Reasons Youth of Color Give for Not Accessing Primary Health Care : A Survey of Patients at a Teen Clinic

Survey research was conducted on patients seen at Grady Teen Clinic in Atlanta, Georgia to investigate the reasons this population, predominantly composed of youth of color, gives for not accessing primary health care. Subjects for the study were males and females aged 13-19 who attended the clinic as patients during the year 2004. Data was collected from forms contained in the teens’ medical records. A majority (53%) of the subjects (n=5210) answered that the cost of medical care was their main reason for not accessing primary health care (53%), followed by lack of health insurance (44%), fear of parents learning about their visit (42%) and not knowing where to access health care (29.4%). Responses regarding cultural and language barriers (7.3%), difficulty getting or keeping appointments (9.1%) and waiting time (3.5%) were the least frequent answers. A chi square analysis revealed males and females differed significantly with respect to reasons for not accessing health care. © 2006 Californian Journal of Health Promotion. All rights reserved.


Introduction
All adolescents, but especially youth of color, need comprehensive and culturally competent primary, sexual, and reproductive health care (Resnick, 1997).Unfortunately, adolescents and young adults have less access to health care than any other age group (Klein, 1993).Teens and young adults, especially those of color, face serious barriers related to primary, sexual, and reproductive health care --barriers that may severely limit their ability to avoid pregnancy and sexually transmitted infections (STIs), including HIV (Melendez and Cheetham, 2003).
It is difficult to dispute the healthcare crisis among youth of color in the United States.Youth of color overall are less likely to have health insurance and less likely to access health care services (Brown, 2000).When youth of color do access healthcare, they are more likely to receive inadequate care compared to other youth (Penn, 1996).Health issues of youth of color exist within a societal context that is complex and many-layered.Notions of race as biology rather than an understanding of the socially constructed nature of race and racism is an issue of ethnicity that contributes to disparities in health (Airhihenbuwa, 1995).Also there is a tension between the effect of structural barriers youth of color face within the health system and beliefs about the individuals' responsibility for healthy behaviors to promote and preserve their health (Walker, 1999).These barrier and beliefs are interrelated and represent the essential foundation for a set of strategies to improve the health of youth of color.By looking critically at both the health issues affecting youth of color and the societal influences that shape them, some health departments, community based organizations, health systems and advocacy groups are working collaboratively to understand the challenges, identify the policy opportunities, and develop promising approaches to improving health outcomes (Ross, 2001).
During adolescence, access to health care plays a significant role in addressing health problems (Klein, 1993).Although concern about access to care pertains to all adolescents, financial and non-financial barriers to access are significantly magnified for poor and minority adolescents (Gans et al., 1991).There are a number of barriers that influence adolescents' use of health services.These barriers include but are not limited to a lack of confidentiality, systems that are designed for younger children and adults that are not responsive to the needs of adolescents, legal restrictions on access, transportation problems, lack of culturally appropriate services, and lack of knowledge, comfort, and interest by health professionals in attending to the needs of adolescents (English, 1986).Adolescents are also less likely to be insured or to have a regular source of healthcare (English et al., 2000).
It is well documented that adolescents, when ill or injured, typically seek health care from hospital emergency rooms rather than from primary care physicians or community health services (Gans et al., 1991).However, it remains unclear whether adolescents have general knowledge of where to obtain primary care (Brown, 2000).
Parental or guardian involvement plays a major role in an adolescents' awareness of the services that are available; however, if parents or caregivers do not receive regular routine care (as is the case for minority populations) then it is more than likely the teen will follow the same pattern.
The intent of this study was to examine: (1) the reasons youth of color give for not accessing primary health care and (2) their knowledge of sources of health care and how it can be obtained.Seven variables were examined in this study: age, gender, race, health insurance status, concerns of confidentiality, the main reasons teens gave for not accessing health care, and whether or not the teen would pay for services.The first was gender and the researcher wanted to know if there was a difference between the reasons that male and female teen's gave for not accessing health care.The second factor was age, the researcher sought information on whether there was a difference between the reasons the various age groups gave for not accessing health care.

Need for the Study
It is important that parents, communities and health care providers be aware of the need to improve access to health care for youth of color in order to promote, preserve and improve the health of all affected teens.It has been stated that many teens forego much needed health care due to various obstacles and barriers that they are faced with daily.English, Kaplan, and Morreale (2000) noted the following: "According to the U.S. Bureau of the Census, approximately one out of every six teens age 15 to 18 lacks health care coverage.Compared to teens with insurance, uninsured teens are five times more likely to be without a regular source of care, four times more likely to have unmet health needs, and twice as likely to not have annual contact with a physician .Teens engage in more risky behaviors, including alcohol and drug use, cigarette smoking, and sexual activity, than any other age group.Although these risky behaviors can jeopardize their health, teens have the lowest rates of access to, and use of, health care services."Grady Teen Clinic is located in Grady Memorial Hospital in Atlanta, Georgia and serves adolescents from the Metropolitan Atlanta area.The clinic provides family planning services, including female annual exams, pap smears, contraception, and education for females only.It also provides sports physicals, sexually transmitted infection testing and treatment, and confidential HIV screening for both males and females.Additionally, the clinic sends health educators into the Atlanta Public Schools to present a human sexuality and abstinence based education program in eighth grade health classes.

Methods
Subjects Subjects for this study were the 5,210 clients who utilized the reproductive health and

Results
education services provided by Grady Teen Clinic during 2004.These subjects included patients who were initial patients, obtaining reproductive health services from Grady for the first time, and return patients, who had received care at the clinic previously.

Knowledge of Services and Insurance Coverage
Twenty-nine percent of the patients were unaware of available health care services, particularly primary health care, in their community.It seems that the subjects are in need of more education on where to obtain low cost or free health care services that are available in their area.Although these teens did not know where to access health care, it appears that many would not use them even if they did know more about them due to the barriers discussed below.A majority of the patients, 4,033 (75.7%), did not have health insurance coverage, while 1,177 (24.3%) did.
All of the patients were between thirteen and nineteen years of age.There were 4,375 female patients and 835 male patients.Nearly half the subjects -2,308 patients -were African-Americans.A further 1,504 were White, 1,075 Hispanic, 279 Asian, and 44 other.

Data Collection
The data for this study were abstracted from a six page packet that the teen filled out each time they received health services or education at the Grady Teen Clinic.This packet included a reason for the visit check sheet, a health history and physical form, a request for and consent for a contraception method, a patient profile screen, a risk assessment tool, and a voluntary consent for use of latex condoms.Most of the data came from the health history and physical form which contained questions regarding the reason for the visit, how they would like to be contacted (for confidentiality reasons), medical history, reproductive/contraceptive history, social history, family history, a list of clinics the teen has attended, and reasons for not doing so.

Reasons for Not Accessing Care
No reason was given for not accessing primary care in the past by 637 (12.2%) of the patients (Table 1).The most frequently stated reason for not accessing primary care was the cost of medical care 2755 (53%).No health insurance 2277 (44%), Fear of parents learning about their use of the service (confidentiality) 2164 (42 %), and not knowing where to access health care 1534 (29.4%) were also frequent answers.Reasons regarding cultural and language barriers 381 (7.3%), difficulty getting or keeping appointments 473 (9.1%), and wait time before seeing a provider 183 (3.5%) were the least frequent answers.1%) and no reason 100 (4.5%).The major differences appear to be that, compared to male patients, the female patients were more likely to identify the cost of medical care and less likely to identify cultural and language barriers as reasons for not accessing primary care.

Discussion
Adolescents across the country are known to frequently forego needed health care.A series of studies have asked adolescents themselves about their health care; the most common reasons reported for avoiding care include a lack of knowledge about where to get treatment, lack of insurance, transportation difficulties, fear of medical procedures, confidentiality concerns, fear of embarrassment, and poor motivation (Klein, et al., 1998).It was surprising that only a small portion of teens indicated that they did not know where to go for health care.Sometimes teens are being informed of where to go for services, however they are not utilizing the services that are offered in their communities because of selected barriers.
In the population studied here, cost of medical care was identified as the number one barrier to accessing primary healthcare by both female and male patients.This is not surprising given that teens are often in an environment where money is already an issue.Being asked to pay for a service that is not a priority to them is likely to constitute a powerful disincentive.This situation increases the risk of adolescents forgoing health care.The related barrier of lack of health insurance was the next most frequently reported reason.Simply not knowing if they have health insurance, or being told that their parents and guardians cannot afford health insurance, deters teens from accessing care.
Teen patients are often fearful of their parents finding out they are receiving care and, more to the point, what they are receiving care for -sexual activity.Teens fear either that the health care professional will inform their parents or that they will run into someone they know who will tell their parents.
Transportation is an issue for most adolescents, yet, they did not respond in high numbers that would indicate that would keep them from accessing care.
The study has provided a better understanding of the health concerns of young people and their health seeking behavior.It is crucial that health services become more youth friendly and that young people and their support networks, such as family and friends, are informed and educated about available services and how to access them.For young people, the key to connecting them with health care services is providing appropriate opportunities for them to access health care.
The following recommendations are advanced based on the study findings.First of all, the results appear to make a clear case for additional education regarding the importance of health care, not foregoing needed health care, and healthcare services that are low or no cost in various areas.Education should be conducted in schools, community centers, and doctor's offices.This should be the first line of defense in educating adolescents about the need for primary health care.At the local level, public health entities, including the public health departments and community health clinics, could make concentrated efforts to educate adolescents.
Second, all adolescents and young adults through age 24 should have access to affordable health insurance coverage.Insurance coverage should be continuous and not subject to exclusions based on pre-existing conditions.Eligibility for health insurance through public programs, particularly Medicaid and the state Children's Health Insurance Program (SCHIP), should be expanded to make coverage available to all uninsured adolescents and young adults who do not have access to affordable private insurance.Intensive outreach efforts should be undertaken to ensure that adolescents who are eligible for Medicaid and SCHIP actually enroll and benefit from these programs.
Third, adolescents should be able to receive confidential services based on their own consent.Federal and state laws should support confidential access to healthcare for adolescents.Existing laws that provide for adolescents who are minors to give their own consent for health care and to receive services on a confidential basis should be maintained and fully implemented.Efforts to repeal minor consent laws or to place limits on the confidentiality of services for adolescents who are minors could undermine their access to essential services.
Finally, further research must be conducted to more fully understand the reasons youth do not access primary health care.The research should expand on this study.Instead of conducting a review of charts, one might undertake this study in a face to face interview in a confidential setting.However, it is important to make it clear that the information will be kept anonymous.It would be beneficial to discover if the subjects know how important it is to access primary health care and to take that opportunity to educate them while you have their attention.By accomplishing this, knowledge about the importance of receiving health care may be increased.

Table 1
Frequency and Percentages of Reasons for Not Accessing Primary Care Given by Adolescent Patients Seen at Grady Teen Clinic in Atlanta, Georgia in 2004 a Number of responses exceeds number of subjects due to multiple responses by some subjects.