Abstract
Access to healthcare is a Social Determinant of Health that is associated with public health outcomes and barriers to access disproportionately affect African American adults. This study used a health and financial literacy approach to qualitatively assess how African American adults access healthcare and potential barriers faced (n = 20). Results indicated a wide range of experiences generally split between positive and negative experiences in access to healthcare. Specific themes that emerged included scheduling issues and appointment availability, expense of care, lack of transparency in insurance coverage, the need for more primary care clinics and enhanced community outreach and education on how to access healthcare. This research identifies a need for increased education surrounding health insurance coverage and an identified need for more local physicians or ease of scheduling. All participants in this study stated they were covered by health insurance of some form. Future research should examine these issues in the context of socioeconomic and insurance status.
Keywords
Introduction
Access to healthcare is linked to health outcomes and barriers disproportionately impacts racial and ethnic minority populations.1,2 Access to healthcare is a Social Determinant of Health, meaning a component of how we live work and play impacts our health outcomes. 3 Access to healthcare is defined as timely use of personal health services to achieve the best possible health outcomes 4 and can be determined by things like insurance status, having a primary care provider, and structural barriers like transportation and hours clinics are open. 3
African Americans are more likely to encounter health inequities in access to healthcare in part due to an enduring history of structural racism that has led to persistent income inequality, de facto segregation, and lack of access to resources.5,6 Particularly, people living in the rural south have higher mortality rates than those living in urban areas or rural areas in other regions of the country and among these, people of color experience the highest rates of death. 7 South Carolina is among the states in the Southeastern U.S. with higher rates of premature death among African Americans, which can be understand further by exploring barriers in access to healthcare. 8 Improving the health of African American adults through greater access to healthcare is an opportunity for social justice. 9
One determinant of access to healthcare services is insurance status and there are a higher rate of uninsured people in South Carolina compared to the national average. 10 Within South Carolina, according to the 2019 Tri-County Community Health Needs Assessment over 1 in 5 Charleston County Residents report not typically being able to visit a doctor when needed. 11 Members of racial and ethnic minority groups were less likely to report a physical exam in the past year, with African American adults reporting the lowest percentages (24% vs. 44% overall). 10 The current study explores health and financial literacy in relation to lack of access to healthcare services among African American adults in a Tri-County region of South Carolina.
Health and financial literacy are the ability to access, understand and utilize health and financial information to promote good health and financial outcomes. 12 It is important to further understand financial health literacy among this population to shed light on barriers to healthcare access with the ultimate goal of reducing racial and ethnic health inequities.
This research adds to the discussion of how to properly address health disparities, and aid in the efforts to minimize them. Specifically, this study explores health and financial literacy issues among African American adults in the Tri-County area to gain further understanding about how social determinants of health play a role in healthcare access. This work sheds light on the issues important to community members and provides groundwork for future interventions that combine both public health and financial expertise. The purpose of this study was to understand how African American adults access healthcare and potential barriers faced in the process of accessing healthcare.
Methods
Eligible participants for this study included African American adults ages 18 to 65 living in a tri-county area of a Southeastern U.S. state. Participants were recruited through social media posts and paid Facebook ads. Interested participants contacted study staff via email and were scheduled for a 30 min, individual, online Zoom interview with study staff. Prior to the interview, participants completed an informed consent for the interview using the Qualtrics program. Following the interview the participants were asked to answer demographic questions via a quantitative Qualtrics survey. Participants completed a separate consent for the quantitative demographic survey. Interviews were auto-transcribed using Zoom. All procedures were approved by the College of Charleston Institutional Review Board.
Researchers created a semi-structured interview guide that was used in all interviews. Questions on accessing healthcare. Questions included asking participants what they normally do when they need to see a doctor in non-emergency and emergency situations; if and why they have ever found it difficult to see a doctor and how their finances, work, friends and family, local community, and other factors impacted their ability to see a doctor. Participants were also asked how they accessed other types of care such as a dentist or pharmacist and about difficulties with those encounters in addition to describing the health insurance available to them or barriers to access. Participants were also asked their input on improving access to healthcare and health in general in the local area. The full interview guide is included in Figure 1.
Demographic survey questions.
Participants completed an online demographic survey in addition to the qualitative interview. Participants responded to demographic questions asking “How old are you?” (dropdown menu of 18-65); “Are you Hispanic of Latino” (Yes or No); “What is your gender?” (Male, Female, Non-binary, Other); “What is the highest level of education you have completed?” (Some high school; High school diploma or GED; Some college education; Associates degree; Bachelor’s degree; Graduate or Professional degree); “What is your current relationship status?” (Married, Divorced, Widowed, Separated, Never Married, Member of unmarried couple, Single, Other); “Which of the following best describes your work status?” (Employed full-time, Employed part-time, Going to school, Taking care of house or family, Unable to work for health reasons, On layoff, Disabled, Retired, Looking for work, Other). Additional questions included “What was the total combined income of those living in your house during the past 12 months?” (Response options of under $10 000 to $90 000 or more in intervals of $10 000); “In what county do you live?” (Charleston, Dorchester, Berkely, Other); “Are you covered by health insurance or some other kind of health plan?” (Yes, No, Don’t Know); “What type of healthcare coverage do you have?” (Private health insurance, Medicare, Medicaid, Military healthcare, Other government program, No coverage); “In the last 12 months, was there any time when you did not have any health insurance coverage?” (Yes, No, Don’t know). Participant responses to the demographic survey were collected online using Qualtrics and not tied to participant responses in the qualitative interview. The interview guide is displayed in Figure 2.
Interview Guide Access to Healthcare Questions.
Two research team members worked as coders to conduct thematic analysis. Coders met to compare codes and discuss any differences in coding. Coding and analysis for themes was overseen by the Principal Investigator. In order to be determined a theme, a topic must have been mentioned by at least 5 participants. All analyses were completed using Microsoft Office Suite.
Results
Descriptions of Accessing Routine Healthcare
Most participants stated that when they need to see a doctor for a non-emergency reason, they call and schedule an appointment (n = 13). However, some participants acknowledged that it is difficult to schedule an appointment and often had a back up plan, such as urgent care, emergency room, or a “minute clinic” if a doctor was not available (n = 4). Most participants stated they have seen a family doctor at some point (n = 15) but several acknowledged that they did not have a current physician (n = 3). When participants were asked how they make an appointment to see a doctor, a majority stated that they call (n = 11), but some schedule online (n = 4), and a few also mentioned needing to look up online or in an insurance booklet whether the provider is in-network (n = 3).
Participant Quote: “First I contact my primary physician and if she’s not available and I can’t get in, I would go to the emergency room that’s in my network.”
Descriptions Accessing Emergency Healthcare
Eight participants reported having to see a doctor in an emergency, but half of those stated it was not recently. Participants who described their situations in accessing emergency had stories including having an ambulance arrive (n = 1), not being able to get an appointment so going to the Emergency room (n = 2), or a physician telling them to go to the emergency room because urgent care was not capable of handling the situation (1).
Participant Quote: “So I end up like passing out one day and I just, someone was nearby, so they call 911 for me and so um I’m actually currently. . .because the hospital or like what some stuff that they did was like not covered under my insurance. . .I’m currently fighting that to this day.”
Yes, yeah they didn’t consent it well, I guess, they can’t really consent, if you pass out, so I guess [you] can see that’s what’s implied.
Difficulties in Accessing Routine Healthcare
Participants were split on whether they had ever found it difficult to see a doctor (Yes, n = 11; No, n = 8). Of those who had found it difficult, reasons mentioned included doctors being overbooked and taking awhile to get and appointment (n = 6) or because of COVID-19 (n = 2).
Participant Quote: “Yes, because, like I said, like they’re really like they’re just overbooked lately. That’s the new trend in healthcare and they don’t buffer in between appointments, and they’re just always busy. So yes, very difficult and I’m actually searching for another doctor, because of that reason.”
Difficulties in Accessing Other Forms of Healthcare (Dental, Optician, Pharmacy)
More participants stated that they did not have difficulties accessing other forms of healthcare (n = 11) than those who stated they did have difficulties (n = 8). Of those who did not have difficulties, participants mentioned consistent providers, personal connections in getting appointments, and ease of scheduling or open hours of pharmacies. Difficulties stated in accessing other forms of healthcare included COVID-19, pharmacies closing on Sundays, miscommunication with pharmacies, poor treatment, high fees, and difficulty getting appointments.
Participant Quote: “Well, my daughter was born with a precondition, and the pharmacy, this medicine is hard to come by. I didn’t know that. So, the pharmacy said they [. . .] would have had it in like 24 hours and they did not. They did not let me know about it, so I had to go call the doctors and explain to them what happened. The specialist for my daughter, said only I could get this medicine at [local hospital], only [location hospital] carried this particular medicine. But [the pharmacy] had me to believe that it was full, and it was like a whole, like, a lot of drama behind that.”
Impact of Finances on Access to Healthcare
Participants were largely split over whether their finances did (n = 9) or did not (n = 8) impact their access to healthcare.
Participant Quote: “Um, I guess my finances would affect that if I was using the emergency room as a primary way to visit the doctor but um, I guess, even if I don’t have the cash I always have a card handy, just in case I do have emergencies that I can’t cover.”
Participants stated specific, yet varying examples of how finances affected healthcare in terms of use of copays, urgent care, emergency room, surgeries, mental health care, or prescriptions.
Participant Quote: “Oh, yes, Lord. Yes ma’am. I was waiting one time to be [determined for eligibility] disabled by Social Security and I was unable to go to a doctor. I had a really good doctor. He was really good. He worked with me for a long time. He would give me samples and stuff for the medication because he knew my situation. But after awhile, you know, I guess it was impossible for him to continue doing that, and you know his medical practice to thrive. So I eventually got a letter from them, saying that they couldn’t see me anymore.”
Impact of Friends and Family on Access to Healthcare
Participants overwhelmingly stated that family and friends do not impact their access to healthcare (n = 12).
Participant Quote: “Um, I would say no, they do give you like advice on like what kind of providers to use sometimes, um, but they don’t really affect my access to healthcare, no.”
Impact of Work on Access to Healthcare
Most participants (n = 12) did not find that their work affected how they accessed healthcare. For those that did (n = 7) the most common reasons were doctors offices not being open when they are off work (n = 4) or not a lot of free time because of working multiple jobs (n = 3).
Participant Quote: “Yes, because of the job that I have, I do sometimes have to work two jobs to like provide, so it is oftentimes very difficult because I do work on the weekends, so a lot of times, I do have to take off time from work, which is very difficult to schedule an appointment and so. It’s kind of hard to having a traditional like nine to five and then also having to work on the weekends like I do to make ends meet.”
Impact of Local Community on Access to Healthcare
Most participants stated that the local community does not affect how they impact healthcare (n = 14), of those that stated that it did (n = 4), negative reasons included a growing area with not enough doctors, COVID-19 and living in a rural area.
Participant Quote: “I feel like yes, and I say that because I think the [City Name] area is just growing so rapidly that we just don’t have the infrastructure to like maintain everybody’s moving here so fast and like a lot of doctors, even when you’re calling to get a new patient appointment it takes like two and three and four months, and like especially someone who has an illness already like you can’t wait that long in between seeing a doctor.”
Other Impacts on Access to Healthcare
Half of responding participants stated that they had other impacts on their access to healthcare (n = 8) while half did not (n = 8). Of those who mentioned other impacts on healthcare the reasons varied as widely as childcare, representative physicians, transportation, cost transparency, availability, and own choices.
Participant Quote: “I think just um, And now this is just like my personal, you know, preference or whatever. But when I go to like a website and you know sometimes they’ll have pictures of the doctors and everything, I mean I just it would just be nice to see a black doctor. You know, I can’t honestly think of a time where I’ve had a black doctor, and I just feel like I mean I’ve had some good experiences with doctors and I’ve had some bad experiences with doctors and I feel like you know with those bad experiences in the back of my mind and I’m just like if you looked like me would I be having a better experience or what not. And so like last week, not last week but the week before I had to go see an allergen doctor to see what was going on with these allergic reactions I’m having. He just shut me down and was like oh it has to be bed bugs [. . .].and he just was not able to answer my questions and he’s just like I want you to do this first and you can come back and again, going back to the availability and time, I’m thinking where am I supposed to find time to come back. And then you know I’m looking online, at pictures and stuff and thinking, Well, this looks different on, you know, like black skin. And I’m kind of wondering like has he even you know worked with anyone, or seen, you know, like that, patient-wise and all of this is going through my head and I’m thinking if I had a black dermatologist or like a black allergy doctor would I be going through the same thing, would I be shut down as easily?”
Description of Health Insurance Status for Self and Family
All responding participants stated that they had health insurance (n = 19), but not all of their family members did (n = 3).
Participant Quote: “So I decided to get healthcare, just because . . . just in case I got sick to the point that I needed like hospitalization, or say, for example, I needed like advanced testing. Then I felt it would be cheaper for me to have health insurance to offset those costs. As far as my father not having health insurance, that I can’t . . . I can’t explain the rationale of why he doesn’t have health assurance.”
Knowledge About Health Insurance Coverage
Participants providing more information about what healthcare they can get with their insurance most often described some aspects of their coverage (n = 12). Three participants stated they did not know what their health insurance covered.
Participant Quote: “My medical. . .the dental I do on my own, because I only see the dentist twice a year, so I didn’t want to pay the higher ease for the dental portion of it. . .But normally I’ll do the health care through them of other than that. . .I haven’t used them yet, for like, they were saying that you can get one free Covid test a month with reimbursement. I haven’t used them for that yet because my fear was I pay for it, and then I have to wait months for reimbursement, or they may not reimburse me.”
Participant Input on Improving Access to Healthcare in the Local Community
Participants gave a wide ranges of responses on how to increase access to healthcare in the local community. The most common responses included the need community education, awareness, and outreach about healthcare (n = 8). Participants also identified a need for more medical clinics (n = 3), especially primary care in low income and rural areas and financial assistance.
Participant Quote: “Getting the word out, I would say, doing things at the local level meeting people where they are. Having, because Covid it’s not going anywhere, so folks’ churches [are] now back in session, a lot of them and, as far as speaking to the African American community a lot of information is found at churches and here at barbershops especially. A lot of the male counterparts, they don’t want to go to the doctor, but they get a hair cut every two weeks.
So, having the connection with the barbers. You know, just letting them know, hey, have you been seeing a doctor, you know prostate cancer is real. So um. I would say, putting flyers up at the laundromat. The bus stops. You know, you can do radio advertisement but also word of mouth is the best thing, so I would just say start with local organizations partnership with them. Our Spanish sisters and brothers Latino same thing.”
Discussion
Overall themes that emerged from this research include scheduling issues and appointment availability, expense of care, lack of transparency in insurance coverage, and the need for more clinics and community education. To qualify as a theme, the topic must have been mentioned by at least 5 of the 20 participants.
A main theme from the study was issues with scheduling doctor’s appointments. Not being able to schedule a routine doctor’s appointment in a timely manner can lead to more visits to urgent care or the emergency room, or the advancement of adverse health conditions due to delay of care. A qualitative study on healthcare seeking conducted in the Mississippi Delta region with low income African American adults found mentions of a lack of medical specialists or transportation to see them. 13 Unlike our study, many participants did not have health insurance. In addition, research has shown that African American adults are more likely to utilize emergency rooms than adults of other racial and ethnic backgrounds, 14 which is more expensive than primary care and provides less continuity of care for chronic conditions.
Our sample had some level of access to healthcare in that they all reported having health insurance, yet even with health insurance, the expense of care was often reported as a barrier. Other qualitative studies exploring access to care among similar populations, have also found cost to be a theme; particularly the unknown costs when seeking care. 15 Expense of care among those with health insurance links with the need for more transparency of health insurance coverage costs and patient education on their insurance coverage. A 2018 study examining health insurance literacy gaps in an African American population in the state of Kentucky found that participants shared similar stories of difficulty navigating complex health insurance systems and finding health providers. 15 Like our study, experiences of high costs were also mentioned. Community identified needs for improvement in access to healthcare are particularly important in including the voice of the community in our efforts. In fact, it was only in this area that participants largely voiced the need for greater health education and community outreach on how to access healthcare that was not directly asked about in our interview questions. Past research has indicated that community input is vital in reducing health disparities and improving community interventions. 16 Historically, African American communities have not been a part of the conversation when strategies to address health inequities are planned. 9
This study is not without limitations. As an exploratory, qualitative study our sample was not representative of the entire community. Our participants self-selected to participate in the study based on recruitment ads on social media and may have missed participants not active on social media. In addition, the 2 step process of participants first indicating interest in the study and then scheduling an interview may have contributed to non-completion of the interview. Despite our broad inclusion criteria, we did not recruit any participants who reported not having access to health insurance, which limits the experiences shared to those with at least some formal access to healthcare.
Conclusion
Community identified barriers exist in accessing healthcare, primarily in scheduling, insurance, and expense. This research identifies a need for increased transparency surrounding health insurance coverage, an identified need for more local physicians and greater ease of scheduling physician appointments. Future research should examine these issues in the context of socioeconomic and insurance status and may consider expanding on our qualitative study with a quantitative methods representative of the local community.
Footnotes
Author Contributions
S. Maness and J. Low contributed to study conception. J. Low and T. Vu completed study analyses. S. Maness wrote manuscript draft.
Consent to Participate
Informed consent was obtained from all participants.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding from the University of Hawaii Minority Health Research Training Program in Health Disparities. The MHRT program is funded through the National Institute on Minority Health and Health Disparities, National Institutes of Health Grant #5T37MD008636
Ethics Approval
This study was approved by the College of Charleston Institutional Review Board.
