BACKGROUND: Because of their challenging social and economic environments, low-income women may find particular features of primary care uniquely important. For this qualitative study we explored which features are priorities to women from low-income settings and whether those priorities fit into an established primary care framework.
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.