Social Norms and Self-Management Ability among Uninsured Primary Care Patients.

OBJECTIVES: The purpose of this study was to examine the association between social norms and self-management ability among uninsured low-income primary care patients. METHODS: Data were collected from adult patients at a free clinic using a self-administered survey from August to December 2018. RESULTS: Higher levels of social norms to exercise were associated with higher levels of all aspects of self-management ability. Lower levels of social norms to use substances were associated with higher levels of all aspects of self-management ability, except for variety in self-management. Better health was associated with higher levels of investment behavior of self-management ability. CONCLUSIONS: The findings of this study suggest the association between social norms and self-management ability and its impact on health among low-income, uninsured primary care patients. Self-management ability is important for maintaining health. Providing intervention programs on self-management skills should focus on not only individual behaviors but also social norms that affect their health behaviors.

Risks of opioid abuse among uninsured primary care patients utilizing a free clinic.

The annual number of opioid prescriptions for pain relief has been increasing in the United States. This increase has raised concerns about prescription opioid abuse and overdose. The purpose of this study was to examine opioid risks (risk factors that increase the chance of opioid abuse) among uninsured primary care patients utilizing a free clinic. Data were collected using a self-administered paper survey in the waiting room of the free clinic from May to July 2017 (N = 506). Higher levels of somatic symptoms were associated with higher levels of opioid risks. U.S.-born English speakers had higher levels of opioid risk than non-U.S.-born English speakers and Spanish speakers. Being employed was associated with higher levels of opioid risk while attending college or being postcollegiate was related to lower levels of opioid risk. Research surrounding best practices, prescription trends, and population risk is vital in driving health and social policy. Further research would benefit from examining where people are obtaining opioids. In addition, further research on opioid abuse among Hispanic populations would be beneficial. Finally, future studies should examine how prescribing practices are different among free clinic health professionals in comparison to health care professionals working in-patient or at for-profit clinics.

Cancer Risk Awareness among Uninsured Primary Care Patients.

OBJECTIVES: Underserved populations are at risk of low cancer risk awareness. The purpose of this study was to examine cancer risk awareness and lifestyle issues among uninsured primary care patients in the United States. METHODS: Data were collected using a self-administered survey from May to July 2017 of adult free clinic patients (N = 506) who spoke English or Spanish. RESULTS: The following factors were associated with higher levels of cancer risk awareness: higher educational attainment, better self-perceived health, and having a family history of cancer. More than 40% of free clinic patients reported a family history of cancer. Contradictory findings existed between perceived diet quality and perceived weight. CONCLUSIONS: The intersection of cancer risk awareness and lifestyle issues among underserved populations is a vital topic to improve cancer prevention and promote screening uptake. Continued research is needed to understand which types of cancer underserved populations are cognizant of developing. In addition, because community-level interventions are effective in increasing cancer risk awareness, 3 research is needed to determine ways in which health education programs focused at cancer risk awareness directed to underserved populations can be effectively implemented and evaluated.

Prevention and Management of Hypertension and Diabetes Using Social Capital and Physical Activity Among Socioeconomically Disadvantaged Populations.

The purpose of this study is to examine the association between physical activity adherence and social capital among uninsured primary care patients with or without hypertension and/or diabetes. Uninsured adults using a free clinic (N = 374) participated in a self-administered survey from January to April in 2016. The percentage of participants who were adherent to physical activity was low regardless of having hypertension and/or diabetes, or not. Individuals who reported a high sense of community were associated with a higher percentage of physical activity adherence. Good weight management was associated with less likelihood of physical activity adherence.

The association between tobacco, alcohol, and drug use, stress, and depression among uninsured free clinic patients: U.S.-born English speakers, non-U.S.-born English speakers, and Spanish speakers.

The abuse of substances is a significant public health issue. Perceived stress and depression have been found to be related to the abuse of substances. The purpose of this study is to examine the prevalence of substance use (i.e., alcohol problems, smoking, and drug use) and the association between substance use, perceived stress, and depression among free clinic patients. Patients completed a self-administered survey in 2015 (N = 504). The overall prevalence of substance use among free clinic patients was not high compared to the U.S. general population. U.S.-born English speakers reported a higher prevalence rate of tobacco smoking and drug use than did non-U.S.-born English speakers and Spanish speakers. Alcohol problems and smoking were significantly related to higher levels of perceived stress and depression. Substance use prevention and education should be included in general health education programs. U.S.-born English speakers would need additional attention. Mental health intervention would be essential to prevention and intervention.

The Role of Health Literacy in Reducing Negative Perceptions of Breast Health and Treatment Among Uninsured Primary Care Patients.

Breast cancer is the second leading cause of cancer death among women in the United States. There are disparities in breast cancer mortality by race/ethnicity and socio-economic factors. Health literacy may have an impact on breast health disparities. In addition, learning about people's perceptions of breast health and treatment is important to understand why some do not seek a mammogram or treatment for breast cancer. The purpose of this study is to examine the association between health literacy and negative perceptions of breast health and treatment among female uninsured primary care patients utilizing a free clinic for underserved populations. Women utilizing a free clinic who were aged 40 years or older (N = 276) participated in a self-administered survey from September to December in 2015. Higher levels of health literacy were associated with lower levels of negative perceptions of breast cancer and treatment. Non-US born English speakers reported higher levels of negative perceptions of breast cancer and treatment than US born English speakers and Spanish speakers. While there were no significant differences in health literacy among the groups, US born English speakers were less likely to have had a mammogram in the past 3 years compared with non-US born English speakers and Spanish speakers. Future research should consider where women are obtaining information and how the method of exposure shapes their attitudes towards breast health and in turn, their rates of examinations for breast cancer. Cultural factors may be also important determinants of the perceptions and need to be further examined.

Promoting Healthy Eating Attitudes Among Uninsured Primary Care Patients.

Obesity is associated with a number of chronic health problems such as cardiovascular disease, diabetes and cancer. While common prevention and treatment strategies to control unhealthy weight gain tend to target behaviors and lifestyles, the psychological factors which affect eating behaviors among underserved populations also need to be further addressed and included in practice implementations. The purpose of this study is to examine positive and negative emotional valence about food among underserved populations in a primary care setting. Uninsured primary care patients (N = 621) participated in a self-administered survey from September to December in 2015. Higher levels of perceived benefits of healthy food choice were associated with lower levels of a negative emotional valence about food while higher levels of perceived barriers to healthy food choice are related to higher levels of a negative emotional valence about food. Greater acceptance of motivation to eat was associated with higher levels of positive and negative emotional valence about food. Spanish speakers reported greater acceptance of motivation to eat and are more likely to have a negative emotional valence about food than US born or non-US born English speakers. The results of this study have important implications to promote healthy eating among underserved populations at a primary care setting. Healthy food choice or healthy eating may not always be achieved by increasing knowledge. Psychological interventions should be included to advance healthy food choice.

Why Uninsured Free Clinic Patients Don't Apply for Affordable Care Act Health Insurance in a Non-expanding Medicaid State.

Even after the introduction of the Patient Protection and Affordable Care Act (ACA), uninsured visits remain high, especially in states that opted out of Medicaid expansion. Since the ACA does not provide universal coverage, free clinics serve as safety nets for the un- or under-insured, and will likely continue serving underserved populations. The purpose of this study is to examine factors influencing intentions to not apply for health insurance via the ACA among uninsured free clinic patients in a state not expanding Medicaid. Uninsured primary care patients utilizing a free clinic (N = 551) completed a self-administered survey in May and June 2015. Difficulty obtaining information, lack of instruction to apply, and cost, are major factors influencing intention not to apply for health insurance through the ACA. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of perceived barriers to applying for health insurance through the ACA. Age is an important factor impacting individuals' intentions not to apply for health insurance through the ACA, as older patients in particular need assistance to obtain relevant information about the ACA and other resources. A number of unchangeable factors limit the free clinics' ability to promote enrollment of health insurance through the ACA. Yet free clinics could be able to provide some educational programs or the information of resources to patients. In particular, non-US born English speakers, Spanish speakers, and older adults need specific assistance to better understand health insurance options available to them.

Satisfaction with healthcare services among free clinic patients.

Free clinics provide free or reduced fee health services to the un- or under-insured. Patient engagement is important to understand patients' needs and to improve healthcare systems. There are few studies that examined patient engagement and satisfaction among the underserved and how patients perceive the quality of healthcare services in a free clinic setting. This study examined free clinic patients' satisfaction in order to better understand how free clinic patients perceive quality of healthcare services. English or Spanish speaking patients (N = 351), aged 18 years or older completed a self-administered survey using standardized measures of patient satisfaction and health status. Additional questions of patient satisfaction and experience with healthcare which fit a free clinic setting were developed. While the satisfaction with interpreter services was overall high, there were potential issues of a family member as an interpreter and unmet needs for interpreter services. Participants reported different levels of patient satisfaction by three language categories: native English speakers, non-native English speakers, and Spanish speakers. Health status is an important indicator to determine patient satisfaction. To improve patient satisfaction and engagement among free clinic patients, factors such as: quality of a family interpreter, unmet needs for interpreter services, social support, and health education programs may need to be considered. The differences in these three language groups indicate that not all free clinic patients may be combined together into a general category of free clinic patients. It may be necessary to provide customized treatment for each of these groups.

Women in Free Clinics: An Assessment of Health-Related Quality of Life for Prevention and Health Education.

Understanding gender influences on health-related quality of life (HRQoL) is important to improve women's health when considering diseases that afflict women specifically. The target population of this study was uninsured female free clinic patients who are low socio-economic status and lack access to healthcare resources. Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged. While approximately half of free clinic patients are women, there is a paucity of comprehensive health-related data for female free clinic patients. US born English, non-US born English, and Spanish speaking female free clinic patients completed a self-administered survey using a standardized women's HRQoL measure in Fall 2014 (N = 389). Female free clinic patients reported lower HRQoL on all aspects of women's health compared to the US baseline scores, and were less likely to utilize preventive care including: mammograms, Pap smear, and HPV vaccination compared to the US general population. Spanish speakers reported a higher percentage of having had mammography and Pap smear, and heard about HPV compared to the other two groups. US born English speakers reported lower levels of HRQoL in vasomotor symptoms and sleep symptoms, and the lowest percentage of breast health and Pap smear screenings compared to non-US born English and Spanish speakers. Non-US born English speakers reported higher preference for female physician compared to US born English speakers and Spanish speakers. Free clinic female patients need preventative interventions and educational opportunities to improve their overall HRQoL.

Impact of Neighborhood Environments on Health Consciousness, Information Seeking, and Attitudes among US-Born and Non-US-Born Free Clinic Patients.

OBJECTIVES: This study examined the impact of neighborhood environments on health consciousness, information seeking, and attitudes among uninsured free clinic patients to better understand the specific needs of the population for health promotion and prevention efforts. METHODS: US-born English-speaking, non-US-born English-speaking, and Spanish-speaking free clinic patients completed a self-administered survey using reliable measures in autumn 2014 (N = 769). RESULTS: The results of this study suggest that social cohesion is positively associated with health consciousness, information seeking, and attitudes. Lower levels of available healthy food in the community were associated with higher levels of health consciousness. Although Spanish speakers reported lower levels of the availability of healthy food, social cohesion, and access to the Internet or text messaging compared with US-born or non-US-born English speakers, they were more likely to be health conscious and have higher levels of health information seeking. Spanish speakers as well as non-US-born English speakers, were more likely to attend health education classes compared with US-born English speakers. CONCLUSIONS: Health education programs for free clinic patients should include strategies to increase social cohesion. Health education programs should consider the diverse needs of these individual populations to maximize the effectiveness of the programs for free clinic patients.

Quality of life among free clinic patients associated with somatic symptoms, depression, and perceived neighborhood environment.

Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged. The purpose of this study is to examine health-related quality of life (HRQoL) among free clinic patients and its association with somatic symptoms, depression, and perceived neighborhood environment. Free clinic patients (n = 186) aged 18 years or older completed a self-administered survey. HRQoL, depression, somatic symptoms, and perceived neighborhood environment were measured using standardized instruments. Overall, the participants reported low level of HRQoL compared to the general healthy population. US born participants (n = 97) reported poorer psychological QoL and social relations, more somatic symptoms, and were more likely to be depressed than non-US born participants (n = 89). Higher numbers of somatic symptoms were associated with poorer environmental QoL. Depression was associated with all aspects of QoL; a higher level of depression was related to poorer QoL in all aspects. Our findings show that free clinic patients, especially US born patients, have poor HRQoL. Depression and perceived neighborhood satisfaction are key factors to determine HRQoL among free clinic patients. Mental health services and collaboration with other community organizations may help in improving HRQoL among free clinic patients. Finally, health promotion programs at the community level, not just at the clinic level, would be valuable to improve health of free clinic patients as perceived neighborhood environment is associated with their HRQoL.

The relationship between diabetes attitudes and treatment among free clinic patients and volunteers.

Free clinics provide free primary care to the under or uninsured and have been playing an important role in serving the socio-economically disadvantaged. Free clinic patients represent a group of people who experience significant barriers to receiving diabetes prevention and intervention. This study examined diabetes attitudes among free clinic patients and volunteers. English or Spanish speaking patients and volunteers (N = 384), aged 18 years or older completed a self-administered survey. Diabetic patients and volunteers shared similar levels of diabetes attitudes compared to non-diabetic patients. Among patients, ethnicity, education level, diabetes education, and family history affected diabetes attitudes. Among volunteers, diabetes education was an important factor associated with positive diabetes attitudes. Whether the volunteer is a healthcare professional or student was related only to one aspect of diabetes attitudes, seriousness of type 2 diabetes. The results, indicating free clinic diabetic patients and volunteers shared similar levels of diabetes attitudes, were positive for maintaining and developing diabetes education programs at a free clinic. Unfortunately, the average length of volunteering at this free clinic was short and student volunteers likely leave the clinic upon graduation. Future research should examine issues of volunteer retention in free clinics. Diabetes education for patients may need to be diversified according to ethnicity, family history of diabetes, and educational level. Finally, non-healthcare professional volunteers could potentially be involved in diabetes education at a free clinic.

Health and diabetes self-efficacy: a study of diabetic and non-diabetic free clinic patients and family members.

Free clinics across the country provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged. This study examined perceived health status among diabetic and non-diabetic free clinic patients and family members of the patients. Diabetes self-efficacy among diabetic free clinic patients was also investigated with the goal of developing appropriate diabetes health education programs to promote diabetes self-management. English or Spanish speaking patients and family members (N = 365) aged 18 years or older completed a self-administered survey. Physical and mental health and diabetes self-efficacy were measured using standardized instruments. Diabetic free clinic patients reported poorer physical and mental health and higher levels of dysfunction compared to non-diabetic free clinic patients and family members. Having a family history of diabetes and using emergency room or urgent care services were significant factors that affected health and dysfunction among diabetic and non-diabetes free clinic patients and family members. Diabetic free clinic patients need to receive services not only for diabetes, but also for overall health and dysfunction issues. Diabetes educational programs for free clinic patients should include a component to increase diabetes empowerment as well as the knowledge of treatment and management of diabetes. Non-diabetic patients and family members who have a family history of diabetes should also participate in diabetes education. Family members of free clinic patients need help to support a diabetic family member or with diabetes prevention.

Depression, somatic symptoms, and perceived neighborhood environments among US-born and non-US-born free clinic patients.

OBJECTIVES: The study's purpose was to examine the impact of somatic symptoms and perceived neighborhood environment on depression using a comparison among US-born and non-US-born free clinic patients. METHODS: US-born English speakers (n = 99), non-US-born English speakers (n = 89), and non-US-born Spanish speakers (n = 158) 18 years old or older (N = 346) were surveyed at a free clinic that provides primary care to people without health insurance. Depression, somatic symptoms, and perceived neighborhood environment were measured using standardized instruments. RESULTS: US-born English speakers reported higher levels of depression and a greater number of somatic symptoms than non-US-born Spanish speakers and non-US-born English speakers. Non-US born English speakers reported lower levels of depression and fewer somatic symptoms than Spanish speakers. Somatic symptoms and perceived neighborhood satisfaction were related to depression. CONCLUSIONS: Developing mental health services for patients in a free clinic setting is needed; however, because of limited financial and human resources, providing mental health services in a free clinic setting often is difficult. Community-based health promotion programs as supplements to efforts within clinical settings would be valuable in improving the mental health of free clinic patients. Future studies should implement collaborative pilot programs and evaluate health outcomes.

Patients utilizing a free clinic: physical and mental health, health literacy, and social support.

This cross sectional study assessed the physical and mental health, health literacy and social support of the uninsured utilizing a free clinic to develop intervention programs and research projects to improve the health of free clinic patients. Free clinics are nonprofit organizations that provide underserved and uninsured individuals access to a broad array of free or low cost healthcare services. English or Spanish speaking patients (N = 187) aged 18 years or older completed a self-administered survey. Physical, mental and oral health, health literacy, and social support were measured using standardized instruments. Eighty-two participants (45 US born and 37 non-US born) chose the English version of the survey (English speakers) while 105 participants (2 US born and 103 non-US born) chose the Spanish version (Spanish speakers). Overall, both the physical and mental health functioning of the participants was lower than that of the US general population. The participants reported being moderately depressed. US-born English speakers reported the poorest physical and mental health while Spanish speakers reported the best physical health and the lowest level of depression. A higher level of health literacy was associated with better physical health functioning, whereas reporting higher social support was associated with better mental health functioning and less severe depression. Because most free clinics have limited resources, developing services and programs that fit free clinics' circumstances are needed. Our study finding indicates that health literacy education, mental health services, and social support are key services needed by free clinic patients to achieve better health.

The Awareness of Cancer Risk and Healthy Lifestyle among Non-refugees Compared with Refugees Resettled in the United States.

PURPOSE: The purpose of this study is to examine the following questions: 1) Do refugees and non-refugees differ in self-rated health? 2) Do refugees and non-refugees differ in cancer risk awareness? and 3) Are lifestyle factors such as diet, physical activity participation, and weight status risk or protective factors of cancer risk awareness? METHODS: A self-administered or interviewer-administered survey were collected from adults with a refugee background from spring to fall in 2017 in Salt Lake County, Utah. Free clinic data (a non-refugee comparison group) were collected using a self-administered survey from May to June in 2017 from a free clinic in Salt Lake County, Utah. RESULTS: Refugees reported better self-rated health and were less likely to be obese/overweight, have family history of cancer, and have healthy diet. Refugees reported lower levels of cancer risk awareness than free clinic non-refugee patients. Having a healthy diet was associated with higher levels of cancer risk awareness. CONCLUSION: Future studies should examine cultural differences related to cancer risk awareness among refugee populations.

The Use of Complementary and Alternative Medicine Strategies, Opioids, and Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Among Patients Attending a Free Clinic.

The purpose of this study was to describe the use of opioids and complementary and alternative medicine (CAM) among uninsured free clinic patients. A self-administered paper survey was collected to describe the use of opioids, complementary, and alternative medicine, and other pain relievers from 877 free clinic patients from January to April 2018. The US born English speakers are more likely to use CAM, nonprescription pain relievers, and prescription opioids, and to be more knowledgeable about opioids compared to non-US born English speakers and Spanish speakers. The main source of opioids for free clinic patients is a health care facility other than a free clinic as well as friends. Although nonprescription pain relievers are commonly used among free clinic patients, CAM is less common to use for pain control. More health education programs are needed to increase the knowledge of opioid risks among free clinic patients as well as other underserved population.

Patient-Provider Relationships Among Vulnerable Patients: The Association With Health Literacy, Continuity of Care, and Self-Rated Health.

While the patient-provider relationship is one factor that can improve access to primary care for underserved populations, vulnerable patients often experience challenges to have a good relationship with providers. The purpose of this study is to examine factors that affect patient-provider relationship among vulnerable patients; in particular, among uninsured primary care patients. This study focused on health literacy, continuity of care, and self-rated health as predictors of patient-provider relationship. A self-administered survey was collected from uninsured primary care patients utilizing a free clinic in the metropolitan area in the Rocky Mountain Region in the United States from May to July in 2018. Higher levels of health literacy and continuity of care are associated with a better patient-provider relationship. Better self-rated health is associated with better patient-provider relationship. Health literacy may improve by the communication and connection with a specific provider because patients better understand the care and/or medications that are being prescribed. Seeing the same provider helps patients develop a better relationship and make clinical decisions in a way that they prefer. Improving the patient-provider relationship can potentially change health outcomes positively for vulnerable patients. Informing patients that they can request a specific medical provider may allow them to increase continuity of care, and improve communication, partnering, connection, and patient centeredness, leading to an increase in health literacy and better self-rated health.

Continuity of Care: Perspectives of Uninsured Free Clinic Patients.

BACKGROUND: Continuity of care is vital to the success of a health-care system because it improves patient satisfaction and health outcomes, and reduces hospitalizations and emergency room visits. OBJECTIVE: The purpose of this study was to examine free clinic patients' perspectives of continuity of care in the United States. METHOD: A convenience sample of free clinic patients who were the age of 18 or older and spoke English or Spanish participated in a self-administered survey from January to April in 2017 (N = 580). RESULTS: Better instructions from providers were associated with higher levels of continuity of care (P < .01). Higher levels of stress and worse self-rated general health were related to lower levels of continuity of care (P < .05 for stress, P < .01 for general health). Being employed was associated with lower levels of continuity of care (P < .05). Non-US born English speakers and Spanish speakers rated continuity of care higher than US born English speakers (P < .01). CONCLUSION: Even if a patient is unable to see the same physician over time, quality instructions from a well-coordinated provider team may enhance continuity of care from patient perspectives. The social context of patients such as working poor individuals is very important for providers to understand in order to identify barriers to continuity of care.