Challenging Dogma


...Using social sciences to improve the practice of public health

Sunday, April 22, 2007

The Failure of Free Clinics: Why Changing Financial Access to Health Care Does Not Yield a Healthier Population-Ananta Addala

Public health and medical practitioners have pioneered free clinics as a solution to the ever-growing number of uninsured persons in America (1). The founders of free clinics have a genuine interest in providing health care to all and embracing health care as a right, not a privilege (2). Free clinics depend on donations of time from the volunteer practitioners, money for supplies, and space to set up the clinic. Free clinics assume that the sole reason why uninsured populations do not seek preventive care is because they do not have access to affordable care; however, before people can access care, awareness of the need for preventive care and embracing the right to preventive care must be fostered.

The Health Belief Model’s Inability to Look Past Finance
Free clinics are interventions that are based on the health belief model. The health belief model cites an individual’s perceived risks and perceived benefits as sole factors in forming an individual’s intention to act. Once the intention to act is formed, the model states that the individual will act to change his or her behavior (3). This assessment of perceived risks and benefits is the keystone of the health belief model. Free clinics assume people will weigh the risks and benefits of accessing preventive care resulting and intend to seek care, but are limited by finances, and therefore, do not execute the behavior.

The heavy dependence on the health belief model has prevented free clinics from accounting for barriers created by program set up, thereby failing as an intervention. Research suggests that access to quality food and health facilities are perceived barriers that hinder people’s health (4). However, investigators fail to ask if there are barriers other than finance. If the only barrier that a researcher finds is finance, then he or she is not asking novel and truly insightful questions. Financial access is clearly an issue, but the clinic does not address equally influential barriers to accessing care such as location and clinic timings. Practitioners, often times, work hours that are convenient to them and not necessarily at the convenience of the population they strive to serve. Many free clinics are located at inconvenient locations that are not easily accessible via public transportation. Research has shown that those who do not have health insurance, as compared to those are insured, are more likely to cite transportation as a barrier for accessing free care (6). Free clinics are failing interventions because of the health belief model’s inability to account for these barriers and free clinics’ inability to incorporate other models.

Theory of Reasoned Action: Expanding to Education and Addressing Social Norms
Free clinics have also failed to account for aspects of the theory of reasoned action in formulating and executing the intervention. The theory of reasoned action states that perception of social norms and attitudes towards a behavior results in an intention to act which in turn translates to behavioral change (6). The target populations’ social norms and attitudes affect their use of preventive and urgent care in the free clinic. Free clinics, in their current form, do not educate their target population about the need for preventive care. Investigators have shown that the target populations’ education level, with respect to the need for preventive care, is associated with whether the population utilizes care (5). Research suggests that having a regular physician was the most significant characteristic associated with obtaining preventive services (7). When individuals consistently seek care from the same physician there is continuity in education and counseling on lifestyle choices’ impact on health and well-being (8).The inherent set up of a free clinic, with its rotating shifts of doctors and nurses, cannot offer this necessary service to its patients.

Free clinics fail to educate their patients or provide them with realistic expectations of medical care. Unrealistic expectations can lead to uninformed choices. For instance, women are unlikely to seek contraceptive care if they are worried about potential side effects of hormone therapy (5). Similarly, those attending the free clinic are less likely to adhere to treatments if they are unsure of side effects. It is for this reason that without adequate education, treatments in a free clinic cannot be effective or successful. For many health outcomes, patients may believe that even if they were to receive treatment, their ailment and societal status would inhibit their recovery (8). Therefore, this education needs to transcend the biological aspects and include social and behavioral education of health.

Patients’ decisions never occur solely on individual level. Familial, cultural and community support are imperative in utilizing medical care. This is particularly true among the free clinics’ target populations. Data show that patients are not interested in making exclusively individual level decisions without the help of their families because there would not be a support network if any unexpected or adverse situation occurred (4). If diagnosed with a chronic disease or a grave ailment, patients at free clinics are likely to have similar needs for support. If they do not have adequate support and education on how to control the disease while living a healthy life, it is easy to see how they may fall into a fatalistic approach and deny that they have a disease that they can beat (5).

Research has also shown that familial and cultural expectations are particularly influential in the most commonly targeted population of Spanish speaking communities. Not surprisingly, research of this population has demonstrated a significant influence of attitudes, perceived approval, self-pride, and parental pride on intentions of utilizing care (2). Practitioners do not understand this about their target populations and, therefore, waste their patients’ time. Practitioners’ inability to provide adequate care is because they do not understand these pressures that go beyond the mechanics of the physical body. It is for this reason that free clinics cannot simply address access and expect the trends of the community to change. Free clinics should facilitate and embrace a broader medical paradigm that values disease prevention and health promotion (8). This would influence how target populations perceive their health and well-being while encouraging empowerment in making important lifestyle changes.

A study examining suicide prevention in Aboriginals cited gatekeepers, members within the community who counsel the suicidal, were essential in changing the cultural norms and taboos surrounding suicide (9). Although many free clinics do not offer medical health services, it is clear that they can adapt the benefits of incorporating the community in the intervention. Currently, free clinics are not able to integrate into the community, and therefore, cannot influence social norms and empower the community as a whole. This inability to absorb into the community causes a rift between the clinic and the community, allowing for the intervention to be a perceived charity, not a communal effort. It is unclear why free clinics do not incorporate interested members in the community to aid in the mission. This would be a sound way to include the community into the project so they too have a stake in it, empower the community with the pride that they have a hand in the improvement of health, demystify the medical system, and yield communal respect.

Self-Efficacy: Embracing the Right to Comprehensive Health Care
Hand in hand with education and support as tools for helping people cope with and fully utilize the free clinic, is the concept of self-efficacy. Self-efficacy is the perceived ease with which an individual can execute an action. Self-efficacy points to the individual’s perceived ease as the most influential factor in behavioral change (6). If the support and education were in place but people did not believe it to be possible to access health care, then they would not. Free clinics do not foster self-efficacy as an integral part of addressing the health disparities and treating its patients. It is imperative that the target populations understand their right to access to health care and that they are capable of accounting for their health. Without self-efficacy, the number of clinics and breadth of coverage would not be effective. A successful free clinic does not simply offer a solution to financial access; it also extends the notion that health care is a right for all populations.

Addressing the attitude of the volunteer practitioners is imperative to improving self-efficacy of an individual in a target population. Many practitioners enter the clinic with the notion that they are bestowing the gift of health care onto the patients (10). Practitioners undermine their target population when their service is offered with the notion that those on the receiving end are indebted to the giver. This is how practitioners at free clinics compromise the self-esteem and respect of the individual. Self-respect and self-esteem are very strongly associated with self-efficacy (11). Although a free clinic cannot address the root causes that result in uninsured populations, it is imperative that practitioners understand the reasons why certain populations frequent free clinics. Once this is understood, the practitioners would naturally treat the patients with more respect, both in the publicizing the free clinic as well as in treating those who attend. Many free clinics fail to recognize that addressing the issues of uninsured goes past providing access to providing care to fostering self-respect leading to self-efficacy.

Conclusion
Health care has never been proposed to be a resource within the frame of the uninsured populations’ reality. It has rather been toted as a valuable asset the uninsured have to acquire exclusively through free clinics. Although it is better to have a free clinic than nothing, I would challenge those who have set up clinics to see how they can further benefit their target population. There are many models with which to approach an intervention, each with its benefits and drawbacks. Founders of free clinics are obligated to make their intervention increasingly penetrative of the weakness in health allocation.

Practitioners of free clinics fail to recognize that their efforts are being dwarfed by their inability to incorporate more than the health belief model. Investigators state a victory in addressing health disparities and ethnic barriers to accessing the influenza vaccine (2), but it is a small victory in comparison to what they should be capable of doing. There are inherent flaws not only to their approach but also in their analysis of their success. The assessment of the clinics addresses only barrier of financial access. When the investigators only measure success as improvement of financial access, they are likely to see that it has been improved. It seems a falsely assuring and ineffective question to ask if the financial access has improved for those who are attending the free clinic. I would challenge them to see who, of their target population, is not attending the free clinic and why. The questions founders and practitioners should be addressing include the percentage of the target population they are able to reach and whether they are conveniently located. They need to ask how efficient the treatment is by seeing if the education and perception of health has improved in the community. They need to see if their intervention has involved the community and improved an individual’s ability to take health into their own hands. Until free clinics address these questions, they will continue to fail.

References:
1. Holahan J. and Cook A. Why Did the Number of Uninsured continue to increase in 2005? The Kaiser Commission on Medicaid and the Uninsured. October 2006.
2. Chen et al. Health Disparities And Prevention Racial ethnic Barriers To Flu Vaccinations. Journal of Community Health; 2007 Feb; 32(1): 5-20.
3. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
4. Adams LB. An overview of adolescent eating behavior barriers to implementing dietary guidelines. Annual New York Academy of Sciences. 1997 May 28; 817:36-48.
5. Sable et al. Factors affecting contraceptive use in women seeking pregnancy tests: Missouri, 1997. Family Planning Perspectives; 2000 May-Jun; 32(3): 124-31.
6. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
7. Carney et al. Improving future preventive care through educational efforts at a women's community screening program. Journal of Community Health; 1992 Jun; 17(3): 167-74.
8. Scariati et al. The utility of health risk assessment in providing care for a rural free clinic population. Osteopathic Medicine and Primary Care. 2007 Mar 23; 1(1): 8.
9. Capp et al. Suicide prevention in Aboriginal communities- application of community gatekeeper training. Australian and New Zealand Journal of Public Health; 2001 Aug; 25(4): 315-21.
10. Personal Experience: Free Clinic. August 2006.
11. Gardner et al. Self-Esteem and Self-Efficacy within the Organizational Context. Group & Organization Management, Vol. 23, No. 1, 48-70 (1998).
12. Ndubani et al. Understanding young men's sexual health and prospects for sexual behaviour change in rural Zambia. Scandinavian Journal of Public Health; 2003, vol. 31, no4, pp. 291-296.
13. Forrest et al. The Family Planning Attitudes and Experiences of Low-Income Women. Family Planning Perspectives. 1996 Nov-Dec; 28(6): 246-55, 277.

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