Parrish, Deidra D. MD, MPH&TM; Kent, Charlotte K. PhD, MPH
DIFFERENTIAL ACCESS TO CARE between black and white populations has long been noted. Decreased access to health services among blacks contributes significantly to health disparities across a multitude of diseases and health outcomes.1 Sexually transmitted diseases are no exception, with reduced access contributing to higher rates of STDs in this population.2
The broad definition of access to care encompasses several dimensions, including utilization of services, barriers and facilitators to care, patient satisfaction, and quality of care.3,4 Others define it more narrowly as availability of care that is needed by a patient.5 In practical terms, access to care necessarily includes those factors that determine whether the patient-provider encounter occurs. Factors such as availability, utilization, health care seeking, and acceptability are closely intertwined and directly influence whether care is obtained.
STD care includes assessment of patients' health history and risk, clinical examination, lab testing, diagnosis, treatment, and health counseling, in addition to provision of broader public health services. These include identifying, locating, testing, and treating partners of patients who have STDs, screening targeted populations for certain diseases, and promoting changes in behavior that reduce the risk of acquiring an STD.6 Although these broader services are typically provided by publicly funded STD programs, most clinical visits for STDs are now performed in the private sector.7 Of the positive STD test results reported to the CDC in 2005, 77% of the chlamydia, 65% of the gonorrhea, and 71% of the syphilis came from health care providers outside of public STD clinics.8 Racial/ethnic differences influence where people get STD care. Blacks are more likely to get care at public clinics than are whites, and many public STD clinics are more likely to serve patients of minority races/ethnicities.7,9 Not surprisingly, a population-based survey of sexual behavior found that the percentage of patients who reported seeking STD care in the emergency department was as high as the percentage seeking care in public STD clinics.7 Use of the emergency department safety net for nonemergent illnesses such as STDs is indicative of problems accessing care in other settings. In several studies, emergency department patients have been found to have a high prevalence of STDs, reflecting the high-risk populations that rely on EDs for care.10,11
It is important to examine access to care issues for blacks as a whole due to the disparate STD rates across age and gender strata within the group.8 Yet, there are subpopulations of particular interest that shoulder the highest burden of STDs and that also have significant access to care issues. Adolescents consistently have the highest rates of STDs of any age group8 and are notoriously hard to reach, having low levels of health care utilization.12 Men and women in correctional facilities are another subgroup that has been shown consistently to have higher STD rates13,14 and inadequate access to care outside of correctional facilities.2
Individual Level Barriers to Access
There are many interconnected factors that contribute to reducing access to healthcare in general, and access to STD care specifically, among blacks. They can be categorized as structural and nonstructural factors acting at both the individual and health system levels. The most important individual level structural factor influencing access to care is poverty. Rust et al.15 found poverty to be a significant determinant in decreased health care utilization among blacks. Rates of poverty are higher among blacks than among white persons.16 Poverty acts as a barrier to access because of inability to pay for health services or to afford health insurance. Compounding the issue, poorer people are less likely to have jobs that provide health insurance.17 Additionally, poorer people may lack phones and means of transportation, resources that are often necessary to secure and meet appointments.18
In terms of accessing publicly funded STD services, poverty and insurance status are typically less of an issue because free services have frequently been available. However, in times of dwindling resources, some clinics have begun charging fees. The institution of a copayment at one public STD clinic resulted in significantly reduced clinic attendance and decreased numbers of diagnoses of chlamydia and gonorrhea.19 The investigators found that the drop in attendance was particularly pronounced among the poorest patients. Indeed, patients often cite cost as a barrier to accessing STD services.20,21
Lack of health insurance, independent of poverty, is a significant barrier to accessing health care.15 Most uninsured people have incomes up to 200% of the federal poverty level and members of racial/ethnic minority groups are disproportionately represented in this group.17 Many of these working poor or “near poor” are ineligible for Medicaid.15,18 Although blacks make up only about 12.3% of the US population, 17% of those without health insurance are black.17 The influence of insurance status on STD rates is demonstrated by data from a nationally representative survey of sexually active young adults, which found that having health insurance was associated with a lower risk of prevalent chlamydial infections.22
Another individual level structural factor found to contribute to reduced healthcare utilization among blacks is lack of a regular source of care.15 In general, a regular source of care is preferred by patients for addressing new problems, providing preventive care, and getting referrals.23 Regarding STD care, there is conflicting data about preference for a regular provider. Some anecdotal reports suggest that people would prefer not to see their regular provider for STD care due to stigma or shame. A survey of predominately black, mostly uninsured public STD clinic patients found that even if they had free choice of any source of care, two thirds indicated that they would still use the STD clinic.9 Reasons cited included confidentiality concerns related to keeping insurance companies from knowing about the STD visit. Another study of men attending an STD clinic found that 32% of them reported having a regular doctor.24 One would expect that studies of patients attending STD clinics would show a preference for STD clinic care. However, according to a national survey, the most common place chosen for STD treatment was a private physician's office.7 One study of low income women in Missouri, over one third of whom were black, found that most of them preferred to be tested for STDs by their own doctor.25 Furthermore, in a study of symptomatic, predominately black emergency department patients, a significantly higher number of patients testing negative for STDs were able to name their primary physician (47%) when compared to patients testing positive for STDs, of whom only 25% were able to name their doctor.11 Also, the same study of men with regular doctors attending STD clinics found that those men were significantly less likely to test positive for an STD than men without regular doctors.24 Finally, data from the nationally representative Add Health study of sexually active young adults found lower prevalent chlamydial infections in men who reported a primary care site versus an emergency room (adjusted OR 1.96) as their usual source of care.22 This compilation of findings supports the idea that lack of a regular care provider most likely decreases access to STD care, and contributes to STD disparities, for black communities.
Other interconnected factors that influence access to care at the individual level include acceptability of services and patients' perceptions and health care-seeking behaviors (explored more fully in this issue by Hogben and Leichliter26). Concerns about confidentiality, particularly among adolescents, may lead to decreased utilization of STD services.20 Privacy is another concern, especially in public STD clinics where patients have expressed anxiety about being seen in the waiting room by passers-by.27 Van Houtven et al28 found that patients' perceptions of discrimination and racism were associated with delays in filling prescriptions and with delaying tests or treatment. Some patients may falsely perceive that they are at low risk of acquiring STDs and thus fail to seek care or delay seeking care.10,29
Health System Barriers to Access
At the health system level, availability of providers influences access to care. Both rural areas and poor urban neighborhoods suffer from lack of healthcare providers.18,30 For STD services, patients report that distance to care is key; both adults and adolescents cite the importance of a facility that is close by and easy to get to by bus or walking.20,31 Organizational aspects of STD clinic sites can negatively affect access to care. The notorious inefficiency of public STD clinics coupled with the large volume of patients limits the actual number of patients that can be seen.2 Long wait times may cause patients to walk out without being seen by a health care provider.32 A facility's hours of operation may prohibit access to those who work full time, are in school, or who have child care concerns.18,20,31 Sometimes public clinics do not advertise their services because of fear of overloading an understaffed facility.18 Thus, patients are not even aware of the services that they can obtain. Bureaucracy related to enrolling in public or private healthcare systems can also be an obstacle.18 Lack of partner services is an issue, particularly for emergency departments and private sector clinics. Access to the full complement of STD services is effectively reduced in those settings not focused specifically on provision of STD care.33
Several nonstructural factors at the health system level have an effect on whether patients obtain care. Van Ryn and Burke found that physicians tended to rate blacks more negatively than whites, especially concerning compliance and risk behaviors.34 These types of perceptions can influence provider decision-making regarding appropriate care and turn away patients who sense the provider's bias. Mistreatment of patients by health system personnel and clinic staff can also turn away patients.18 Complaints by patients about 1 STD clinic included front desk staff giving them knowing looks, possibly laughing or joking at them, and treating them as dirty or promiscuous.27
Cultural competence, defined as the knowledge, skills, attitudes, and behavior required of a practitioner to provide optimal health care services to persons from a wide range of cultural and ethnic backgrounds,35 is often advocated to overcome some of these barriers,36 though no published findings address the affect of cultural competence on access to care. One factor shown to facilitate utilization of health services overall for blacks is having a provider of the same race.37 It is unclear whether this is also the case for STD care because there is limited STD-specific race concordance data. One small qualitative study of blacks in a southern city found that most of the respondents felt that race was not a factor in choosing an STD provider.38 In an STD/HIV prevention counseling intervention, race-matched counselors and clients were similar to nonrace-matched dyads in terms of clients completing the intervention and preventing acquisition of a new STD.39
Strategies to Improve Access to STD Care
Given that a multitude of factors contribute to STD disparities by reducing access to care in black communities, multiple approaches are required to address the challenges. Providing STD services in nontraditional venues is one approach. Educational settings are important venues for reaching segments of blacks at risk. Evaluation of a chlamydia screening program in California found high prevalence of disease in alternative high schools, facilities educating children who have been expelled from regular high school.40 Secondary school students tend to be amenable to receiving STD services in school settings20,41 but have expressed confidentiality concerns.31 Home STD testing may be another option, particularly for populations with confidentiality concerns. In one study, adolescent females preferred urine-based home testing for chlamydia and gonorrhea to clinic-based testing.42 For a home STD testing approach to be successful, however, there needs to be easy access to treatment and further evaluation. Providing STD services in correctional facilities is high yield in terms of finding and treating cases, among both adults and adolescents of both genders.14,41 Considering blacks' disproportionate incarceration rates in the context of social/sexual network dynamics, controlling STDs in populations in corrections has the potential to impact community rates of disease. Mobile community outreach has also had high acceptability in black communities.38
Utilizing new communications technologies to reach at-risk groups, particularly adolescents, has shown promise. An internet-based chlamydia screening project was able to reach higher risk females through mailed test kits containing vaginal swabs for self collection of specimens.43 Positives were referred to local clinics for treatment. This approach was well received by those visiting the website and yielded high treatment rates. Another intervention used phone text messaging to provide information and referrals for STD services, which was successful in reaching black adolescents.44 Notably, both of these interventions were designed with the input of the target populations,45 indicating the importance of community input in shaping acceptable, successful programs.
Other broad strategies to improve access to STD care are collaboration and service integration to enhance and expand STD service delivery. Partnerships between academia, public health departments, and community organizations for the purposes of rolling out interventions to target groups has worked in different settings.46,47 In the private sector, there are missed opportunities to provide comprehensive STD care that can and should be addressed, including screening high-risk patients for syphilis in primary care settings,48 increasing the low levels of prenatal syphilis screening,49,50 and assessing patients for risk of STDs during routine medical checkups.51 Because of the higher risk population served, the emergency department is also a site where more comprehensive STD services are warranted.11 One Institute of Medicine recommendation that should be further explored is integration of HIV and STD service delivery,2 which could incorporate testing for STDs in HIV clinical settings in addition to combining outreach activities, including awareness, education, training, and screening. Both CDC and the Infectious Diseases Society of America have developed guidelines for STD screening in HIV care settings.52,53
Though public STD clinics are seeing a smaller proportion of the STD burden each year, they are still important sources of STD care for large numbers of patients and are important entities for reducing STD disparities in black communities. Improving service delivery in these facilities will improve access to care. Very little attention or emphasis has been placed on quality of care in public STD clinics.2 Focusing on quality indicators and quality improvement in this setting can optimize care delivery and improve patient satisfaction.
Strategies such as these that address one or more of the individual level or health system level barriers to access are important short and intermediate term approaches. In the long term, the underlying structural determinants that are critical to health care accessibility in black communities, such as income, insurance status, and having a regular source of care, must be addressed. Individual strategies can only go so far when millions of Americans are uninsured and even more live in poverty. The fact that racial disparities exist across a plethora of acute and chronic conditions attests to the need for more substantial change in areas related to healthcare access.
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