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African American Adolescent Males' Views on Doctors and the Health Care System
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African American Adolescent Males’ Views on Doctors and the Health Care System Raymond C.W. Perry, MD; Alyna T. Chien, MD, MS; William J. Walker, MA, LSW; Thomas L. Fisher, MD, MPH; Waldo E. Johnson, PhD
Funding/Support: This study was completed during the first author’s residency training in The University of Chicago Department of Pediatrics. The study was internally funded by the Department of Pediatrics Research in Residency Program at The University of Chicago, Chicago, Illinois. Objective: African American adolescent males have disproportionately high rates of morbidity and mortality and low levels of primary care use. To optimize health care for this group, there is a need to understand their views on doctors and health care, reasons for foregone care, and preferences regarding provision of health care. Methods: This was a pilot survey of African American adolescent males attending community groups in Chicago. Results: A majority of respondents agreed with declarative statements about doctors being considerate, truthful, and respectful (63%, 80%, and 80%, respectively). A majority also indicated that the health care system informs them of ways to stay healthy (65%), but fewer agreed that it meets the needs of adolescents and minorities (44% and 33%, respectively). Race/gender concordance with physicians did not seem to be a high priority. Significant reasons for foregone care included conflict with school hours, parents not having time, and lack of transportation. Despite access issues, only a minority of participants wanted health care services colocated with other aspects of their daily lives (school, community centers, church, and barbershops). Conclusion: African American adolescent males may view doctors and the health care system positively. Eliminating barriers to care and ensuring positive interactions may create opportunities to improve health issues afflicting these atrisk adolescents. Keywords: African Americans n children/adolescents n men’s health n health care J Natl Med Assoc. 2010;102:312-320 Author Affiliations: Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, Los Angeles, California (Dr Perry); Division of General Pediatrics, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts (Dr Chien); Greenwich
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Children Services, Woolwich, London, United Kingdom (Mr Walker); Section of Emergency Medicine, Department of Medicine (Dr Fisher) and School of Social Service Administration (Dr Johnson), The University of Chicago, Chicago, Illinois. Correspondence: Raymond C.W. Perry, MD, Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, 911 Broxton Ave, Room 317, Los Angeles, CA 90024 ([email protected]).
Introduction
A
frican American adolescent males are an at-risk group within the health care system because they have particularly high rates of potentially preventable morbidity and mortality and low rates of health care utilization. 1 This group faces disproportionately high rates of sexually transmitted diseases and injury-related deaths, particularly if they are from socioeconomically disadvantaged backgrounds.2-7 African American adolescent males represent the youth who could most benefit from more health guidance, but they unfortunately interact with primary health care providers the least. As a result of having fewer interactions with primary care providers, they may receive less guidance or interventions to encourage healthier lifestyle choices and improve health outcomes. What is known about African American adolescent males’ perspectives on health and utilization of health care has to be pieced together from 3 broader sources— the literature on adolescent males (without specific attention to race/ethnicity), African American adolescents (without explicit regard for gender), and African American men (without detailed reference to adolescents). Studies of adolescent males, irrespective of race/ethnicity, have shown that this population seeks or receives primary care at less than desirable rates because of feelings of invincibility, ideals about masculinity, or lack of awareness of resources.8-14 Research on African American adolescent boys and girls has found that these groups use and/or receive primary care at rates less than their white counterparts.14,15 Studies of African American adult males have demonstrated that this group tends to view health care providers and/or the health care system more negatively than other groups of adults and that this may be related to VOL. 102, NO. 4, APRIL 2010
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a sense of distrust of physicians, fear of hearing bad news about their health, prohibitive costs of seeking medical care, lack of knowledge about health care resources, perceptions of race as a barrier, and views of masculinity that contradict health-seeking behaviors.16-20 The views of African American adolescent males regarding their health care can be examined more directly. Because of their developmental stage, race/ethnicity, gender, socioeconomic circumstances, and/or experiences with medical care,8-20 it is possible that inner-city African-American adolescent males have negative views of doctors and the health care system and that they face a range of obstacles when seeking care. The goal of our study is to preliminarily explore the perceptions of a convenience sample of African American adolescent males regarding physicians, the health care system, and their experiences accessing health care. By enhancing our understanding of the perspectives of members of this vulnerable group, we may be able to improve our ability to effectively engage and treat African American adolescent males.
Methods Survey Development We first developed a conceptual model regarding the process of seeking health care (Figure 1) similar to Andersen’s Behavioral Model of Health Services Use.21 Andersen’s model stratifies the factors that affect one’s ultimate utilization of health care into predisposing characteristics, enabling resources, and need, while our
model identifies variables that affect the process of seeking health care and the behavioral outcomes of accessing care. Our model begins with an individual perceiving a health need and then demonstrates the factors that influence his or her attempt to seek care (views of doctors and the health care system, social support/influences, and knowledge of resources/previous medical experiences). This is followed by barriers/reasons for foregone health care that may prevent access even after recognition of need. We then illustrate the potential outcomes of overcoming initial barriers, which include obtaining access to care, relationship with the health care system, and role of self in health maintenance. To investigate the factors in our conceptual model and describe our study population, we developed a selfadministered survey. The survey focused on the conceptual model section entitled “Factors Influencing the Process of Seeking and Obtaining Health Care” and its domains: views of doctors and the health care system, social support/influences, previous medical experiences/ knowledge of resources, and barriers/reasons for foregone care. We modeled some questions based on previously validated survey questions from the Medical Outcomes Study (MOS) Social Support Survey (Sherbourne, Stewart), the MOS Short-Form General Health Survey (Stewart, Hays, Ward), and Trust in Physicians Survey (Anderson, Dedrick).22-24 In addition, we piloted original questions based on prior qualitative responses from adult African American men in the same neighborhoods.17,25,26
Figure 1. Conceptual Model Regarding the Process of Seeking Health Care Recognition of Health Need
Factors Influencing the Process of Seeking and Obtaining Health Care
Interactions with Physicians and the Health Care System
Views on doctors and the health care system
Perception of health and health needs
Social support/ influences
Previous medical experiences/ knowledge of resources
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Relationship with health care system
Barriers/ reasons for foregone care
Access to care Role of self in health maintenance
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Survey Instrument and Survey Administration For demographics, we asked participants for their age (categorized by year), gender, and insurance status (public, private, or unknown). We asked them to rate their overall health (poor, fair, good, or excellent) and inquired about whether or not they had an active health problem and the nature of that problem (if any). We also asked their outlook on their future health, as indicated by their predictions of their own life expectancy. In the section entitled “Views of Doctors and the Health Care System,” we asked participants to rate how much they agreed or disagreed (5-point Likert scale ranging from strongly agree to strongly disagree) with statements such as, “I am worried that doctors will break my confidentiality,” “Doctors are considerate,” and “The health care system is suited to meet the needs of minorities.” We also queried our participants for their preferences regarding race and/or gender concordance with providers since previous studies have described the importance of race and/or gender concordance for cultural competency and perceptions of care provided.27 In the section addressing social support and influences, we asked if they had family and community contacts that may have interest in their (the participants’) health and well-being, and whether or not those people had health concerns of their own. We also inquired about whether or not they had ever been pressured to do something illegal by friends or family members, and whether persons close to them had ever been injured or killed by street violence. In the survey domain regarding previous medical experiences/ knowledge of health care resources, we asked respondents to indicate yes or no to questions such as, “Is there a particular doctor’s office, clinic, or health center where you usually go when you are sick or
need advice about your health?” and “Do you have any active health problems?” We also inquired, “Have any of the following ever been a reason for you not seeking care from a doctor?” Among the optional responses were “did not know where to go” and “did not know how to make an appointment.” In the survey domain pertaining to reasons for foregone care, we asked our participants to respond to the question, “Have any of the following ever been a reason for you not seeking care from a doctor?” by checking as many of the obstacles that they felt they had faced when trying to seek health care, such as: “did not feel comfortable talking to a doctor,” “parent did not have time to take me,” “conflict with school hours,” and “could not find transportation.” Lastly, we queried their views on colocation of health care services since other studies have described the utility of school-based health clinics and other colocation strategies to increase health care accessibility for children and minorities.13 Two of the authors (R.P., W.W.) administered the surveys during regular weekly meetings of the community groups with whom we collaborated. These authors’ roles as a physician and a graduate student in social services were disclosed prior to each session.
Sample Recruitment Our target population was African American adolescent males, aged 13 to 19 years old, living in inner-city neighborhoods on the south and southwest sides of Chicago. In order to recruit a convenience sample within our target communities, we collaborated with 3 youth groups who expressed mutual interest in better understanding this topic—1 at a public high school and 2 at community centers.
Figure 2. Recruited and Actual Participants
77 participants recruited
45 actual participants, included in analysis
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Enrollment criteria: • African American male • 13-19 years old • Able to obtain parental consent, if <18 years old
32 excluded participants (did not return parental consent)
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With the help of youth group sponsors, we recruited 77 participants during their regular weekly meetings at their respective sites from January to March 2007. After explaining the goals of the study, we obtained parental consent for participants under 18 years old, informed consent from those 18 years of age or older, and oral assent of all participants prior to each survey session. Participants were provided with food and with passes for public transportation (if needed) for the survey sessions.
Analysis We used SPSS 15.0.1 (SPSS Inc, Chicago, Illinois) and descriptive statistics to analyze the responses to this survey. The primary measured outcomes were the level of positivity, negativity, or neutrality of the respondents’ views on doctors and the health care system; the prevalence of given barriers to care; and their level of preference for various current and potential sites of health care provision. The institutional review board of The University of Chicago approved this study and survey instrument prior to the study’s initiation.
Table 1. Characteristics of Respondents Demographics Sex Male Female Race/ethnicity Black/African American Other (race not reported) Age Average Range Insurance status Private insurance Public insurance Other Not insured Did not know Health and Health-Seeking Behaviors Rate their current general health as excellent Active health problems Asthma Obesity Seizure disorder Sickle cell disease Health care–seeking behavior: Had sought care in the emergency department Had ever been hospitalized Seen a physician within the last year Turned to friends for health related information Turn to adult family members for health information Have a clinic they usually visit Strongly agree with the statement that they will live to: 25 years of age 40 years of age 70 years of age Social Support and Influences Has a family member or friend who: Can help them get through a tough situation Is concerned about their health Has a family member or friend who: Has health problems Has been injured or killed by street violence Has been arrested Has pressured them to do something illegal
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No. (%) 45 (100) 0 (0) 43 (96) 1 (2) 16.7 y (SD, 1.5 y) 13-19 y 13 15 1 2 12
(29) (33) (2) (4) (27)
15 (33) 13 3 2 1
(29) (7) (4) (2)
30 21 33 21 20 25
(71) (50) (73) (47) (45) (56)
36 (80) 36 (80) 29 (64)
39 (87) 40 (89) 37 29 32 13
(82) (64) (71) (29)
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Results Demographics Forty-five of 77 male youth group members completed the survey (58% response rate) (Figure 2). Those who did not complete the survey had not returned the parental consent form prior to survey administration. Reasons for failure to obtain parental consent and the characteristics of those potential participants were not queried. The participants came from Chicago neighborhoods that were, on average, 67% African American, had high school completion rates of 70% (among those aged 25 years and older), and had a median household income of approximately $33 19—below the median for the entire US population ($41 994) but above the national median of for black households ($29 423).28 As Table 1 displays, the vast majority of respondents identified themselves as black/African American (2% identified themselves as other), and the average age of participants was 16.7 years old (SD, 1.5 years; range, 13-19 years old). A majority reported that they were either publicly or privately insured (62%), but approximately one-quarter (27%) did not know their insurance status, and 2 (4%) were uninsured.
Views of Doctors and the Health Care System As detailed in Table 2, our survey participants had generally favorable opinions of doctors but more neutral views on the health care system. A majority of respondents agreed or strongly agreed with declarative statements about doctors being considerate, truthful, and respectful (65%, 84%, and 84%, respectively). A majority also indicated that was important to develop a relationship with a doctor and disagreed with the statement that doctors would
break their confidentiality (63% and 68%, respectively). Participants did not necessarily indicate a preference for having doctors that were both race- and gender concordant. In response to the statement that “I would prefer that my doctor look like me,” a minority agreed or strongly agreed (21%), while nearly half disagreed or strongly disagreed (47%) and one-third were neutral. A majority (68%) felt that the health care system informed them of ways to stay healthy, but fewer than half agreed or strongly agreed that it met the needs of adolescent males (45%), and just one-third (34%) affirmed that it met the needs of minorities. Approximately half (41-52%) of respondents considered the health care system accessible to those who seek care with or without insurance.
Social Support/Influences Table 1 includes responses to the questions regarding social support and community influences. In terms of family and community contacts, the vast majority indicated that they had a family member or friend that they felt was concerned about their (the respondents’) health (89%). About half (47%) reported that they turned to friends for health-related information, and an almost equal proportion (45%) reported turning to adult family members for the same information. The majority also reported that they had a family member or friend who could help them get through “tough situations” (87%). Most respondents indicated that they knew of friends or family members who had health problems of their own (82%). A majority knew someone injured or killed by street violence (64%) and had a family-member or friend who had been arrested (71%), although just 29% had been pressured to do something illegal by a family member or friend.
Table 2. Views of Doctors and the Health Care System
Statements About doctors Doctors are considerate. Doctors tell the truth about my health needs. Doctors treat me with respect. It is important to develop a relationship with a doctor. I am worried that doctors will break my confidentiality. I would prefer that my doctor look like me. About the health care system The health care system informs me about ways to stay healthy. The health care system is accessible to those who seek care. Regardless of insurance, you can receive medical care. The health care system meets the needs of adolescent males. The health care system is suited to meet the needs of minorities.
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Disagreed or Strongly Disagreed N (%)
Neutral N (%)
Agreed or Strongly Agreed N (%)
3 (7%) 3 (7%) 2 (5%) 6 (14%) 29 (68%) 20 (47%)
12 (28%) 4 (9%) 5 (12%) 10 (23%) 6 (14%) 14 (33%)
28 (65%) 36 (84%) 36 (84%) 27 (63%) 8 (19%) 9 (21%)
3 (7%) 7 (16%) 9 (20%) 4 (9%) 9 (21%)
11 14 17 20 20
29 23 18 20 15
(26%) (32%) (39%) (46%) (46%)
(68%) (52%) (41%) (46%) (34%)
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Past Medical Experiences/ Knowledge of Health Care Resources As shown in Table 1, only one-third (33%) indicated that their general health was excellent. Forty-two percent of participants reported that they were currently enduring health problems. The most reported health problem was asthma (29%), followed by obesity (7%). One in 5 (20%) did not expect to live to the age of 25; two-thirds (64%) of our respondents expected to live as long as the average American man (ie, 70 years of age). Approximately three-quarters had seen a doctor in the past year (73%), but fewer had a clinic they usually visited (58%).
Barriers/Reasons for Foregone Care Table 3 shows how our participants responded when asked to indicate why they had foregone health care even when they felt it was needed. The most common reasons were: conflict with school hours (33%), parents’ not having time to take them or lack of transportation (19% each), and being unsure of how to make an appointment or of where to go for an appointment (12% each). Less than 10% of our population indicated that they had foregone health care because they were “afraid of what the doctor might say” (9%), “did not want [their] parents to know” (9%), “did not feel comfortable talking to a doctor” (7%), “could not afford the cost” (7%), or “did not know if [they] had insurance” (5%). No additional obstacles were offered by respondents in the fillin-the-blank option provided. Table 4 summarizes the respondents’ opinions on sites for colocation of services as potential solutions to logistic barriers to health care access. The vast majority of our study participants preferred health care services to be delivered in traditional settings—the outpatient office (93%), emergency room (86%), or a board of health clinic (73%). Except for colocation in their homes, where 71% of participants were open to having health care provided, participants expressed little interest in the idea of colocating health care services with other activities (school, community centers, church, and
barber shops). Only a small fraction (9%) stated that they would want health care services to be provided in barber shops.
Discussion
Our pilot survey of African American adolescent males living in socioeconomically disadvantaged circumstances (but engaged in extracurricular or community youth groups) demonstrates that this at-risk population generally holds optimistic views of their health despite a significant proportion having active health problems. These respondents also expressed generally positive views of doctors and of the health care system, although their views of the health care system were more neutral. In certain regards, these findings are consistent with other studies on adolescent males.8-14 Our finding of optimistic views regarding future health status despite a high prevalence of chronic disease and environmental risk factors may belie this group’s sense of its own invincibility, or it may simply reflect a lay person’s understanding of health risk and prognosis. Our findings regarding foregone health care and concomitant barriers are consistent with descriptions of adolescent males as potentially unable to engage effectively with existing resources, therefore yielding lower primary care visit rates.8-15 Our study did not detect significantly negative views of physicians and health care (eg, mistrust, fatalism), as have been found in previous studies of adult African American men from similar neighborhoods, though the views on the health care system seemed more neutral than positive.16,17 This difference between our participants and adults suggests that adolescence may be an opportune time to ensure that emerging African American men have positive experiences with providers and the health care system. The fact that the respondents felt more positively about doctors as individuals compared to the health care system as a whole stresses the importance for providers to ensure a positive point-ofcontact influence in the adolescents’ lives even though they may be starting to develop greater concerns or dis-
Table 3. Barriers to Care Respondents Citing the Following Reasons for Foregone Care Conflict with school hours Parents did not have time Could not find transportation Did not know where to go Did not know how to make an appointment Afraid of what the doctor might say Did not want parent to know Did not feel comfortable talking to a doctor Could not afford the cost Did not know if I had insurance
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N (%) 14 (33%) 8 (19%) 8 (19%) 5 (12%) 5 (12%) 4 (9%) 4 (9%) 3 (7%) 3 (7%) 2 (5%)
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trust with societal institutions such as health care. Improving health care accessibility is likely to be an important component of reaching and meeting the needs of this at-risk population. Addressing an apparent paradox in their desires will be necessary—these youths cite issues such as hours of operation and lack of transportation as reasons for foregone care, but far less than half would like health care services colocated with their daily activities. Interestingly, their receptivity to having services colocated with schools, community centers, or churches was far greater than for barbershops, which have been used successfully in one model to increase health maintenance and access to care for African American adult males.29 Future research should focus on verifying whether significant proportions of African American adolescent males are, in fact, resistant to the provision of health care in nontraditional settings alongside non–health-related activities, and if so, for what reasons. Previous studies cite the significance of fear of disclosure of health information and concerns about stigmatization as pivotal in adolescents’ choice to forego care.12,30,31 While only one-fifth of our respondents were worried about breach of confidentiality and less than 10% reported being uncomfortable talking to their doctor, the concern about ensuring a comfortable environment for discussion of health issues may still play a role in where these males are willing to seek care. Clarification of these findings may facilitate the design of successful solutions to the barriers to care faced by this particular group. In terms of preference for racial and/or gender concordance, only a small proportion of our subjects felt that their physician should “look like [them].” With respect to gender, this relative indifference is consistent with previous findings for African American adolescent males32 and may reflect their thoughts about receiving care for nongendered ailments that are more prevalent in this age group (asthma, upper respiratory illnesses, musculoskeletal injuries). Further studies may determine if there are differences in gender preference that arise when seeking care for sexually related issues or mental health issues. In these scenarios, having a male provider may allow enhanced discussion regarding gender-relevant physical and emotional concerns. Alternatively,
gender concordance may present a sense of embarrassment in disclosing what may be considered vulnerabilities to another male or discomfort during the physical examination. The discrepancy between adolescents and adults in the African American population for racial concordance may be due to different temporal exposure to institutional racism both within and outside health care (ie, adults having experienced more due to greater age).25 Furthermore, if they have had no or less personal experience with prejudice in the health care system, adolescents may be less likely than adults to embrace historical or cultural views regarding potential differences in health care provision based on race (though, as mentioned above, adolescence may be the period in which these perceptions are beginning to develop). Another possibility is that today’s adolescents may be indifferent to racial concordance because they have grown up with exposure to more ethnically diverse environments in school, extracurricular activities, media, and pop culture. Given these findings and interpretations, it seems that focusing intervention efforts on gender- and racebased factors for optimal engagement with the health care system will require important further investigation. However, ensuring overall accessibility in the African American adolescent male demographic is a more clear and significant issue that should be addressed first.
Limitations The first main limitation of this study is its generalizability. Our study population was derived from 3 youth groups located in the south and southwest sides of Chicago, Illinois, so there may be community or regional, as well as socioeconomic and cultural factors that affect how this group perceives and interacts with the health care system. Our participants were different from African Americans nationally in terms of median household income and health insurance status—both being higher than the national average for African Americans.26,28 The goals of this study, however, were pilot in nature and geared toward gathering information on and testing questions on a subset of adolescents whose views are not well represented in previous studies
Table 4. Preferred Locations for Health Care Services Respondents Who Would Like Health Care Services Provided at… Doctor’s office Emergency room Board of health clinic Home School Community center Church Barber shop
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N (%) 40 (93%) 38 (86%) 32 (73%) 31 (71%) 18 (42%) 14 (32%) 13 (30%) 4 (9%)
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and toward providing a foundation for future, more representative work. The second main limitation is social desirability bias in the responses. The survey was administered by 2 African American men who introduced themselves as members of the health care system (one with a social work background, the other a physician). Participants may have been less likely to report negative feelings towards health care providers and the system at large as a result of their interactions with or in the presence of these moderators. While disclosing our identities may have introduced some social desirability bias, it was essential for building rapport with the study participants and community groups. The main protection from this source of bias came from reassurances of participants’ anonymity. Future efforts will better separate participant recruitment from survey administration.
Conclusions
Although this study is pilot in nature, it addresses important gaps in our understanding of African American adolescent males. These findings are intended to be interpreted within developmental and life course frameworks that are affected by multiple internal and external influences. Adolescence marks a stage of life in which youth are increasingly independent, eager to make decisions and to find their own solutions to daily problems.12,30 As teenagers, despite their desire for independence, they may lack the maturity, experience, or knowledge to appropriately utilize health care resources on their own.30,31 Their commitments to school and other extracurricular activities, as well as their reliance on parents/guardians for financial assistance and transportation, create more potential barriers to convenient care. The power of social stigmas attached to health problems likely has greater effects on adolescents than on adults and on males greater than on females. Lastly, as emerging African American adults, they may also be dealing with personal and/or cultural issues within a societal construct, and they may have increasing exposure to or recognition of prejudice (both real and/or perceived). All of these factors may influence when, where, and with whom African American adolescent males are willing to seek health care. The medical community must address the personal, social, and logistic factors in the process of seeking health care in order to eliminate the barriers to care and become more accessible to African American adolescent males. By doing so, this at-risk group may increasingly seek and obtain appropriate primary health care and may develop better understandings of resources available to them during their adolescence and adulthood.12,17,31 Health-seeking behaviors initiated and/or habituated during adolescence may have long-term implications for patterns of health seeking in adulthood.12,14 Eliminating the barriers to care during adolescence may permit more JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
frequent and beneficial interactions between African American males and primary health care providers. Ultimately, this may help to decrease the preventable morbidity and mortality rates among African American adolescent males and continue to have a positive influence on their health in adulthood.
Acknowledgments
We thank the administrators and participants at the study sites for their support and cooperation.
References
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African American Adolescent Males’ Views on Doctors and the Health Care System Raymond C.W. Perry, MD; Alyna T. Chien, MD, MS; William J. Walker, MA, LSW; Thomas L. Fisher, MD, MPH; Waldo E. Johnson, PhD
Funding/Support: This study was completed during the first author’s residency training in The University of Chicago Department of Pediatrics. The study was internally funded by the Department of Pediatrics Research in Residency Program at The University of Chicago, Chicago, Illinois. Objective: African American adolescent males have disproportionately high rates of morbidity and mortality and low levels of primary care use. To optimize health care for this group, there is a need to understand their views on doctors and health care, reasons for foregone care, and preferences regarding provision of health care. Methods: This was a pilot survey of African American adolescent males attending community groups in Chicago. Results: A majority of respondents agreed with declarative statements about doctors being considerate, truthful, and respectful (63%, 80%, and 80%, respectively). A majority also indicated that the health care system informs them of ways to stay healthy (65%), but fewer agreed that it meets the needs of adolescents and minorities (44% and 33%, respectively). Race/gender concordance with physicians did not seem to be a high priority. Significant reasons for foregone care included conflict with school hours, parents not having time, and lack of transportation. Despite access issues, only a minority of participants wanted health care services colocated with other aspects of their daily lives (school, community centers, church, and barbershops). Conclusion: African American adolescent males may view doctors and the health care system positively. Eliminating barriers to care and ensuring positive interactions may create opportunities to improve health issues afflicting these atrisk adolescents. Keywords: African Americans n children/adolescents n men’s health n health care J Natl Med Assoc. 2010;102:312-320 Author Affiliations: Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, Los Angeles, California (Dr Perry); Division of General Pediatrics, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts (Dr Chien); Greenwich
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Children Services, Woolwich, London, United Kingdom (Mr Walker); Section of Emergency Medicine, Department of Medicine (Dr Fisher) and School of Social Service Administration (Dr Johnson), The University of Chicago, Chicago, Illinois. Correspondence: Raymond C.W. Perry, MD, Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, 911 Broxton Ave, Room 317, Los Angeles, CA 90024 ([email protected]).
Introduction
A
frican American adolescent males are an at-risk group within the health care system because they have particularly high rates of potentially preventable morbidity and mortality and low rates of health care utilization. 1 This group faces disproportionately high rates of sexually transmitted diseases and injury-related deaths, particularly if they are from socioeconomically disadvantaged backgrounds.2-7 African American adolescent males represent the youth who could most benefit from more health guidance, but they unfortunately interact with primary health care providers the least. As a result of having fewer interactions with primary care providers, they may receive less guidance or interventions to encourage healthier lifestyle choices and improve health outcomes. What is known about African American adolescent males’ perspectives on health and utilization of health care has to be pieced together from 3 broader sources— the literature on adolescent males (without specific attention to race/ethnicity), African American adolescents (without explicit regard for gender), and African American men (without detailed reference to adolescents). Studies of adolescent males, irrespective of race/ethnicity, have shown that this population seeks or receives primary care at less than desirable rates because of feelings of invincibility, ideals about masculinity, or lack of awareness of resources.8-14 Research on African American adolescent boys and girls has found that these groups use and/or receive primary care at rates less than their white counterparts.14,15 Studies of African American adult males have demonstrated that this group tends to view health care providers and/or the health care system more negatively than other groups of adults and that this may be related to VOL. 102, NO. 4, APRIL 2010
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a sense of distrust of physicians, fear of hearing bad news about their health, prohibitive costs of seeking medical care, lack of knowledge about health care resources, perceptions of race as a barrier, and views of masculinity that contradict health-seeking behaviors.16-20 The views of African American adolescent males regarding their health care can be examined more directly. Because of their developmental stage, race/ethnicity, gender, socioeconomic circumstances, and/or experiences with medical care,8-20 it is possible that inner-city African-American adolescent males have negative views of doctors and the health care system and that they face a range of obstacles when seeking care. The goal of our study is to preliminarily explore the perceptions of a convenience sample of African American adolescent males regarding physicians, the health care system, and their experiences accessing health care. By enhancing our understanding of the perspectives of members of this vulnerable group, we may be able to improve our ability to effectively engage and treat African American adolescent males.
Methods Survey Development We first developed a conceptual model regarding the process of seeking health care (Figure 1) similar to Andersen’s Behavioral Model of Health Services Use.21 Andersen’s model stratifies the factors that affect one’s ultimate utilization of health care into predisposing characteristics, enabling resources, and need, while our
model identifies variables that affect the process of seeking health care and the behavioral outcomes of accessing care. Our model begins with an individual perceiving a health need and then demonstrates the factors that influence his or her attempt to seek care (views of doctors and the health care system, social support/influences, and knowledge of resources/previous medical experiences). This is followed by barriers/reasons for foregone health care that may prevent access even after recognition of need. We then illustrate the potential outcomes of overcoming initial barriers, which include obtaining access to care, relationship with the health care system, and role of self in health maintenance. To investigate the factors in our conceptual model and describe our study population, we developed a selfadministered survey. The survey focused on the conceptual model section entitled “Factors Influencing the Process of Seeking and Obtaining Health Care” and its domains: views of doctors and the health care system, social support/influences, previous medical experiences/ knowledge of resources, and barriers/reasons for foregone care. We modeled some questions based on previously validated survey questions from the Medical Outcomes Study (MOS) Social Support Survey (Sherbourne, Stewart), the MOS Short-Form General Health Survey (Stewart, Hays, Ward), and Trust in Physicians Survey (Anderson, Dedrick).22-24 In addition, we piloted original questions based on prior qualitative responses from adult African American men in the same neighborhoods.17,25,26
Figure 1. Conceptual Model Regarding the Process of Seeking Health Care Recognition of Health Need
Factors Influencing the Process of Seeking and Obtaining Health Care
Interactions with Physicians and the Health Care System
Views on doctors and the health care system
Perception of health and health needs
Social support/ influences
Previous medical experiences/ knowledge of resources
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Relationship with health care system
Barriers/ reasons for foregone care
Access to care Role of self in health maintenance
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Survey Instrument and Survey Administration For demographics, we asked participants for their age (categorized by year), gender, and insurance status (public, private, or unknown). We asked them to rate their overall health (poor, fair, good, or excellent) and inquired about whether or not they had an active health problem and the nature of that problem (if any). We also asked their outlook on their future health, as indicated by their predictions of their own life expectancy. In the section entitled “Views of Doctors and the Health Care System,” we asked participants to rate how much they agreed or disagreed (5-point Likert scale ranging from strongly agree to strongly disagree) with statements such as, “I am worried that doctors will break my confidentiality,” “Doctors are considerate,” and “The health care system is suited to meet the needs of minorities.” We also queried our participants for their preferences regarding race and/or gender concordance with providers since previous studies have described the importance of race and/or gender concordance for cultural competency and perceptions of care provided.27 In the section addressing social support and influences, we asked if they had family and community contacts that may have interest in their (the participants’) health and well-being, and whether or not those people had health concerns of their own. We also inquired about whether or not they had ever been pressured to do something illegal by friends or family members, and whether persons close to them had ever been injured or killed by street violence. In the survey domain regarding previous medical experiences/ knowledge of health care resources, we asked respondents to indicate yes or no to questions such as, “Is there a particular doctor’s office, clinic, or health center where you usually go when you are sick or
need advice about your health?” and “Do you have any active health problems?” We also inquired, “Have any of the following ever been a reason for you not seeking care from a doctor?” Among the optional responses were “did not know where to go” and “did not know how to make an appointment.” In the survey domain pertaining to reasons for foregone care, we asked our participants to respond to the question, “Have any of the following ever been a reason for you not seeking care from a doctor?” by checking as many of the obstacles that they felt they had faced when trying to seek health care, such as: “did not feel comfortable talking to a doctor,” “parent did not have time to take me,” “conflict with school hours,” and “could not find transportation.” Lastly, we queried their views on colocation of health care services since other studies have described the utility of school-based health clinics and other colocation strategies to increase health care accessibility for children and minorities.13 Two of the authors (R.P., W.W.) administered the surveys during regular weekly meetings of the community groups with whom we collaborated. These authors’ roles as a physician and a graduate student in social services were disclosed prior to each session.
Sample Recruitment Our target population was African American adolescent males, aged 13 to 19 years old, living in inner-city neighborhoods on the south and southwest sides of Chicago. In order to recruit a convenience sample within our target communities, we collaborated with 3 youth groups who expressed mutual interest in better understanding this topic—1 at a public high school and 2 at community centers.
Figure 2. Recruited and Actual Participants
77 participants recruited
45 actual participants, included in analysis
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Enrollment criteria: • African American male • 13-19 years old • Able to obtain parental consent, if <18 years old
32 excluded participants (did not return parental consent)
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With the help of youth group sponsors, we recruited 77 participants during their regular weekly meetings at their respective sites from January to March 2007. After explaining the goals of the study, we obtained parental consent for participants under 18 years old, informed consent from those 18 years of age or older, and oral assent of all participants prior to each survey session. Participants were provided with food and with passes for public transportation (if needed) for the survey sessions.
Analysis We used SPSS 15.0.1 (SPSS Inc, Chicago, Illinois) and descriptive statistics to analyze the responses to this survey. The primary measured outcomes were the level of positivity, negativity, or neutrality of the respondents’ views on doctors and the health care system; the prevalence of given barriers to care; and their level of preference for various current and potential sites of health care provision. The institutional review board of The University of Chicago approved this study and survey instrument prior to the study’s initiation.
Table 1. Characteristics of Respondents Demographics Sex Male Female Race/ethnicity Black/African American Other (race not reported) Age Average Range Insurance status Private insurance Public insurance Other Not insured Did not know Health and Health-Seeking Behaviors Rate their current general health as excellent Active health problems Asthma Obesity Seizure disorder Sickle cell disease Health care–seeking behavior: Had sought care in the emergency department Had ever been hospitalized Seen a physician within the last year Turned to friends for health related information Turn to adult family members for health information Have a clinic they usually visit Strongly agree with the statement that they will live to: 25 years of age 40 years of age 70 years of age Social Support and Influences Has a family member or friend who: Can help them get through a tough situation Is concerned about their health Has a family member or friend who: Has health problems Has been injured or killed by street violence Has been arrested Has pressured them to do something illegal
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No. (%) 45 (100) 0 (0) 43 (96) 1 (2) 16.7 y (SD, 1.5 y) 13-19 y 13 15 1 2 12
(29) (33) (2) (4) (27)
15 (33) 13 3 2 1
(29) (7) (4) (2)
30 21 33 21 20 25
(71) (50) (73) (47) (45) (56)
36 (80) 36 (80) 29 (64)
39 (87) 40 (89) 37 29 32 13
(82) (64) (71) (29)
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Results Demographics Forty-five of 77 male youth group members completed the survey (58% response rate) (Figure 2). Those who did not complete the survey had not returned the parental consent form prior to survey administration. Reasons for failure to obtain parental consent and the characteristics of those potential participants were not queried. The participants came from Chicago neighborhoods that were, on average, 67% African American, had high school completion rates of 70% (among those aged 25 years and older), and had a median household income of approximately $33 19—below the median for the entire US population ($41 994) but above the national median of for black households ($29 423).28 As Table 1 displays, the vast majority of respondents identified themselves as black/African American (2% identified themselves as other), and the average age of participants was 16.7 years old (SD, 1.5 years; range, 13-19 years old). A majority reported that they were either publicly or privately insured (62%), but approximately one-quarter (27%) did not know their insurance status, and 2 (4%) were uninsured.
Views of Doctors and the Health Care System As detailed in Table 2, our survey participants had generally favorable opinions of doctors but more neutral views on the health care system. A majority of respondents agreed or strongly agreed with declarative statements about doctors being considerate, truthful, and respectful (65%, 84%, and 84%, respectively). A majority also indicated that was important to develop a relationship with a doctor and disagreed with the statement that doctors would
break their confidentiality (63% and 68%, respectively). Participants did not necessarily indicate a preference for having doctors that were both race- and gender concordant. In response to the statement that “I would prefer that my doctor look like me,” a minority agreed or strongly agreed (21%), while nearly half disagreed or strongly disagreed (47%) and one-third were neutral. A majority (68%) felt that the health care system informed them of ways to stay healthy, but fewer than half agreed or strongly agreed that it met the needs of adolescent males (45%), and just one-third (34%) affirmed that it met the needs of minorities. Approximately half (41-52%) of respondents considered the health care system accessible to those who seek care with or without insurance.
Social Support/Influences Table 1 includes responses to the questions regarding social support and community influences. In terms of family and community contacts, the vast majority indicated that they had a family member or friend that they felt was concerned about their (the respondents’) health (89%). About half (47%) reported that they turned to friends for health-related information, and an almost equal proportion (45%) reported turning to adult family members for the same information. The majority also reported that they had a family member or friend who could help them get through “tough situations” (87%). Most respondents indicated that they knew of friends or family members who had health problems of their own (82%). A majority knew someone injured or killed by street violence (64%) and had a family-member or friend who had been arrested (71%), although just 29% had been pressured to do something illegal by a family member or friend.
Table 2. Views of Doctors and the Health Care System
Statements About doctors Doctors are considerate. Doctors tell the truth about my health needs. Doctors treat me with respect. It is important to develop a relationship with a doctor. I am worried that doctors will break my confidentiality. I would prefer that my doctor look like me. About the health care system The health care system informs me about ways to stay healthy. The health care system is accessible to those who seek care. Regardless of insurance, you can receive medical care. The health care system meets the needs of adolescent males. The health care system is suited to meet the needs of minorities.
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Disagreed or Strongly Disagreed N (%)
Neutral N (%)
Agreed or Strongly Agreed N (%)
3 (7%) 3 (7%) 2 (5%) 6 (14%) 29 (68%) 20 (47%)
12 (28%) 4 (9%) 5 (12%) 10 (23%) 6 (14%) 14 (33%)
28 (65%) 36 (84%) 36 (84%) 27 (63%) 8 (19%) 9 (21%)
3 (7%) 7 (16%) 9 (20%) 4 (9%) 9 (21%)
11 14 17 20 20
29 23 18 20 15
(26%) (32%) (39%) (46%) (46%)
(68%) (52%) (41%) (46%) (34%)
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Past Medical Experiences/ Knowledge of Health Care Resources As shown in Table 1, only one-third (33%) indicated that their general health was excellent. Forty-two percent of participants reported that they were currently enduring health problems. The most reported health problem was asthma (29%), followed by obesity (7%). One in 5 (20%) did not expect to live to the age of 25; two-thirds (64%) of our respondents expected to live as long as the average American man (ie, 70 years of age). Approximately three-quarters had seen a doctor in the past year (73%), but fewer had a clinic they usually visited (58%).
Barriers/Reasons for Foregone Care Table 3 shows how our participants responded when asked to indicate why they had foregone health care even when they felt it was needed. The most common reasons were: conflict with school hours (33%), parents’ not having time to take them or lack of transportation (19% each), and being unsure of how to make an appointment or of where to go for an appointment (12% each). Less than 10% of our population indicated that they had foregone health care because they were “afraid of what the doctor might say” (9%), “did not want [their] parents to know” (9%), “did not feel comfortable talking to a doctor” (7%), “could not afford the cost” (7%), or “did not know if [they] had insurance” (5%). No additional obstacles were offered by respondents in the fillin-the-blank option provided. Table 4 summarizes the respondents’ opinions on sites for colocation of services as potential solutions to logistic barriers to health care access. The vast majority of our study participants preferred health care services to be delivered in traditional settings—the outpatient office (93%), emergency room (86%), or a board of health clinic (73%). Except for colocation in their homes, where 71% of participants were open to having health care provided, participants expressed little interest in the idea of colocating health care services with other activities (school, community centers, church, and
barber shops). Only a small fraction (9%) stated that they would want health care services to be provided in barber shops.
Discussion
Our pilot survey of African American adolescent males living in socioeconomically disadvantaged circumstances (but engaged in extracurricular or community youth groups) demonstrates that this at-risk population generally holds optimistic views of their health despite a significant proportion having active health problems. These respondents also expressed generally positive views of doctors and of the health care system, although their views of the health care system were more neutral. In certain regards, these findings are consistent with other studies on adolescent males.8-14 Our finding of optimistic views regarding future health status despite a high prevalence of chronic disease and environmental risk factors may belie this group’s sense of its own invincibility, or it may simply reflect a lay person’s understanding of health risk and prognosis. Our findings regarding foregone health care and concomitant barriers are consistent with descriptions of adolescent males as potentially unable to engage effectively with existing resources, therefore yielding lower primary care visit rates.8-15 Our study did not detect significantly negative views of physicians and health care (eg, mistrust, fatalism), as have been found in previous studies of adult African American men from similar neighborhoods, though the views on the health care system seemed more neutral than positive.16,17 This difference between our participants and adults suggests that adolescence may be an opportune time to ensure that emerging African American men have positive experiences with providers and the health care system. The fact that the respondents felt more positively about doctors as individuals compared to the health care system as a whole stresses the importance for providers to ensure a positive point-ofcontact influence in the adolescents’ lives even though they may be starting to develop greater concerns or dis-
Table 3. Barriers to Care Respondents Citing the Following Reasons for Foregone Care Conflict with school hours Parents did not have time Could not find transportation Did not know where to go Did not know how to make an appointment Afraid of what the doctor might say Did not want parent to know Did not feel comfortable talking to a doctor Could not afford the cost Did not know if I had insurance
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N (%) 14 (33%) 8 (19%) 8 (19%) 5 (12%) 5 (12%) 4 (9%) 4 (9%) 3 (7%) 3 (7%) 2 (5%)
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trust with societal institutions such as health care. Improving health care accessibility is likely to be an important component of reaching and meeting the needs of this at-risk population. Addressing an apparent paradox in their desires will be necessary—these youths cite issues such as hours of operation and lack of transportation as reasons for foregone care, but far less than half would like health care services colocated with their daily activities. Interestingly, their receptivity to having services colocated with schools, community centers, or churches was far greater than for barbershops, which have been used successfully in one model to increase health maintenance and access to care for African American adult males.29 Future research should focus on verifying whether significant proportions of African American adolescent males are, in fact, resistant to the provision of health care in nontraditional settings alongside non–health-related activities, and if so, for what reasons. Previous studies cite the significance of fear of disclosure of health information and concerns about stigmatization as pivotal in adolescents’ choice to forego care.12,30,31 While only one-fifth of our respondents were worried about breach of confidentiality and less than 10% reported being uncomfortable talking to their doctor, the concern about ensuring a comfortable environment for discussion of health issues may still play a role in where these males are willing to seek care. Clarification of these findings may facilitate the design of successful solutions to the barriers to care faced by this particular group. In terms of preference for racial and/or gender concordance, only a small proportion of our subjects felt that their physician should “look like [them].” With respect to gender, this relative indifference is consistent with previous findings for African American adolescent males32 and may reflect their thoughts about receiving care for nongendered ailments that are more prevalent in this age group (asthma, upper respiratory illnesses, musculoskeletal injuries). Further studies may determine if there are differences in gender preference that arise when seeking care for sexually related issues or mental health issues. In these scenarios, having a male provider may allow enhanced discussion regarding gender-relevant physical and emotional concerns. Alternatively,
gender concordance may present a sense of embarrassment in disclosing what may be considered vulnerabilities to another male or discomfort during the physical examination. The discrepancy between adolescents and adults in the African American population for racial concordance may be due to different temporal exposure to institutional racism both within and outside health care (ie, adults having experienced more due to greater age).25 Furthermore, if they have had no or less personal experience with prejudice in the health care system, adolescents may be less likely than adults to embrace historical or cultural views regarding potential differences in health care provision based on race (though, as mentioned above, adolescence may be the period in which these perceptions are beginning to develop). Another possibility is that today’s adolescents may be indifferent to racial concordance because they have grown up with exposure to more ethnically diverse environments in school, extracurricular activities, media, and pop culture. Given these findings and interpretations, it seems that focusing intervention efforts on gender- and racebased factors for optimal engagement with the health care system will require important further investigation. However, ensuring overall accessibility in the African American adolescent male demographic is a more clear and significant issue that should be addressed first.
Limitations The first main limitation of this study is its generalizability. Our study population was derived from 3 youth groups located in the south and southwest sides of Chicago, Illinois, so there may be community or regional, as well as socioeconomic and cultural factors that affect how this group perceives and interacts with the health care system. Our participants were different from African Americans nationally in terms of median household income and health insurance status—both being higher than the national average for African Americans.26,28 The goals of this study, however, were pilot in nature and geared toward gathering information on and testing questions on a subset of adolescents whose views are not well represented in previous studies
Table 4. Preferred Locations for Health Care Services Respondents Who Would Like Health Care Services Provided at… Doctor’s office Emergency room Board of health clinic Home School Community center Church Barber shop
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N (%) 40 (93%) 38 (86%) 32 (73%) 31 (71%) 18 (42%) 14 (32%) 13 (30%) 4 (9%)
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and toward providing a foundation for future, more representative work. The second main limitation is social desirability bias in the responses. The survey was administered by 2 African American men who introduced themselves as members of the health care system (one with a social work background, the other a physician). Participants may have been less likely to report negative feelings towards health care providers and the system at large as a result of their interactions with or in the presence of these moderators. While disclosing our identities may have introduced some social desirability bias, it was essential for building rapport with the study participants and community groups. The main protection from this source of bias came from reassurances of participants’ anonymity. Future efforts will better separate participant recruitment from survey administration.
Conclusions
Although this study is pilot in nature, it addresses important gaps in our understanding of African American adolescent males. These findings are intended to be interpreted within developmental and life course frameworks that are affected by multiple internal and external influences. Adolescence marks a stage of life in which youth are increasingly independent, eager to make decisions and to find their own solutions to daily problems.12,30 As teenagers, despite their desire for independence, they may lack the maturity, experience, or knowledge to appropriately utilize health care resources on their own.30,31 Their commitments to school and other extracurricular activities, as well as their reliance on parents/guardians for financial assistance and transportation, create more potential barriers to convenient care. The power of social stigmas attached to health problems likely has greater effects on adolescents than on adults and on males greater than on females. Lastly, as emerging African American adults, they may also be dealing with personal and/or cultural issues within a societal construct, and they may have increasing exposure to or recognition of prejudice (both real and/or perceived). All of these factors may influence when, where, and with whom African American adolescent males are willing to seek health care. The medical community must address the personal, social, and logistic factors in the process of seeking health care in order to eliminate the barriers to care and become more accessible to African American adolescent males. By doing so, this at-risk group may increasingly seek and obtain appropriate primary health care and may develop better understandings of resources available to them during their adolescence and adulthood.12,17,31 Health-seeking behaviors initiated and/or habituated during adolescence may have long-term implications for patterns of health seeking in adulthood.12,14 Eliminating the barriers to care during adolescence may permit more JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
frequent and beneficial interactions between African American males and primary health care providers. Ultimately, this may help to decrease the preventable morbidity and mortality rates among African American adolescent males and continue to have a positive influence on their health in adulthood.
Acknowledgments
We thank the administrators and participants at the study sites for their support and cooperation.
References
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