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).