Purvi PatelJD/MPH Class of 2010Tufts University School of MedicineDepartment of Public Health & Professional DegreesMaster...
IRB exemption was sought and granted because analysis consisted of evaluating de-identifiedqualitative data from focus gro...
Problem AnalysisLewis & Clark County, home to Montana state capital Helena, hosts 60,925 residents,121% ofwhom currently l...
Human Rights Network (MHRN) and NESRI to better understand the needs of county residentsthrough a health needs assessment....
Using a Human Rights Framework of AnalysisInitial drafting of the focus group protocol used basic tenets of a human rights...
that affect their health, including in the organization and implementation of health careservices. Accountability: Privat...
Residency Status(Unknowns excluded) number percentageUS-born Citz. 45 98%Naturalized Citz. 1 2%Immigrant 0 0%Race/Ethnicit...
“Some of the doctors, that are listed in the yellow pages, they’re full. I’ve been having trouble finding a familydoctor b...
patients go out-of-county or out-of-network for services, the latter resulting in the patient having topay out of pocket f...
cases of extreme emergency. Because of the expense, participants reported forgoing care or waitingto get care until they c...
Acceptability & Dignity in TreatmentSome respondents, particularly low-income participants, expressed concern about being ...
a middle ground of “moderate” guidance by thegovernment in healthcare matters. Participants didgenerally agree that childr...
comments, the role of the hospital in the community would need to be improved with someurgency.LimitationsThe fact that we...
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Qualitative Research on Health as a Human Right in Lewis & Clark County, Montana

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The findings and final work product [abridged] of my Applied Learning Experience Presentation (ALE), the thesis requirement for my Masters of Public Health degree. The National Economic and Social Rights Initiative (NESRI) served as the host organization for my project.

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Qualitative Research on Health as a Human Right in Lewis & Clark County, Montana

  1. 1. Purvi PatelJD/MPH Class of 2010Tufts University School of MedicineDepartment of Public Health & Professional DegreesMaster of Public HealthApplied Learning Experience (ALE)Project Title: Implementing a Human Right to Healthcare: A Qualitative Case Study in Lewis &Clark County, Montana.Project Site: National Economic & Social Rights InitiativePreceptor: Anja Rudiger, Human Right to Health Program DirectorCommunity Presentation: available at http://www.slideshare.net/patelpurvip/qualitative-research-on-health-as-a-human-right-in-lewis-clark-county-montanaAbstractLewis & Clark County, Montana is home to approximately 60,000 Montana residents, many ofthem concentrated in a few small towns, such as Helena (the state capital), Augusta, and Lincoln.The best available data indicated that 21% of county residents live without health insurance.Furthermore, residents without health insurance experience serious lack of access to healthcare,factors that contribute to serious health problems such as increased risk of dying from cancer,serious complications and worse clinical outcomes for chronic diseases like diabetes, cardiovasculardisease, and mental illness. On December 4, 2008, the Lewis & Clark County Board passed aresolution declaring health and healthcare to be a human right for all of its county residents, andcreating a task force charged with conducting a countywide health needs assessment to investigateways to implement the new mandate.To assist with the county’s health needs assessment, this project (working with NESRI) soughtto evaluate qualitative focus group data gathered from Lewis & Clark county residents regardingcurrent access to healthcare, quality of services, and barriers to receiving or seeking care, as well asopinions on the notion of health and health care as a human right. Qualitative research wasconducted by NESRI and the Montana Human Rights Network (MHRN) through eight focus groupsin four towns within Lewis & Clark County between mid-August and early-November 2009.Groups ranged in size from two to fourteen participants, with a total of 47 participants. Focusgroups sought:1. To identify how sample populations (rural, uninsured, underinsured, etc.) use healthservices;2. To identify barriers to accessing health care;3. To identify unmet health needs;4. To solicit recommendations on what measures the county should take to move towarduniversal access; and5. To obtain feedback on the Board of Health’s resolution
  2. 2. IRB exemption was sought and granted because analysis consisted of evaluating de-identifiedqualitative data from focus group transcripts. Group-by-group demographics were gathered throughthe use of participant monitoring forms, and aggregated to provide an overall picture of researchdemographics for the project. Over half of focus group participants were between the ages of 45-64years; none of the participants fell between 35-44 years-old, which was seen as a short coming inthe sample groups researchers were able to recruit. Education level was fairly well distributedamong participants, however about two-thirds or participants had $50,000 of income per year orless. Almost two-thirds of participants depended on employer-sponsored or governments-sponsored(i.e. Medicare or Medicaid) plans for health insurance; around one quarter of participants wereuninsured.Qualitative data was analyzed according to a human right to health framework, looking atthemes of access to care (costs and financing), availability of services, quality of care, and dignity intreatment. Participants of all groups except one (Augusta) were also asked to discuss whether theybelieve health and healthcare to be a human right. Participants offered a range of suggestions forthe county in the areas of expanding health care services, particularly primary care, improving carecoordination, improving the navigability of the health system, improving transportation, andexpanding financing options. Based on these findings, we drafted preliminary recommendations forreform to the Lewis & Clark County Health Task Force.
  3. 3. Problem AnalysisLewis & Clark County, home to Montana state capital Helena, hosts 60,925 residents,121% ofwhom currently live without health insurance – which amounts to thousands of individuals.2In2006, it was estimated that 12% of the Montana adult population in general was unable to visit adoctor due to cost.3Such data suggest serious complications and worse clinical outcomes forchronic diseases like diabetes, cardiovascular disease, and mental illness.4Montana is also rankedhighest in the country in the number of completed suicides.5In Lewis & Clark County specifically: Almost 29% of people in Lewis and Clark County live below 200% of the federal povertylevel (FPL) 21% lack health insurance 7% are on Medicaid 54% of Community Health Center clients were uninsured in 20046As the 2008-09 debate over national healthcare reform grew increasingly contentious, manystate and local governments increasingly felt compelled to respond to the health needs of theirresidents. Based on statistics such as those above, and in the shadow of the ongoing debate overhealth reform, and the fierce arguments over a potential national pubic health insurance option, theHealth Board of Lewis & Clark County in Montana approved a resolution in early December 2008recognizing a “basic human right” to healthcare for all of its residents7.To comply with the new county health care resolution, the Lewis & County Clark CountyHealth Board created a locally-grounded Task Force on local Access to Universal Healthcarecharged with assessing the health care needs in the county, and to make recommendations aboutimplementing the new healthcare mandate. The Task Force is currently developing an action planfor providing access to universal health care in Lewis and Clark County and moving toward auniversal, equitable system. To this end, the Task Force is expected to produce a final report of itsrecommendations by March 2010. Based on the task force’s recommendations, the county HealthBoard will then try to design some a plan or system that provides universal health care for the area.8In the words of one Helena city commissioner and Health Board member, “[the Board] said, ‘Let’ssee what we can do to change the debate, and maybe end up with some solutions that we don’t evenknow exist at this point.’ ”9Description of the Agency and Partners: NESRI & the Montana Human Rights NetworkAs an initial step, the L&C county health Task Force sought the assistance of the Montana1Lewis & Clark County population statistics, 2008. Available at: http://quickfacts.census.gov/qfd/states/30/30049.html.2Mike Dennison, City-County Health Board proposes universal health care. IR State Bureau, HelenaIR.com, Dec 12, 2008.3Lewis & Clark County, 2009 Leading Public Health Indicators, Lewis & Clark City-County Health Department, 13.4Draft resolution available at www.nesri.org/.../Local_Universal_Healthcare_Resolution_Final_December.pdf.5Lewis & Clark County, 2009 Leading Public Health Indicators, , 12.6Health and Health Care in Lewis & Clark County: An Initial Data Review. Human Right to Health Program, NESRI / NHeLP, 18.7Dennison8Dennison.9Dennison.
  4. 4. Human Rights Network (MHRN) and NESRI to better understand the needs of county residentsthrough a health needs assessment.National Economic and Human Rights InitiativeThe National Economic and Social Rights Initiative (NESRI) promotes a human rights visionfor the United States that ensures dignity and access to the basic resources needed for humandevelopment and civic participation. Towards this end, NESRI works with organizers, policyadvocates and legal organizations to incorporate a human rights perspective into their work andbuild human rights advocacy models tailored for the United States. NESRI takes a partnershipapproach to building a human rights culture in the United States, and prioritizes partnerships at thecommunity level.Preceptor: Anja Rudiger (NESRI)Anja Rudiger is the Director of the Human Right to Health Program, a joint program run byNESRI and the National Health Law Program. Ms. Rudiger works with state-based coalitions todevelop human rights approaches and tools for health care reform efforts. She is an expert onhuman rights and equality, specializing in policy analysis of disparities in the exercise of civic,economic and social rights. She has extensive experience integrating a rights-based approach topolicymaking at local, national and international level. Previously, Ms. Rudiger carried outconsultancies for governmental and non-governmental organizations, led the research department atthe British Refugee Council in London, and managed the UK Secretariat of the EuropeanMonitoring Centre on Racism and Xenophobia. She received her Ph.D. in Political Science fromthe University of Kiel in Germany.Collaborators: Montana Human Rights NetworkBased in Helena, the Montana Human Rights Network (MHRN) is a grassroots, membership-based organization of over 1400 members. MHRN’s mission is two-fold: 1) To promotedemocratic values such as pluralism, equality and justice; challenge bigotry and intolerance; andorganize communities to speak out in support of democratic principles and institutions; and 2) Tochallenge hate groups and other extremists who use violence and intimidation as tools for politicalactivism.MethodologyTo implement a countywide health needs assessment, the partner agencies began consultingwith community members and collecting their suggestions for improving access to care. Based onthe belief that community members’ health needs and ideas for improvement can best be exploredthrough qualitative and participatory research, the Task Force and its partners decided to implementuse of a qualitative research component to the assessment through focus groups with communitymembers. Through focus groups, the Task Force hoped to be able to get useful in-depth informationon barriers to access, diagnose specific issues that need to be addressed, gain views on potentialimprovements, and build awareness and support within the community for the planning phase ofproject.[rest of Methods section truncated]
  5. 5. Using a Human Rights Framework of AnalysisInitial drafting of the focus group protocol used basic tenets of a human rights framework toguide the questions asked of participants. The human rights framework protects civil, political,economic, social and cultural rights. Each right recognized under this framework adheres to basicprincipals that are always part of human rights standards and implementation. These principalsinclude universality, indivisibility, participation, accountability, transparency, and non-discrimination.Data gathered from the focus groups was analyzed under a human right to health framework,which assumes that the purpose of a health care system is to protect health of each member ofsociety. As such, its design must be guided by the following key human rights standards: Universal access: Access to health care must be universal, guaranteed for all on an equitablebasis. Health care must be affordable and comprehensive for everyone, and physicallyaccessible where and when needed.o Affordability: Health care must be affordable for everyone, with charges based on theability to pay, regardless of how health care delivery is financedo Equity: Health care must be distributed equitably, with resources allocated and usedaccording to needs and health risks.o Comprehensiveness: Health care must include all screening, treatments, therapiesand drugs needed to preserve and restore health, including reproductive health. Availability: Adequate health care infrastructure (e.g. hospitals, community health facilities,trained health care professionals), goods (e.g. drugs, equipment) and services (e.g. primarycare, mental health) must be available in all geographical areas and to all communities. Acceptability and Dignity: Health care institutions and providers must respect dignity,provide culturally appropriate care, be responsive to needs based on gender, age, culture,language, and different ways of life and abilities. They must respect medical ethics andprotect confidentiality. Quality: All health care must be medically appropriate and of good quality, guided byquality standards and control mechanisms, and provided in a timely, safe, and patient-centered manner.The following principles, which apply to all human rights, are also essential elements of a healthcare system: Non-discrimination: Health care must be accessible and provided without discrimination (inintent or effect) based on health status, race, ethnicity, age, sex, sexuality, disability,language, religion, national origin, income, or social status Information and Transparency: Health information must be easily accessible for everyone,enabling people to protect their health and claim quality health services. Institutions thatorganize, finance or deliver health care must operate transparently. Participation: Individuals and communities must be able to take an active role in decisions
  6. 6. that affect their health, including in the organization and implementation of health careservices. Accountability: Private companies and public agencies must be held accountable forprotecting the right to health care through enforceable standards, regulations, andindependent compliance monitoring.Results: Participant DemographicsOf the 47 participants, across eight focus groups, over half (57.1%) were between 45-64 yearsof age. Not a single participant fell into the 35-44 years-old range, reflecting a gap in our samplingpool. Participants’ education levels were considerable more varied. Three quarters of participantswho responded about their education level had either a high school diploma, an associates degree,or a bachelors degree. An additional 20% of responding participants had obtained a graduatedegree, while 5% had not finished high school.Over two-thirds (almost 70%) of participants made incomes of $50,000 or less. In 16 of thosecases (41%) cases, participants made less than $15,000 per year. Of those who had health careinsurance at the time of the focus group, about 37% had employer based insurance, while over 39%had government sponsored program (i.e. Medicare and Medicaid, excluding coverage through theDepartment of Veterans Affairs). About one quarter of participants (24) were uninsured.Racial or ethnic discrimination was not a big issue. The vast majority of participants identifiedas US-born Caucasians, with two of the participants identifying as Native American, and onedefining as a naturalized America citizen from China. As a result, racial or ethnic/discriminationwas not as much of a concern as economic disparities between participants.Groups Conducted (8 groups, 47 Participants)Group Date # ParticipantsExperts 8/17/09 3YWCA 8/17/09 7Canyon Creek 8/19/09 2Lincoln 1 8/20/09 2Augusta 8/25/09 13FoodShare 10/13/09 10Lincoln 2 10/14/09 3Helena 4 11/5/09 7Gender PercentagesMale Female40% 60%
  7. 7. Residency Status(Unknowns excluded) number percentageUS-born Citz. 45 98%Naturalized Citz. 1 2%Immigrant 0 0%Race/Ethnicity number percentageWhite 45 96%American Indian/Alaskan Native2 4%Education no HS DiplomaHS/GEDAssociatesBachelorsGraduateEducation Level(Unknowns excluded) number percentageno HS Diploma 2 5%HS/GED 14 34%Associates 4 10%Bachelors 13 32%Graduate 8 20%Income< $20,000$20,000 - $49,999$50,000 - $100,000$100K+HouseholdIn come(Unknowns excluded) number percentage< $20,000 16 41%$20,000 - $49,999 11 28%$50,000 - $100,000 9 23%$100K+ 3 8%Average Age = 52.0 years-old(Unknowns excluded)Age Range number percentage18-24 years 2 5%25-34 years 5 12%35-44 years 0 0%45-54 years 11 26%55-64 years 13 31%65+ years 11 26%Health Insurance StatusUninsuredEmployer-basedGov-sponsoredIndividualOther (e.g. VA,parents)NOTE: some participants had more than one source of insuranceInsurance Status(Unknowns excluded) number percentageUninsured 11 24%Employer-based 17 37%Gov-sponsored 14 30%Individual 6 13%Other (e.g. VA, parents) 5 11%
  8. 8. “Some of the doctors, that are listed in the yellow pages, they’re full. I’ve been having trouble finding a familydoctor because I was going to one, but I can’t see him anymore. I’m trying to find a new one, but the people thatpeople have been referring me to, they’re full so they won’t take any more. And I stopped looking, but I’ve hadthat happen a few times.”YWCA Focus GroupResults: Key FindingsGENERAL OVERVIEWAvailability of health care– lower income residents generally felt there was a shortage of serviceproviders in the county. Rural residents felt this particularly acutely. Low income residents also haddifficulty finding health care providers. Higher income residents experienced fewer problems withfinding service providers, with the possible exception of in-county mental health services.Access (Cost) – Most participants, particularlylow-income and middle-income residents haveexperienced difficulty finding insurance, using theinsurance they have, or paying out of pocket.Quality – There were many positive statementsregarding quality of care, particularly regarding the Lincoln Clinic. However, across the board therewere serious quality concerns, about aspects of care, particularly related to St Peter’s Hospital.Acceptability/Dignity –Concerns about dignity during provision of service were raised by low-income residents – particularly the uninsured and those on Medicaid – as well as residents seekinglong-term mental health care.Health Care as a Human Right –The majority of participants did consider health care to be ahuman right. Several others emphasized ethical obligations to meet health care needs, but did notfeel comfortable expressing that in human rights terms. Many participants stressed that to have ahealthy community, the government or community needed to help everybody to be healthy.Suggestions for reform – participants offered a range of suggestions in the areas of expandinghealth services, improving care coordination, improving navigability, etc.DiscussionAvailability of ServicesAvailability of health services in Lewis and Clark County can be poor. Availability of primarycare to local residents is impeded by a shortage of primary care providers, as well as a lack of off-peak office hours during which patients can make appointments without conflicting with their workschedules. Residents also noted a shortage of specialists, particularly quality dental care for low-income residents as well as mental health providers in general. Referrals to specialists often require“The cost of medical care is probably thenumber one thing preventing anyone fromgoing to the doctor”Augusta Focus Group
  9. 9. patients go out-of-county or out-of-network for services, the latter resulting in the patient having topay out of pocket for care.Physicians working within the current health care model are required to operate as businesses.Because their financial survival depends upon making smart business decisions, health careprofessionals may only open practices in areas that promise large populations to care for and thepotential to recruit and retain staff. Consequently, rural populations will lack local services, and willconsequently have to travel great distances to find available care. This can also be a particularproblem for low-income patients because, working within a market model, health care professionalsmay only take patients with insurance, may restrict the number of publically-insured patients thatthey care for, or may not accept Medicare or Medicaid patients altogether.There is also poor availability of transportation options to get rural residents and the elderly – otherthan private transportation or dependence on family and friends. The ambulance service in Helenais too expensive for many residence, although residents in Lincoln and Augusta praised the serviceprovided local volunteer ambulances. Issues of transportation go hand in hand with geographicisolation from medical facilities, especially for the elderly and northern county residents.The structure of the current system and its many different forms of administration means thateach person, depending on their insurance (or lack of insurance), requires a different set ofinformation in order for them to successfully navigate the health system. Patients often do not knowwhere to go to get the information they particularly need in order to access the available healthservices that they can personally afford. Information about ways to obtain cheaper medication orinsurance is also difficult to come by, and prices for services may not be uniform in differentlocations, making it difficult for patients to determine whether or not they are getting the best deal.Thus, availability can be restricted financially, physically, and through a lack of knowledge of whatis available. Lastly, children and teenagers may face additional barriers such that, even if they doknow where to get the services they need, they may not feel comfortable with telling their parentsabout their health needs, or might have parents who wish for their children not to seek services.Access: Cost & FinancingAlmost all respondents felt that health care and health insurance was too expensive, and manyresidents had (at some point) chosen to forgo health insurance or healthcare, or both, due tofinancial considerations. In some cases, uninsured individuals were uninsured simply because of acalculated decision that insurance was too expensive to be worth purchasing. As a market good,access to health care is based on a person’s ability to pay for it, but there is overwhelming evidencethat market mechanisms fail to provide equal access to health care.Although most respondents had insurance, manyhad very meager plans with high deductibles thatprecluded them from using their insurance to obtainneeded care, instead reserving insurance for use only in“You know, I grew up pretty darn poor. And I remember 15 years of early marriage paying 5 or 10 dollars to awhole bunch of separate medical providers. And not being able to, I mean, it takes 15 years to pay off something.Well that’s going on all over the country right now. And there’s a whole bunch of people that aren’t gettingservice at all. I mean that makes me sad.”2ndLincoln Focus Group“[I]f you don’t have money, then youdon’t have the right to care.”Helena 4 Focus Group
  10. 10. cases of extreme emergency. Because of the expense, participants reported forgoing care or waitingto get care until they can no longer avoid it. In some cases, people felt that it would be better forthem to die so that financial burdens on their families could be eased. When care was sought,information about bills was in several cases confusing or incomprehensible without assistance. Insome cases, bills contained errors that patients had difficulty getting corrected. Many respondentsfelt threatened by medical bills, did not feel supported by their insurer, and in some cases, fearedlegal repercussions on their finances.Government-sponsored insurance was generally seen as a positive option; however there wereproblems with its availability and administration. There was concern that people who neededgovernment-sponsored insurance but were not eligible (particularly poor people who made toomuch for Medicaid and retired individuals that were not yet old enough to qualify for Medicare).There was also concern that applying for the programs, particularly the Medicaid applicationprocess, was too difficult to navigate alone.Quality of CareThere were many services in Lewis and Clark County that garnered praise. However, suchcomments were overshadowed by many negative comments about quality of care received. Thequality of care at the Lincoln clinic, county WIC services, the Helena Foodshare, and volunteerambulance services especially were highly praised. Some concerns were related to the currentsystem’s rewards for the use of technology and pharmaceuticals rather than quality, appropriatecare. Repeated concerns over quality of care were raised regarding St. Peter’s Hospital in Helena,particularly for emergency care.Some, participants, particularly those without financial means, and those with specific healthconditions, felt judged, stigmatized, and treated badly in the local health care system. Theyattributed this to their inability to pay for their care, or a lack of proper understanding of their healthproblems. For example, participants raised multiple concerns over quality, patient-centered mentalhealth care tailored to what was appropriate for the individual patient.Participants also reported a lack of communication between providers in cases where they wereseeing multiple providers, both regarding patient care as well as valuable knowledge andinformation. This created frustration for patients, who may have been subjected to inefficient care.In some cases, participants stated or implied that service providers prioritized profitability at theexpense of quality care. When health care is viewed as a commodity to be bought and sold, low-income people that are unable to pay for their care may be seen to be taking advantage of thesystem, or receiving “charity”. The presence of this view was reflected, and particularly apparent, inprejudice by other participants against alleged “welfare” recipients (a term sometimes erroneouslyused to refer to anyone participating in a government-sponsored program) or “illegal” immigrants.“I was really in pain, and nobody came out in all this time to say ‘ok, is there anything we can do?’ … And I wasgetting madder and madder, but there wasn’t anything I could do about it because I couldn’t move. [He] gave me acouple of pills, and said I could take one or two of them, and said, ‘Alright, I’ll have the nurse get you a walker sothat you can get home alright.’ I have steps going up to my house, and my bathroom was upstairs, I live alone, andI told him this. And he said, you know, ‘I’d really like to admit you but I can’t.’”Taskforce Focus Group
  11. 11. Acceptability & Dignity in TreatmentSome respondents, particularly low-income participants, expressed concern about being treatedwith respect by health providers. Multiple participa9nts felt that doctors had been dismissive oftheir concerns, and in some cases, were made to feel that they had no right to express concerns overquality of care simply because they were not paying for the full cost of their care.There was also concern about mental health care, and particularly a lack of understandingamong county providers about differen mental health disorders (ex: understanding about PTSDamong medical providers outside the VA system). Patients reported being given excessivemedications, or not receiving adequate care such that when their condition worsened, they werereported to the police rather than mental health providers.Health and Healthcare as a Human Right?All but one of the focus groups were posed the question of whether they considered health careto be a human right, and the majority generally agreed that health care was a human right. Low-income participants, as well as Medicare and Medicaid beneficiaries overwhelmingly agreed onhealth and healthcare as a human right. Some participants qualified their agreement with a caveatthat healthcare went hand-in-hand a certain degree of personal responsibility to keep oneselfhealthy. Of those who stated that they did not believe healthcare to be a human right, participantsstill placed high importance on healthcare, and often associated the availability of healthcare withethical responsibility. For example, some participants qualified healthcare as a “human need” ratherthan a “human right.” When asked to explain the term “human need”, the explanation was couchedin human rights doctrine, suggesting that it was the terminology of “human right” that participantshesitated to use, rather than reservations about the concept itself.Participants were more split over the question of government involvement in providing residentswith healthcare. While many participants (especially Medicare beneficiaries) were in favor ofgovernment involvement in providing healthcare coverage, several other participants – especiallyrural participants – were resistant to the idea of government involvement. Some participants chose“I believe [health care] is a right, but it does come with responsibility, and thats the challenge for society, toimpress upon people what their basic responsibility is to each other, as a society what were all responsibleto each other here to do our best to be contributors to society, to be honest, to be good parents, goodfriends, you know its the community. Somehow we have to rise up better, I think, than we do."Lincoln 2 Focus Group“I went in Wednesday, pulled a tooth that was abscessed. I told them I needed antibiotics, and they saidno. I went back Friday as my face was even more swollen than it is now. He kind of laughed and said, “Well,I guess we should have started those antibiotics anyhow.” Then reminded me that I was getting the care forfree. … I’m going to get into a different dentist that will take payments because it broke one tooth, pullingone out, and I was reminded twice that I was getting the service for free.”YWCA Focus Group
  12. 12. a middle ground of “moderate” guidance by thegovernment in healthcare matters. Participants didgenerally agree that children should be covered byhealth insurance. For those who opposed governmentinvolvement, there was a general agreement that whereindividuals had difficulty taking care of themselves,the community should provide some assistance infilling the gap. Some participants voiced skepticismthat there was anything that could be done at thecounty-level to address their concerns, but there wassome hope that the county could maybe address sometransportation issues, improving funding for facilitieslike the cooperative health center, and engage with neighboring counties to better address the needsof residents on the borders. There was, however, a general agreement that some collectiveobligation exists to ensure access to health care for all, especially in order to have a healthycommunity. Most participants saw some role for either government or the local community to helpeverybody to be as healthy as possible.RecommendationsThe focus groups yielded a host of suggestions from participants about what needed to be donein order to improve health care for county residents, most of which centered on expanding existingservices, improving care-coordination, improving navigability of health services, and expanding orimproving financing options. While some suggestions referred to issues outside the county’sauthority, many others would require only minor changes. In many instances, participants did notreadily think of systemic changes and instead focused on specific improvements to make their usageof the system easier. Some participants, mainly from Augusta, voiced skepticism that there wasanything that could be done at the county level to address their concerns.Residents particularly pointed to a need to expand primary care services, especially for low-income and more rural patients. Suggestions included improving funding for satellite or travelingclinics to northern parts of the counties, and expanding office hours to include some options for off-peak hour appointments. There were multiple suggestions to improve the availability of children-centered services, both primary care and mental health services. Improved coordination of health-related information sharingwas a major issue raised in several contexts: disseminating healthservices information to residents, improving communication between providers, and coordinatingwith neighboring counties to ensure adequate services for northern county residents. Multiplesuggestions to improve transportation, particularly for the elderly, were also made.Among the recommendations that may need to be addressed at the state level are extendingeligibility for Medicaid, requiring employers to allow paid sick days, and addressing high costs ofcoverage and care. Some suggestions however could be easily implemented at the county level,starting with improving the availability of comprehensive, user-friendly information and adviceabout health services, for example through creating a health information center or an 800-number,and improving public transportation, particularly within Helena and between Lincoln and Helena.More systemic changes, however, are clearly needed and demanded. Expanding primary careservices, including dental care, through the Cooperative Health Center and satellites would fillcrucial gaps particularly for rural and lower-income communities. Finally, based on participants’“We’re human beings; it doesn’t matterwhether we make $7 an hour or six digitsa year. We’re humans and we all havesomething to offer. … Why can’t we getroom deserves excellent doctors andcaring, patient people. Why is ourincome a factor in that? I don’tunderstand that. So it should be a right,and it is very much about respect.”YWCA Focus Group
  13. 13. comments, the role of the hospital in the community would need to be improved with someurgency.LimitationsThe fact that we were not able recruitparticipants quite in the manner as we hadhoped to do under the sampling frameworkpresented a major limitation. Of the eightfocus groups held, four of them had eitheronly two or three participants, while twogroups had ten or more participants. Thusthe distribution of participants among focus groups was not as even as we would have liked.However, the larger groups were held outside of Helena, and while some of the Helena groups weresmaller, there were more groups conducted in Helena (4) than anywhere else. The other issues insample can be seen in the fact that none of our participants fell into the 35-44 years age group. Theaverage participant age was over 50 years-old, indicating a generally older set of participants.Aside from sampling limitations, there was also acknowledgement that uniformity in how eachof the groups was conducted might be difficult to ensure. This is due to the fact that while the firstfew focus groups were conducted with representatives from NESRI (trained in qualitative research),later groups were run solely by MHRN and Task Force representatives, who had been trained byNESRI but were themselves new and much less familiar with conducting qualitative research.ConclusionOverall, the participants and partner response tothe project seemed positive, and hopefully, the projectwill provide the county health Task Force with someideas for county-level improvements to the existingsystem. While the county might not have the funds to open a full clinic in August to serve northerncounty residents, a small satellite clinic or traveling services to the northern areas of the countymight fill some of the gap. Furthermore, although the county may not be able to require moreproviders to accept sliding-scale fees or payment plans, increased funding to the community healthcenter or a new similar facility would help increase the availability of primary care and dentalservices to low-income patients. The county also needs some way of monitoring respect issues –maybe setting up a forum for residents to voice concerns about care at local facilities, and possiblyaddressing concerns to a county health coordinator position if one is created.“We’re Medicare, and it’s wonderful. It’swonderful. I mean I wish everybody in thecountry had it.”2ndLincoln Focus Group“The group we did last week…it’s not a reflection ofthe entire community, but it’s a reflection of someparts of the community…”Researcher, about one focus group

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