language. This homogeneity prevents analysis of how poverty intersects with race, ethnicity, and immigration status, intersections that are fundamental to understanding health care inequities in Canada’s multicultural context. The absence of racialized and immigrant women’s voices means our analysis cannot address how systemic racism compounds class-based oppression within health care, nor can we examine how linguistic barriers, documentation status, or cultural dismissal intensify the experiences of powerlessness and abandonment we documented. This limitation is particularly significant given that racialized and immigrant women experience higher rates of poverty and face additional barriers to health care access. Future research must prioritize recruiting diverse participants to develop truly intersectional understandings of health care inequity.

Our study aimed to generate deep, context-specific insights into the experiences of women living on a low income. In qualitative research, transferability is supported through rich descriptions that allow readers to assess the applicability of findings to other settings or populations (Lincoln & Guba, 1985). The detailed narratives and transparent account of study context and methods enable practitioners, educators, and policymakers to consider how these findings may resonate within similar environments. The thematic patterns identified offer valuable insight into structural barriers to care and may inform strategies for more equitable health system responses.

Finally, this research was the first study undertaken by the first author. As a novice researcher, they required assistance distinguishing the secondary analysis from the primary study and navigating the volume and complexity of the data. Regular supervision, ongoing self-reflection, and a commitment to the analytical process were all supportive strategies. Despite the learning curve, the study benefited from the first author’s dedication to understanding the data within its broader social and political context.

Conclusion

This study highlighted the complex and often discouraging experiences of women living on a low income as they navigate access to health care in Canada. Through narrative analysis, it became evident that structural barriers, such as provider rejection/gatekeeping, lack of clear health information, experiences of stigma, and a lack of reassurance, create significant obstacles to equitable care. Participants described feelings of powerlessness, discouragement of returning to care, and diminished trust in health systems that are meant to support them. At the same time, their stories revealed resilience, persistence, and a desire for compassionate, informed, and inclusive care. Health care access, as described by participants, is not only about physically reaching services but also about having the support, information, and autonomy to manage one’s health in a system that too often fails to recognize their needs. Systemic change that centers the voices of people with lived experience, promotes equity, and rebuilds trust in care relationships is essential going forward. This study contributes to a growing body of evidence calling for a more responsive and just health care system that treats all individuals with dignity and respect.