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Low-Income Women’s Priorities for Primary Care
METHODS: We performed a qualitative analysis of 4 focus groups of women aged 40 to 65 years from 4 community health clinics in Washington, DC. Prompted by semistructured open-ended questions, the focus groups discussed their experiences with ambulatory care and the attributes of primary care that they found important. The focus groups were audiotaped, and the tapes were transcribed verbatim and coded independently by 3 readers.
RESULTS: The comments were independently organized into 5 content areas of primary care service delivery plus the construct of patient-provider relationship in the following order of frequency: accessibility (37.4%), the physician-patient relationship (37.4%), comprehensive scope of services (11.5%), coordination between providers (6.8%), continuity with a single clinician (3.7%), and accountability (3.2%). Commonly reported specific priorities included a sense of concern and respect from the clinicians and staff toward the patient, a physician who was willing to talk and spend time with them (attributes of the physician-patient relationship), weekend or evening hours, waiting times (attributes of organizational accessibility), location in the inner city and on public transport routes (an attribute of geographic accessibility), availability of coordinated social and clinical services on-site; and, availability of mental health services on-site (attributes of comprehensiveness and of coordination).
CONCLUSIONS: All attributes of care that were priorities for low-income women fit into 1 of 6 content areas. Specific features within the content areas of accessibility, physician-patient relationship, and comprehensiveness were particularly important for thes women.
The literature examining specific attributes of the structure and process of primary care for lower-income populations that suffer from disproportionately poor health1 is relatively modest.2 Most research in primary care has been undertaken in predominantly insured middle-class private settings and in children.3-8 There may be particular features of primary care that are uniquely important to low-income women given their challenging social and economic environments.
Ideally, primary care provides entry into the system for all new health needs, involves person-focused (not disease-oriented) care over time, includes care for all but very uncommon or unusual conditions, and coordinates services delivered by multiple providers.9 In accepted conceptual frameworks of primary care, the essential features# include: a comprehensive range of services, coordination across providers, continuity with a single provider, an accessible source of care, and accountability.*9-10
The purposes of our qualitative study were to determine which particular attributes of primary care were priorities for low-income women and to investigate whether an accepted framework for the conceptualization of primary care9-10 corresponds to the priorities of low-income women aged 40 years and older. We hypothesized that themes raised by low-income women would fit into an established framework of primary care, but particular attributes of the features of primary care would be especially important to this vulnerable population.
Methods
Study Design
We recruited focus group participants using posters and flyers circulated at 4 community clinics in Washington, DC. Those clinics were selected because of their location in medically underserved communities in 3 of the poorest wards of Washington, DC, and because they were examples of the range of structure and funding sources. We used in-depth interviews, audiotaped focus groups,11 and content analysis of the verbatim transcripts12 to identify attributes of primary care that are important to low-income women. At completion of the fourth focus group, similar themes continued to be raised, indicating saturation of themes. Through an iterative process of listening to audiotapes and reading transcripts, an exhaustive taxonomy was created that identified groups of issues that low-income women identified as important in the receipt of primary care.
Focus-Group Participants
The participants were English- or Spanish-speaking women aged 40 years or older who used the clinic for their current care or who had used the clinic in the past and were able to give informed consent. Since our qualitative study is the first component of a larger study to assess the relationship between priorities for primary care and receipt of cancer screening services for low-income women, we restricted the sampling frame to women aged 40 years and older.
Conduct of Focus Group Sessions
A separate focus group was held for each clinic. All focus groups were conducted in convenient, safe, and neutral community settings, and clinic staff was not present. The sessions lasted approximately 2 hours. A total of 24 women participated in the 4 focus groups: 2 of predominantly African American patients facilitated by an independent experienced African American female moderator and 2 of Spanish-speaking patients, conducted in Spanish by an experienced Latin American age-appropriate female moderator. A series of open-ended questions was asked of participants to elicit feelings about and experiences with primary care. table 1.
Development of Taxonomy
Two study team members (an internist and a physician researcher) independently reviewed each transcript in its entirety, identifying distinct topics (themes) and making comments indicating each of these units of text. Repeated or reworded statements of the same idea by the same participant were listed together as one comment.
Each unit of text (a statement that conveyed one idea) from the transcripts was listed by a physician primary care researcher in the order it arose in the transcripts as both a direct quote and as a summary theme on the basis of the comments made by the first 2 study team members. Initially, to avoid imposing any particular framework onto the women’s comments, 2 investigators did independent inductive coding,13-14 in which each unit of text was reviewed in its context from the transcript, categories (labels) were generated, and a list of labels was compiled. When reviewing this exhaustive list, we found that the list of inductive labels (codes) fit fairly well into established conceptual frameworks for primary care. Thus, all units of text from the transcripts were then reclassified independently in duplicate (by a clinical internist and by a physician primary care researcher), using agreed-upon coding rules from the primary care conceptual framework, with the addition of the physician-patient relationship category, which arose as a common theme from the transcripts.
Interrater reliability for the overall coding of distinct units of text into 1 of 6 major primary care content areas was substantial (b = 0.84 overall). Content analysis was performed on the comments for all 4 focus groups, including a count of the number of times a theme was mentioned by different respondents and the primary care content area into which the themes fit.
Results
A total of 24 women participated in the discussions: 8 Latinas, 15 African Americans, and 1 white woman. The mean age of the participants was 46.6 years (median = 44.5; one third were aged 50 years and older.) Eight of the participants had an 11th grade education or less; 5 were high-school graduates; and 11 had some college education. Four were married. The majority worked: 8 full time, 8 part time, and the rest were unpaid, retired, or unemployed. Sixteen of these women cared for dependents part or full time. Eighty-two percent of the participants had a household income of less than $20,000, reflecting our success in recruiting the population we sought. Twenty-two women were uninsured, but most of the African American participants had had Medicaid or private insurance in the past.
The most important conceptual modification arising from the women’s comments was the addition of the physician-patient relationship as an important and unique feature encompassing many of the women’s priorities. The percentages of focus group participant comments falling into each of the major primary care codes were as follows: an accessible source of care (37.4%), the physician-patient relationship (37.4%), a comprehensive range of services (11.5%), coordination across providers (6.8%), continuity with a single provider (3.7%), and accountability (3.2%). Table 2 gives the frequency distribution of participants’ priorities for primary care and some of the more commonly stated priorities.
Within the content area of the physician-patient relationship, themes mentioned most often were communication between physician and patient, having staff who listen, getting personal attention, and most important, a staff that was concerned and respectful. For Latinas, clinicians’ knowledge of the Latin community and of the fear and trust issues experienced by recent immigrants toward the medical system and toward other members of the community were mentioned often.
Specific attributes mentioned frequently within the category of accessibility were a clinic that had evening and weekend hours, was open to all regardless of insurance status, was located in the inner city or was accessible by using public transport, and was attentive to waiting times. Among Latinas, having a doctor fluent in Spanish and from a similar cultural background was an additional priority.
Within the category of comprehensiveness, the most frequently mentioned themes were the availability of multiple services at one site, presence of an intake procedure that recognized one’s needs, coordination of medical and social services on-site, and the availability of counseling and treatment for emotional and mental health concerns. Sample quotes from the focus group transcripts, organized within the 6 content areas, are presented in Table 3
Discussion
Eighty-six percent of participants’ comments fit into 1 of 3 content areas: physician-patient relationship, accessibility, and comprehensiveness. The breadth and depth9 of physician-patient interactions in primary care make its relationship unique. Heavy emphasis on interactions with their primary care physicians (one third of all comments) supports other authors’ statements about vulnerable patients placing a special emphasis on this relationship.15-16 Underinsured people lacking access to alternate providers have a heightened reliance on a physician’s competence, skills, and good will.15 Having a sense that their physician had concern and respect for the patient was the most frequently mentioned priority in the focus groups. When working with low-income minority or immigrant patients, physicians might want to be especially sensitive to their voice, tone, and posture to communicate a sense of respect and concern for patients who may already feel vulnerable. It appears that the category of physician-patient relationship is vital to the conceptual framework of primary care for these low-income women, and it may be a link in the chain without which the other features (continuity, comprehensiveness, coordination, accessibility, accountability) cannot function optimally.
Accessibility was also a clear priority for these women. Twenty-two of the 24 women in this study were uninsured. This may explain why a large percentage of their comments (37.4%) fell into this category. Even though these uninsured women were receiving medical care in community clinics, issues of access (particularly of organizational access) were still foremost in their minds. This may be due to previous obstacles encountered in obtaining care or to deficiencies or strengths perceived in their current systems. Juxtaposed against the reality of increasing underinsurance for even basic access to services, this underscores a serious and worsening problem of unmet health care delivery needs. This emphasis on accessibility demonstrates the need to improve both the financing and organization of the primary care safety net.
The themes most frequently raised with respect to comprehensiveness highlight how the needs of economically vulnerable people may differ from those who are financially secure. For example, previous research shows that poor women have a higher prevalence of mood disorders than the general population,18 and most would prefer to be treated for these in the primary care setting,19-21 since they often do not have the choice of going directly to specialty mental health services. This supports the provision of basic mental health care for the more common and treatable mood and anxiety disorders in the primary care setting. Stronger ties between primary care and certain specialty services may be needed to ensure such comprehensiveness.
A comparison of these participants’ priorities with those of the general population in the literature yields similarities and differences. Priorities vary with sociodemographic characteristics22: younger patients valued coordination of care and technical proficiency most, while older patients ranked continuity of care and comprehensiveness highest.23 Older patients placed more emphasis on cost issues15,23 and on attributes of accountability.17,24-25 Differences have also been shown by health status: Patients with a chronic illness preferred continuity over other features.23 In the general population, accessibility, coordination, information, communication, education, respect for patients’ values and expressed needs, and emotional support are the greatest concerns.26 Population differences in priorities demonstrate that primary care systems must be tailored to the specific needs and priorities of the populations served.
Comparison of our study’s findings with those of the general population raises the issue of what these low-income women were not saying. For example, issues of accountability were infrequently mentioned. This may reflect the participants’ greater concerns with having accessible care. Also continuity of care, while accounting for only 3.7% of comments, was tied to other specific attributes considered important by these women. For example, attributes of the physician-patient relationship, such as communication, are directly tied to the presence of an ongoing relationship with a physician over time. Furthermore, given the dependence of economically vulnerable persons on their primary care physician for access to services and the important role this physician has in coordinating their care, continuity seems especially important.15
Limitations
Several limitations should be considered in interpreting these findings. We investigated the research questions in this exploratory study by using focus groups and qualitative analysis. Such methods, if mindful of established standards,12 can yield well-grounded and detailed data. However, we cannot determine their generalizability. Further work to rank women’s priorities for primary care and to tie them to utilization and health outcomes will be pursued in the future through a population-based study. Also, qualitative data are subject to researcher bias. Our use of 3 independent raters and our careful attention to coding using established methods12 should have minimized this limitation.
Conclusions
Established frameworks for primary care, with the addition of the category of the physician-patient relationship, have qualitative (content) validity in this sample of low-income women; therefore, these content areas provide a useful language to discuss their health care delivery needs. The physician-patient relationship, accessibility, and comprehensiveness were the categories into which most of the women’s specific priorities fell. Health systems that fail to address low-income women’s specific needs may not adequately meet their clients’ expectations for health care.
Acknowledgments
Primary funding source: DAMD 17-97-1-7131 from the US Department of Army (Dr O’Malley).
1. Amler RW, Dull HB. Closing the gap: the burden of unnecessary illness. New York, NY: Oxford University Press; 1987.
2. Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups. Health Serv Res 1995;30:253-73.
3. Stewart AL, Grumbach K, Osmond DH, Vranizan K, Komaromy M, Bindman AB. Primary care and patient perceptions of access to care. J Fam Pract 1997;44:177-85.
4. Bindman AB, Grumbach K, Osmond D, Vranizan K, Stewart AL. Primary care and receipt of preventive services. J Gen Intern Med 1996;11:269-76.
5. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20.
6. Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract 1997;45:64-74.
7. Zemencuk JK, Feightner JW, Hayward RD, Skarupcki KA, Katz SJ. Patients’ desires and expectations for medical care in primary care clinics. J Gen Intern Med 1998;13:273-6.
8. Starfield B, Cassady C, Nanda J, Forrest CB, Berk R. Consumer experiences and provider perceptions of the quality of primary care: implications for managed care. J Fam Pract 1998;46:216-26.
9. Starfield B. Primary care: balancing health needs, services and technology. New York, NY: Oxford University Press; 1998.
10. Institute of Medicine. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
11. Stewart DW, Shamdasani PN. Focus groups: theory and practice. Applied social research method series volume 20. Newbury Park, Calif: Sage Publications Inc; 1990.
12. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Newbury Park, Calif: Sage Publications, Inc; 1994.
13. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago, Ill: Aldine; 1967.
14. Strauss AL, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, Calif: Sage Publications, Inc; 1990.
15. Goold SD, Lipkin M. The doctor-patient relationship. J Gen Intern Med 1999;14:S26-33.
16. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA 1995;273:1913-8.
17. Lee Y, Kasper JD. Assessment of medical care by elderly people: general satisfaction and physician quality. Health Serv Res 1998;32:741-58.
18. Miranda J, Azocar F, Komaromy M, Golding JM. Unmet mental health needs of women in public-sector gynecologic clinics. Am J Obstet Gynecol 1998;178:212-7.
19. Von Korff M, Myers L. The primary care physician and psychiatric services. Gen Hosp Psychiatry 1987;9:235-40.
20. Ford DE, Kamerow DB, Thompson JW. Who talks to physicians about mental health and substance abuse problems? J Gen Intern Med 1988;3:363-9.
21. Brody DS, Khaliq AA, Thompson TL. Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Med 1997;12:403-6.
22. Stratmann WC. A study of consumer attitudes about health care: the delivery of ambulatory services. Med Care 1975;8:537-48.
23. Fletcher RH, OíMalley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care 1983;21:234-42.
24. Office of Inspector General. Surveying Medicare beneficiaries. Washington, DC: US Department of Health and Human Services; 1995.
25. Frederick/Schneiders, Inc. Analysis of focus groups concerning managed care and Medicare. Prepared for The Henry J. Kaiser Family Foundation. Washington, DC: Frederick/Schneiders, Inc; 1995.
26. Edgman-Levitan S, Cleary PD. What information do consumers want and need? Health Aff 1996;15:42-56.
27. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-9.
METHODS: We performed a qualitative analysis of 4 focus groups of women aged 40 to 65 years from 4 community health clinics in Washington, DC. Prompted by semistructured open-ended questions, the focus groups discussed their experiences with ambulatory care and the attributes of primary care that they found important. The focus groups were audiotaped, and the tapes were transcribed verbatim and coded independently by 3 readers.
RESULTS: The comments were independently organized into 5 content areas of primary care service delivery plus the construct of patient-provider relationship in the following order of frequency: accessibility (37.4%), the physician-patient relationship (37.4%), comprehensive scope of services (11.5%), coordination between providers (6.8%), continuity with a single clinician (3.7%), and accountability (3.2%). Commonly reported specific priorities included a sense of concern and respect from the clinicians and staff toward the patient, a physician who was willing to talk and spend time with them (attributes of the physician-patient relationship), weekend or evening hours, waiting times (attributes of organizational accessibility), location in the inner city and on public transport routes (an attribute of geographic accessibility), availability of coordinated social and clinical services on-site; and, availability of mental health services on-site (attributes of comprehensiveness and of coordination).
CONCLUSIONS: All attributes of care that were priorities for low-income women fit into 1 of 6 content areas. Specific features within the content areas of accessibility, physician-patient relationship, and comprehensiveness were particularly important for thes women.
The literature examining specific attributes of the structure and process of primary care for lower-income populations that suffer from disproportionately poor health1 is relatively modest.2 Most research in primary care has been undertaken in predominantly insured middle-class private settings and in children.3-8 There may be particular features of primary care that are uniquely important to low-income women given their challenging social and economic environments.
Ideally, primary care provides entry into the system for all new health needs, involves person-focused (not disease-oriented) care over time, includes care for all but very uncommon or unusual conditions, and coordinates services delivered by multiple providers.9 In accepted conceptual frameworks of primary care, the essential features# include: a comprehensive range of services, coordination across providers, continuity with a single provider, an accessible source of care, and accountability.*9-10
The purposes of our qualitative study were to determine which particular attributes of primary care were priorities for low-income women and to investigate whether an accepted framework for the conceptualization of primary care9-10 corresponds to the priorities of low-income women aged 40 years and older. We hypothesized that themes raised by low-income women would fit into an established framework of primary care, but particular attributes of the features of primary care would be especially important to this vulnerable population.
Methods
Study Design
We recruited focus group participants using posters and flyers circulated at 4 community clinics in Washington, DC. Those clinics were selected because of their location in medically underserved communities in 3 of the poorest wards of Washington, DC, and because they were examples of the range of structure and funding sources. We used in-depth interviews, audiotaped focus groups,11 and content analysis of the verbatim transcripts12 to identify attributes of primary care that are important to low-income women. At completion of the fourth focus group, similar themes continued to be raised, indicating saturation of themes. Through an iterative process of listening to audiotapes and reading transcripts, an exhaustive taxonomy was created that identified groups of issues that low-income women identified as important in the receipt of primary care.
Focus-Group Participants
The participants were English- or Spanish-speaking women aged 40 years or older who used the clinic for their current care or who had used the clinic in the past and were able to give informed consent. Since our qualitative study is the first component of a larger study to assess the relationship between priorities for primary care and receipt of cancer screening services for low-income women, we restricted the sampling frame to women aged 40 years and older.
Conduct of Focus Group Sessions
A separate focus group was held for each clinic. All focus groups were conducted in convenient, safe, and neutral community settings, and clinic staff was not present. The sessions lasted approximately 2 hours. A total of 24 women participated in the 4 focus groups: 2 of predominantly African American patients facilitated by an independent experienced African American female moderator and 2 of Spanish-speaking patients, conducted in Spanish by an experienced Latin American age-appropriate female moderator. A series of open-ended questions was asked of participants to elicit feelings about and experiences with primary care. table 1.
Development of Taxonomy
Two study team members (an internist and a physician researcher) independently reviewed each transcript in its entirety, identifying distinct topics (themes) and making comments indicating each of these units of text. Repeated or reworded statements of the same idea by the same participant were listed together as one comment.
Each unit of text (a statement that conveyed one idea) from the transcripts was listed by a physician primary care researcher in the order it arose in the transcripts as both a direct quote and as a summary theme on the basis of the comments made by the first 2 study team members. Initially, to avoid imposing any particular framework onto the women’s comments, 2 investigators did independent inductive coding,13-14 in which each unit of text was reviewed in its context from the transcript, categories (labels) were generated, and a list of labels was compiled. When reviewing this exhaustive list, we found that the list of inductive labels (codes) fit fairly well into established conceptual frameworks for primary care. Thus, all units of text from the transcripts were then reclassified independently in duplicate (by a clinical internist and by a physician primary care researcher), using agreed-upon coding rules from the primary care conceptual framework, with the addition of the physician-patient relationship category, which arose as a common theme from the transcripts.
Interrater reliability for the overall coding of distinct units of text into 1 of 6 major primary care content areas was substantial (b = 0.84 overall). Content analysis was performed on the comments for all 4 focus groups, including a count of the number of times a theme was mentioned by different respondents and the primary care content area into which the themes fit.
Results
A total of 24 women participated in the discussions: 8 Latinas, 15 African Americans, and 1 white woman. The mean age of the participants was 46.6 years (median = 44.5; one third were aged 50 years and older.) Eight of the participants had an 11th grade education or less; 5 were high-school graduates; and 11 had some college education. Four were married. The majority worked: 8 full time, 8 part time, and the rest were unpaid, retired, or unemployed. Sixteen of these women cared for dependents part or full time. Eighty-two percent of the participants had a household income of less than $20,000, reflecting our success in recruiting the population we sought. Twenty-two women were uninsured, but most of the African American participants had had Medicaid or private insurance in the past.
The most important conceptual modification arising from the women’s comments was the addition of the physician-patient relationship as an important and unique feature encompassing many of the women’s priorities. The percentages of focus group participant comments falling into each of the major primary care codes were as follows: an accessible source of care (37.4%), the physician-patient relationship (37.4%), a comprehensive range of services (11.5%), coordination across providers (6.8%), continuity with a single provider (3.7%), and accountability (3.2%). Table 2 gives the frequency distribution of participants’ priorities for primary care and some of the more commonly stated priorities.
Within the content area of the physician-patient relationship, themes mentioned most often were communication between physician and patient, having staff who listen, getting personal attention, and most important, a staff that was concerned and respectful. For Latinas, clinicians’ knowledge of the Latin community and of the fear and trust issues experienced by recent immigrants toward the medical system and toward other members of the community were mentioned often.
Specific attributes mentioned frequently within the category of accessibility were a clinic that had evening and weekend hours, was open to all regardless of insurance status, was located in the inner city or was accessible by using public transport, and was attentive to waiting times. Among Latinas, having a doctor fluent in Spanish and from a similar cultural background was an additional priority.
Within the category of comprehensiveness, the most frequently mentioned themes were the availability of multiple services at one site, presence of an intake procedure that recognized one’s needs, coordination of medical and social services on-site, and the availability of counseling and treatment for emotional and mental health concerns. Sample quotes from the focus group transcripts, organized within the 6 content areas, are presented in Table 3
Discussion
Eighty-six percent of participants’ comments fit into 1 of 3 content areas: physician-patient relationship, accessibility, and comprehensiveness. The breadth and depth9 of physician-patient interactions in primary care make its relationship unique. Heavy emphasis on interactions with their primary care physicians (one third of all comments) supports other authors’ statements about vulnerable patients placing a special emphasis on this relationship.15-16 Underinsured people lacking access to alternate providers have a heightened reliance on a physician’s competence, skills, and good will.15 Having a sense that their physician had concern and respect for the patient was the most frequently mentioned priority in the focus groups. When working with low-income minority or immigrant patients, physicians might want to be especially sensitive to their voice, tone, and posture to communicate a sense of respect and concern for patients who may already feel vulnerable. It appears that the category of physician-patient relationship is vital to the conceptual framework of primary care for these low-income women, and it may be a link in the chain without which the other features (continuity, comprehensiveness, coordination, accessibility, accountability) cannot function optimally.
Accessibility was also a clear priority for these women. Twenty-two of the 24 women in this study were uninsured. This may explain why a large percentage of their comments (37.4%) fell into this category. Even though these uninsured women were receiving medical care in community clinics, issues of access (particularly of organizational access) were still foremost in their minds. This may be due to previous obstacles encountered in obtaining care or to deficiencies or strengths perceived in their current systems. Juxtaposed against the reality of increasing underinsurance for even basic access to services, this underscores a serious and worsening problem of unmet health care delivery needs. This emphasis on accessibility demonstrates the need to improve both the financing and organization of the primary care safety net.
The themes most frequently raised with respect to comprehensiveness highlight how the needs of economically vulnerable people may differ from those who are financially secure. For example, previous research shows that poor women have a higher prevalence of mood disorders than the general population,18 and most would prefer to be treated for these in the primary care setting,19-21 since they often do not have the choice of going directly to specialty mental health services. This supports the provision of basic mental health care for the more common and treatable mood and anxiety disorders in the primary care setting. Stronger ties between primary care and certain specialty services may be needed to ensure such comprehensiveness.
A comparison of these participants’ priorities with those of the general population in the literature yields similarities and differences. Priorities vary with sociodemographic characteristics22: younger patients valued coordination of care and technical proficiency most, while older patients ranked continuity of care and comprehensiveness highest.23 Older patients placed more emphasis on cost issues15,23 and on attributes of accountability.17,24-25 Differences have also been shown by health status: Patients with a chronic illness preferred continuity over other features.23 In the general population, accessibility, coordination, information, communication, education, respect for patients’ values and expressed needs, and emotional support are the greatest concerns.26 Population differences in priorities demonstrate that primary care systems must be tailored to the specific needs and priorities of the populations served.
Comparison of our study’s findings with those of the general population raises the issue of what these low-income women were not saying. For example, issues of accountability were infrequently mentioned. This may reflect the participants’ greater concerns with having accessible care. Also continuity of care, while accounting for only 3.7% of comments, was tied to other specific attributes considered important by these women. For example, attributes of the physician-patient relationship, such as communication, are directly tied to the presence of an ongoing relationship with a physician over time. Furthermore, given the dependence of economically vulnerable persons on their primary care physician for access to services and the important role this physician has in coordinating their care, continuity seems especially important.15
Limitations
Several limitations should be considered in interpreting these findings. We investigated the research questions in this exploratory study by using focus groups and qualitative analysis. Such methods, if mindful of established standards,12 can yield well-grounded and detailed data. However, we cannot determine their generalizability. Further work to rank women’s priorities for primary care and to tie them to utilization and health outcomes will be pursued in the future through a population-based study. Also, qualitative data are subject to researcher bias. Our use of 3 independent raters and our careful attention to coding using established methods12 should have minimized this limitation.
Conclusions
Established frameworks for primary care, with the addition of the category of the physician-patient relationship, have qualitative (content) validity in this sample of low-income women; therefore, these content areas provide a useful language to discuss their health care delivery needs. The physician-patient relationship, accessibility, and comprehensiveness were the categories into which most of the women’s specific priorities fell. Health systems that fail to address low-income women’s specific needs may not adequately meet their clients’ expectations for health care.
Acknowledgments
Primary funding source: DAMD 17-97-1-7131 from the US Department of Army (Dr O’Malley).
METHODS: We performed a qualitative analysis of 4 focus groups of women aged 40 to 65 years from 4 community health clinics in Washington, DC. Prompted by semistructured open-ended questions, the focus groups discussed their experiences with ambulatory care and the attributes of primary care that they found important. The focus groups were audiotaped, and the tapes were transcribed verbatim and coded independently by 3 readers.
RESULTS: The comments were independently organized into 5 content areas of primary care service delivery plus the construct of patient-provider relationship in the following order of frequency: accessibility (37.4%), the physician-patient relationship (37.4%), comprehensive scope of services (11.5%), coordination between providers (6.8%), continuity with a single clinician (3.7%), and accountability (3.2%). Commonly reported specific priorities included a sense of concern and respect from the clinicians and staff toward the patient, a physician who was willing to talk and spend time with them (attributes of the physician-patient relationship), weekend or evening hours, waiting times (attributes of organizational accessibility), location in the inner city and on public transport routes (an attribute of geographic accessibility), availability of coordinated social and clinical services on-site; and, availability of mental health services on-site (attributes of comprehensiveness and of coordination).
CONCLUSIONS: All attributes of care that were priorities for low-income women fit into 1 of 6 content areas. Specific features within the content areas of accessibility, physician-patient relationship, and comprehensiveness were particularly important for thes women.
The literature examining specific attributes of the structure and process of primary care for lower-income populations that suffer from disproportionately poor health1 is relatively modest.2 Most research in primary care has been undertaken in predominantly insured middle-class private settings and in children.3-8 There may be particular features of primary care that are uniquely important to low-income women given their challenging social and economic environments.
Ideally, primary care provides entry into the system for all new health needs, involves person-focused (not disease-oriented) care over time, includes care for all but very uncommon or unusual conditions, and coordinates services delivered by multiple providers.9 In accepted conceptual frameworks of primary care, the essential features# include: a comprehensive range of services, coordination across providers, continuity with a single provider, an accessible source of care, and accountability.*9-10
The purposes of our qualitative study were to determine which particular attributes of primary care were priorities for low-income women and to investigate whether an accepted framework for the conceptualization of primary care9-10 corresponds to the priorities of low-income women aged 40 years and older. We hypothesized that themes raised by low-income women would fit into an established framework of primary care, but particular attributes of the features of primary care would be especially important to this vulnerable population.
Methods
Study Design
We recruited focus group participants using posters and flyers circulated at 4 community clinics in Washington, DC. Those clinics were selected because of their location in medically underserved communities in 3 of the poorest wards of Washington, DC, and because they were examples of the range of structure and funding sources. We used in-depth interviews, audiotaped focus groups,11 and content analysis of the verbatim transcripts12 to identify attributes of primary care that are important to low-income women. At completion of the fourth focus group, similar themes continued to be raised, indicating saturation of themes. Through an iterative process of listening to audiotapes and reading transcripts, an exhaustive taxonomy was created that identified groups of issues that low-income women identified as important in the receipt of primary care.
Focus-Group Participants
The participants were English- or Spanish-speaking women aged 40 years or older who used the clinic for their current care or who had used the clinic in the past and were able to give informed consent. Since our qualitative study is the first component of a larger study to assess the relationship between priorities for primary care and receipt of cancer screening services for low-income women, we restricted the sampling frame to women aged 40 years and older.
Conduct of Focus Group Sessions
A separate focus group was held for each clinic. All focus groups were conducted in convenient, safe, and neutral community settings, and clinic staff was not present. The sessions lasted approximately 2 hours. A total of 24 women participated in the 4 focus groups: 2 of predominantly African American patients facilitated by an independent experienced African American female moderator and 2 of Spanish-speaking patients, conducted in Spanish by an experienced Latin American age-appropriate female moderator. A series of open-ended questions was asked of participants to elicit feelings about and experiences with primary care. table 1.
Development of Taxonomy
Two study team members (an internist and a physician researcher) independently reviewed each transcript in its entirety, identifying distinct topics (themes) and making comments indicating each of these units of text. Repeated or reworded statements of the same idea by the same participant were listed together as one comment.
Each unit of text (a statement that conveyed one idea) from the transcripts was listed by a physician primary care researcher in the order it arose in the transcripts as both a direct quote and as a summary theme on the basis of the comments made by the first 2 study team members. Initially, to avoid imposing any particular framework onto the women’s comments, 2 investigators did independent inductive coding,13-14 in which each unit of text was reviewed in its context from the transcript, categories (labels) were generated, and a list of labels was compiled. When reviewing this exhaustive list, we found that the list of inductive labels (codes) fit fairly well into established conceptual frameworks for primary care. Thus, all units of text from the transcripts were then reclassified independently in duplicate (by a clinical internist and by a physician primary care researcher), using agreed-upon coding rules from the primary care conceptual framework, with the addition of the physician-patient relationship category, which arose as a common theme from the transcripts.
Interrater reliability for the overall coding of distinct units of text into 1 of 6 major primary care content areas was substantial (b = 0.84 overall). Content analysis was performed on the comments for all 4 focus groups, including a count of the number of times a theme was mentioned by different respondents and the primary care content area into which the themes fit.
Results
A total of 24 women participated in the discussions: 8 Latinas, 15 African Americans, and 1 white woman. The mean age of the participants was 46.6 years (median = 44.5; one third were aged 50 years and older.) Eight of the participants had an 11th grade education or less; 5 were high-school graduates; and 11 had some college education. Four were married. The majority worked: 8 full time, 8 part time, and the rest were unpaid, retired, or unemployed. Sixteen of these women cared for dependents part or full time. Eighty-two percent of the participants had a household income of less than $20,000, reflecting our success in recruiting the population we sought. Twenty-two women were uninsured, but most of the African American participants had had Medicaid or private insurance in the past.
The most important conceptual modification arising from the women’s comments was the addition of the physician-patient relationship as an important and unique feature encompassing many of the women’s priorities. The percentages of focus group participant comments falling into each of the major primary care codes were as follows: an accessible source of care (37.4%), the physician-patient relationship (37.4%), a comprehensive range of services (11.5%), coordination across providers (6.8%), continuity with a single provider (3.7%), and accountability (3.2%). Table 2 gives the frequency distribution of participants’ priorities for primary care and some of the more commonly stated priorities.
Within the content area of the physician-patient relationship, themes mentioned most often were communication between physician and patient, having staff who listen, getting personal attention, and most important, a staff that was concerned and respectful. For Latinas, clinicians’ knowledge of the Latin community and of the fear and trust issues experienced by recent immigrants toward the medical system and toward other members of the community were mentioned often.
Specific attributes mentioned frequently within the category of accessibility were a clinic that had evening and weekend hours, was open to all regardless of insurance status, was located in the inner city or was accessible by using public transport, and was attentive to waiting times. Among Latinas, having a doctor fluent in Spanish and from a similar cultural background was an additional priority.
Within the category of comprehensiveness, the most frequently mentioned themes were the availability of multiple services at one site, presence of an intake procedure that recognized one’s needs, coordination of medical and social services on-site, and the availability of counseling and treatment for emotional and mental health concerns. Sample quotes from the focus group transcripts, organized within the 6 content areas, are presented in Table 3
Discussion
Eighty-six percent of participants’ comments fit into 1 of 3 content areas: physician-patient relationship, accessibility, and comprehensiveness. The breadth and depth9 of physician-patient interactions in primary care make its relationship unique. Heavy emphasis on interactions with their primary care physicians (one third of all comments) supports other authors’ statements about vulnerable patients placing a special emphasis on this relationship.15-16 Underinsured people lacking access to alternate providers have a heightened reliance on a physician’s competence, skills, and good will.15 Having a sense that their physician had concern and respect for the patient was the most frequently mentioned priority in the focus groups. When working with low-income minority or immigrant patients, physicians might want to be especially sensitive to their voice, tone, and posture to communicate a sense of respect and concern for patients who may already feel vulnerable. It appears that the category of physician-patient relationship is vital to the conceptual framework of primary care for these low-income women, and it may be a link in the chain without which the other features (continuity, comprehensiveness, coordination, accessibility, accountability) cannot function optimally.
Accessibility was also a clear priority for these women. Twenty-two of the 24 women in this study were uninsured. This may explain why a large percentage of their comments (37.4%) fell into this category. Even though these uninsured women were receiving medical care in community clinics, issues of access (particularly of organizational access) were still foremost in their minds. This may be due to previous obstacles encountered in obtaining care or to deficiencies or strengths perceived in their current systems. Juxtaposed against the reality of increasing underinsurance for even basic access to services, this underscores a serious and worsening problem of unmet health care delivery needs. This emphasis on accessibility demonstrates the need to improve both the financing and organization of the primary care safety net.
The themes most frequently raised with respect to comprehensiveness highlight how the needs of economically vulnerable people may differ from those who are financially secure. For example, previous research shows that poor women have a higher prevalence of mood disorders than the general population,18 and most would prefer to be treated for these in the primary care setting,19-21 since they often do not have the choice of going directly to specialty mental health services. This supports the provision of basic mental health care for the more common and treatable mood and anxiety disorders in the primary care setting. Stronger ties between primary care and certain specialty services may be needed to ensure such comprehensiveness.
A comparison of these participants’ priorities with those of the general population in the literature yields similarities and differences. Priorities vary with sociodemographic characteristics22: younger patients valued coordination of care and technical proficiency most, while older patients ranked continuity of care and comprehensiveness highest.23 Older patients placed more emphasis on cost issues15,23 and on attributes of accountability.17,24-25 Differences have also been shown by health status: Patients with a chronic illness preferred continuity over other features.23 In the general population, accessibility, coordination, information, communication, education, respect for patients’ values and expressed needs, and emotional support are the greatest concerns.26 Population differences in priorities demonstrate that primary care systems must be tailored to the specific needs and priorities of the populations served.
Comparison of our study’s findings with those of the general population raises the issue of what these low-income women were not saying. For example, issues of accountability were infrequently mentioned. This may reflect the participants’ greater concerns with having accessible care. Also continuity of care, while accounting for only 3.7% of comments, was tied to other specific attributes considered important by these women. For example, attributes of the physician-patient relationship, such as communication, are directly tied to the presence of an ongoing relationship with a physician over time. Furthermore, given the dependence of economically vulnerable persons on their primary care physician for access to services and the important role this physician has in coordinating their care, continuity seems especially important.15
Limitations
Several limitations should be considered in interpreting these findings. We investigated the research questions in this exploratory study by using focus groups and qualitative analysis. Such methods, if mindful of established standards,12 can yield well-grounded and detailed data. However, we cannot determine their generalizability. Further work to rank women’s priorities for primary care and to tie them to utilization and health outcomes will be pursued in the future through a population-based study. Also, qualitative data are subject to researcher bias. Our use of 3 independent raters and our careful attention to coding using established methods12 should have minimized this limitation.
Conclusions
Established frameworks for primary care, with the addition of the category of the physician-patient relationship, have qualitative (content) validity in this sample of low-income women; therefore, these content areas provide a useful language to discuss their health care delivery needs. The physician-patient relationship, accessibility, and comprehensiveness were the categories into which most of the women’s specific priorities fell. Health systems that fail to address low-income women’s specific needs may not adequately meet their clients’ expectations for health care.
Acknowledgments
Primary funding source: DAMD 17-97-1-7131 from the US Department of Army (Dr O’Malley).
1. Amler RW, Dull HB. Closing the gap: the burden of unnecessary illness. New York, NY: Oxford University Press; 1987.
2. Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups. Health Serv Res 1995;30:253-73.
3. Stewart AL, Grumbach K, Osmond DH, Vranizan K, Komaromy M, Bindman AB. Primary care and patient perceptions of access to care. J Fam Pract 1997;44:177-85.
4. Bindman AB, Grumbach K, Osmond D, Vranizan K, Stewart AL. Primary care and receipt of preventive services. J Gen Intern Med 1996;11:269-76.
5. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20.
6. Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract 1997;45:64-74.
7. Zemencuk JK, Feightner JW, Hayward RD, Skarupcki KA, Katz SJ. Patients’ desires and expectations for medical care in primary care clinics. J Gen Intern Med 1998;13:273-6.
8. Starfield B, Cassady C, Nanda J, Forrest CB, Berk R. Consumer experiences and provider perceptions of the quality of primary care: implications for managed care. J Fam Pract 1998;46:216-26.
9. Starfield B. Primary care: balancing health needs, services and technology. New York, NY: Oxford University Press; 1998.
10. Institute of Medicine. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
11. Stewart DW, Shamdasani PN. Focus groups: theory and practice. Applied social research method series volume 20. Newbury Park, Calif: Sage Publications Inc; 1990.
12. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Newbury Park, Calif: Sage Publications, Inc; 1994.
13. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago, Ill: Aldine; 1967.
14. Strauss AL, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, Calif: Sage Publications, Inc; 1990.
15. Goold SD, Lipkin M. The doctor-patient relationship. J Gen Intern Med 1999;14:S26-33.
16. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA 1995;273:1913-8.
17. Lee Y, Kasper JD. Assessment of medical care by elderly people: general satisfaction and physician quality. Health Serv Res 1998;32:741-58.
18. Miranda J, Azocar F, Komaromy M, Golding JM. Unmet mental health needs of women in public-sector gynecologic clinics. Am J Obstet Gynecol 1998;178:212-7.
19. Von Korff M, Myers L. The primary care physician and psychiatric services. Gen Hosp Psychiatry 1987;9:235-40.
20. Ford DE, Kamerow DB, Thompson JW. Who talks to physicians about mental health and substance abuse problems? J Gen Intern Med 1988;3:363-9.
21. Brody DS, Khaliq AA, Thompson TL. Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Med 1997;12:403-6.
22. Stratmann WC. A study of consumer attitudes about health care: the delivery of ambulatory services. Med Care 1975;8:537-48.
23. Fletcher RH, OíMalley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care 1983;21:234-42.
24. Office of Inspector General. Surveying Medicare beneficiaries. Washington, DC: US Department of Health and Human Services; 1995.
25. Frederick/Schneiders, Inc. Analysis of focus groups concerning managed care and Medicare. Prepared for The Henry J. Kaiser Family Foundation. Washington, DC: Frederick/Schneiders, Inc; 1995.
26. Edgman-Levitan S, Cleary PD. What information do consumers want and need? Health Aff 1996;15:42-56.
27. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-9.
1. Amler RW, Dull HB. Closing the gap: the burden of unnecessary illness. New York, NY: Oxford University Press; 1987.
2. Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups. Health Serv Res 1995;30:253-73.
3. Stewart AL, Grumbach K, Osmond DH, Vranizan K, Komaromy M, Bindman AB. Primary care and patient perceptions of access to care. J Fam Pract 1997;44:177-85.
4. Bindman AB, Grumbach K, Osmond D, Vranizan K, Stewart AL. Primary care and receipt of preventive services. J Gen Intern Med 1996;11:269-76.
5. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20.
6. Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract 1997;45:64-74.
7. Zemencuk JK, Feightner JW, Hayward RD, Skarupcki KA, Katz SJ. Patients’ desires and expectations for medical care in primary care clinics. J Gen Intern Med 1998;13:273-6.
8. Starfield B, Cassady C, Nanda J, Forrest CB, Berk R. Consumer experiences and provider perceptions of the quality of primary care: implications for managed care. J Fam Pract 1998;46:216-26.
9. Starfield B. Primary care: balancing health needs, services and technology. New York, NY: Oxford University Press; 1998.
10. Institute of Medicine. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
11. Stewart DW, Shamdasani PN. Focus groups: theory and practice. Applied social research method series volume 20. Newbury Park, Calif: Sage Publications Inc; 1990.
12. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Newbury Park, Calif: Sage Publications, Inc; 1994.
13. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago, Ill: Aldine; 1967.
14. Strauss AL, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, Calif: Sage Publications, Inc; 1990.
15. Goold SD, Lipkin M. The doctor-patient relationship. J Gen Intern Med 1999;14:S26-33.
16. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA 1995;273:1913-8.
17. Lee Y, Kasper JD. Assessment of medical care by elderly people: general satisfaction and physician quality. Health Serv Res 1998;32:741-58.
18. Miranda J, Azocar F, Komaromy M, Golding JM. Unmet mental health needs of women in public-sector gynecologic clinics. Am J Obstet Gynecol 1998;178:212-7.
19. Von Korff M, Myers L. The primary care physician and psychiatric services. Gen Hosp Psychiatry 1987;9:235-40.
20. Ford DE, Kamerow DB, Thompson JW. Who talks to physicians about mental health and substance abuse problems? J Gen Intern Med 1988;3:363-9.
21. Brody DS, Khaliq AA, Thompson TL. Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Med 1997;12:403-6.
22. Stratmann WC. A study of consumer attitudes about health care: the delivery of ambulatory services. Med Care 1975;8:537-48.
23. Fletcher RH, OíMalley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care 1983;21:234-42.
24. Office of Inspector General. Surveying Medicare beneficiaries. Washington, DC: US Department of Health and Human Services; 1995.
25. Frederick/Schneiders, Inc. Analysis of focus groups concerning managed care and Medicare. Prepared for The Henry J. Kaiser Family Foundation. Washington, DC: Frederick/Schneiders, Inc; 1995.
26. Edgman-Levitan S, Cleary PD. What information do consumers want and need? Health Aff 1996;15:42-56.
27. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-9.