Description
You have been tasked with reading and critiquing a peer-reviewed journal article. You may choose only ONE article from the attachments above. You have a choice of a semi-quantitative, mixed methods, or qualitative research study. Limit your critique to no more than three double-spaced pages. Again, don’t forget to properly cite and list your article (and any other sources) in APA format. Please, follow the criteria below.
A. Intoduction
After you read the article (critically), include an introductory paragraph to inform the reviewer of:
The author’s name(s), the title of the article, publication year, and the journal information (name, volume, issue)
The author’s main point(s)
A thesis statement to give a preview of your own analysis
B. Summary (15 points)
After your introduction, discuss the following (in your own words):
The main points of the article
The author’s arguments presented in the article
The research findings presented in the article
C. Critique (25 points)
After summarizing the article, it is now your chance to critique the article as follows:
Discuss the strengths and weaknesses of the article, which you should’ve noted during your critical reading.
State your informed opinions (using specific examples from the article to support your statements) about:
1) The clarity of the research design
2) Relevancy of the research methods
3) Accuracy of data collection
D. Conclusion (15 points)
Finally, wrap up your critique with a concluding segment to accomplish the following:
Summarize the key points presented by both— the author(s) in the article and yourself in your analysis thus far.
Close the conclusion with a comment about the significance of this research, as well as include a statement about whether there is need of future research in the field.
E. References (5 points)
Cite and list your sources in APA format
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697439
research-article2017
JPCXXX10.1177/2150131917697439Journal of Primary Care & Community HealthArpey et al
Pilot Studies
How Socioeconomic Status Affects
Patient Perceptions of Health Care:
A Qualitative Study
Journal of Primary Care & Community Health
2017, Vol. 8(3) 169–175
© The Author(s) 2017
Reprints and permissions:
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https://doi.org/10.1177/2150131917697439
DOI: 10.1177/2150131917697439
journals.sagepub.com/home/jpc
Nicholas C. Arpey1, Anne H. Gaglioti2, and Marcy E. Rosenbaum1
Abstract
Introduction: Clinician perceptions of patients with low socioeconomic status (SES) have been shown to affect clinical
decision making and health care delivery in this group. However, it is unknown how and if low SES patients perceive
clinician bias might affect their health care. Methods: In-depth interviews with 80 enrollees in a state Medicaid program
were analyzed to identify recurrent themes in their perceptions of care. Results: Most subjects perceived that their SES
affected their health care. Common themes included treatment provided, access to care, and patient-provider interaction.
Discussion: This study highlights complex perceptions patients have around how SES affects their health care. These
results offer opportunities to reduce health care disparities through better understanding of their impact on the individual
patient-provider relationship. This work may inform interventions that promote health equity via a multifaceted approach,
which targets both providers and the health care system as a whole.
Keywords
low socioeconomic status, patient perceptions, health care disparities, qualitative methods, primary care
There is evidence that socioeconomic status (SES) affects
individual’s health outcomes and the health care they
receive.1-18 People of lower SES are more likely to have
worse self-reported health,5,6 lower life expectancy,7 and
suffer from more chronic conditions8-11 when compared with
those of higher SES. They also receive fewer diagnostic tests
and medications for many chronic diseases12-17 and have
limited access to health care due to cost and coverage.18
Compared with other patients, physicians are less likely to
perceive low SES patients as intelligent, independent, responsible, or rational and believe that they are less likely to comply with medical advice and return for follow-up visits.19,20
These physician perceptions have been shown to impact physicians’ clinical decisions.21-23 Physicians delay diagnostic
testing, prescribe more generic medications, and avoid referral to specialty care for their patients of low SES versus other
patients. Some physicians believe that tailoring care options
to a patient’s socioeconomic circumstances can improve
patient compliance and thereby improve health outcomes.22
However, other studies have shown that physicians believe
that the financial and coverage restrictions faced by low SES
patients limit access to care and results in worse health outcomes for these patients.22,23 There are also some physicians
who do not care for patients of lower SES with publicly
financed insurance due to low reimbursement rates.24-26
While this body of work has improved our understanding of the impact of SES on physicians’ perceptions and
practices, there has been little investigation into the perceptions of low SES patients regarding how their SES affects
the care they receive. Many studies have shown that individuals of lower SES tend to be less satisfied with their care
and face substantial barriers including lack of insurance
coverage and unaffordable costs.27-30 Few studies have
investigated whether patients of low SES are aware of the
attitudes and practices physicians have been shown to have
when caring for low SES patients, and how such perceptions affect the way low SES patients interact with the
health care system and their providers. The purpose of this
study was to determine if and how individuals of lower SES
perceive their care is affected by SES.
1
University of Iowa Carver College of Medicine, Iowa City, IA, USA
National Center for Primary Care, Morehouse School of Medicine,
Atlanta, GA, USA
2
Corresponding Author:
Marcy E. Rosenbaum, Office of Consultation and Research in Medical
Education, 1204 MEB, University of Iowa Carver College of Medicine,
Iowa City, IA, 52242, USA.
Email: marcy-rosenbaum@uiowa.edu
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons AttributionNonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open
Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
170
Journal of Primary Care & Community Health 8(3)
Methods
Table 1. Subject Characteristics (N = 80).
Using public insurance as a proxy for SES, patients were
recruited to participate in in-depth interviews at the
University of Iowa Hospital and Clinics (UIHC) over 2 different 3-month periods in 2013 and 2014. Two different
methods were used for patient enrollment: (1) In 2013, all
scheduled patients from a clinic devoted to patients enrolled
in a state Medicaid program financed through a 1115 waiver
from Centers for Medicare and Medicaid Services were
invited to participate in interviews. Approximately 90% of
the enrollees in this state Medicaid expansion program were
living below 100% of the federal poverty level in 2012
compared with a statewide poverty rate of 12.8%.31-33 (2) In
2014, after statewide Medicaid expansion through the
Affordable Care Act, patients with publicly financed insurance could receive care at a variety of primary care practices throughout the state and were no longer required to
obtain care through specifically assigned practices.34,35
Thus, all patients with publicly financed insurance being
seen in the main Family Medicine outpatient clinic at UIHC
were identified and invited to participate.
The interviews were conducted by a single research
assistant trained in qualitative interviewing techniques.
Each interview began with asking patients to share their
health care experiences in general and was followed by
more specific questions related to health care experiences
and SES; a full interview guide is available on request. This
study was approved by the institutional review board at the
University of Iowa.
The interviews were audio-recorded, transcribed verbatim, and entered into an NVivo10 database,36 for systematic
coding and searching of narrative data. Using the “editing
style” approach described by Miller and Crabtree,37 all
members of the research team read transcript samples and
independently identified key concepts. After comparison, a
preliminary coding scheme was developed, which was then
applied to all transcripts. Research team members coded a
sample of transcripts and compared codes in order to generate a more final coding scheme to be applied to all transcripts and to identify salient, consistently occurring themes
of patient perceptions.
Female, n
Age range, years
Race, n
White
African American/Black
Other
Education, n
Some high school
High school graduate
Some college
College graduate
Marital status, n
Single
Married
Divorced
Widowed
Separated
Employment, n
Employed
Self-employed
Homemaker
Looking for work
Not looking for work
Retired
Unable to work
Previous insurance, n
Length of time on public insurance, n
1 year
Health quality, n
Poor
Fair
Good
Excellent
Results
Complex Perceptions of Care
Subjects (N = 80) included 47 women, 9 patients from
minority racial backgrounds, and 50 patients who had private insurance previously (see Table 1). This level of racial
diversity is reflective of Iowa’s statewide demographics.38
In addition, a majority of subjects had been enrolled in the
program for over a year.
The main finding of this study was that most subjects
perceived that their SES did affect their health care experiences, though they varied in how they experienced the
The majority of subjects resisted directly stating that their
SES influenced their care. While many of them said directly
that there was no difference between the health care they
receive and the health care higher SES patients receive, most
of these subjects later indirectly implied that there was a difference. For example, one subject said, “I don’t feel as if my
private insurance made a difference from my cheap insurance. They don’t treat me any different.” However, later in
the same interview, this subject said, “You don’t get as many
47
21-63
70
7
3
10
27
31
12
27
26
20
5
2
26
8
5
15
7
2
17
50
7
10
21
42
9
37
30
2
impact. We identified 3 main themes representing the range
of patient perceptions of how SES affects health care: (1)
treatment provided, (2) access to care, and (3) patient-provider interactions (see Table 2).
171
Arpey et al
Table 2. Themes of Patient Perceptions and Example Quotes.
Theme 1: Impact on treatment provided
Limited coverage for testing
Long waiting times for testing
Brand name vs generic
Less unnecessary testing or
expensive medications
“I’ve had things where the insurance company wouldn’t cover it so I’ve had doctors work
around it to still help me get what I need but then there’s some doctors that say, ‘well
your insurance company won’t cover it, so we can’t do it’. In those cases, there may be
things going on that they don’t discover because they aren’t running the proper tests.”
“With certain insurance companies, if you got like a first-class insurance company, you’ll
get in anywhere like that. But like if you got anything other than first-class insurance, then
it’s gonna take a minute . . . I’ve been having to wait 3 or 4 months (for tests). If I had the
right insurance, I would have been able to take those tests right away.”
“They say there’s no difference between regular medication and generic medication but
there is. If I’m on low income, I get the low-grade medicine, not the stuff that probably
could really work.”
“When I had private insurance, it seemed like there were an awful lot of tests done. I’m
not sure all of them were absolutely critical.”
“I like when they’re willing to look at generics and samples and that type of thing. They
don’t wanna add more stress because that just impacts health in a huge way.”
Theme 2: Impact on access to care
Cost barriers
“Deciding whether or not you need to go see a doctor when you are sick if you don’t have
insurance is the hardest decision. I face that every day. Do I go? Do I not? What’s the bill
gonna be like?”
Time barriers
“It’s the length of time it takes to get an appointment here. Sometimes it can take 3 or
4 months. That’s why a lot of times if I have something, I have to go to the emergency
room because I couldn’t get in.”
Acceptance barriers
“The problem has always been trying to find someone to accept the [public] insurance
health care. It’s like, okay, Dr. Smith will take it but Dr. Jones won’t and now I need to
find a certain type of doctor or specialist that takes that insurance.”
“With private insurance, we had to pay the deductible of course, but we were free to choose
where we wanted to go…We were free to choose everything and now we’re not.”
Thankful for access to care
“I am just grateful to have it. Even if there are restrictions, at least you’re taken care of.
People like me wouldn’t be getting medical care if it didn’t exist”
Theme 3: Impact on patient-provider interaction
Provider attitude toward patients
“Oh yeah they know [about my SES] but they don’t ask about it. I’m sure but they don’t
treat you any different. I figure they’re in the field because they want to help people”
“If you go in there and you got lots and lots of money, their attitude toward you is a lot
different than if you go in there and you’re low income”
Provider knowledge of patient
“They know what’s covered and what’s not and they decide what they need to do…I don’t
coverage
think it means I’m getting less care…I think it just affects it as far as they know what will
be covered and what won’t. And they try to make sure it’s covered.”
Provider communication
“They talk to you like you’re not a doctor which they need to do because we’re not
doctors. They talk to you in terms that you would understand without making you feel
like you are beneath them.”
“I don’t think the doctors listen to you the same as if you were a paying customer or if you
had different insurance. It’s like you say something and they just kinda skip over it and
ignore you.”
tests as you do when it’s private so I’m still working off the
same x-rays from last year.” In some instances, subjects said
that SES affects health care for many individuals but not for
them, since they were experienced with the health care system and determined to not be treated differently.
Impact on Treatment Provided
Most subjects reported that their SES had some impact on
the treatment they received. Examples of this included perceptions that SES influenced the number, type, and
scheduling of diagnostic tests that physicians performed.
Because of high costs (eg, magnetic resonance imaging),
subjects thought that the testing they were eligible for was
limited; this was interpreted as reducing the amount of diagnostic information available to their provider. Subjects also
perceived that their SES lengthened the time required for
these tests to be approved, which slowed diagnosis and
treatment. Similarly, many subjects perceived that their
SES affected the types of medications that physicians prescribed. While many thought that generic medications were
equal in quality to brand-name medications, there were
172
several patients who thought that generic alternatives were
less effective and did not like when physicians prescribed
them.
In contrast, some subjects felt that the difference in testing and medications actually improved the quality of health
care they received since under private insurance they felt
they received unnecessary testing and expensive brandname medications. A few even asked their physicians to
prescribe generic medications and limit testing.
Impact on Access to Care
Though some subjects indicated that they faced no cost,
time, or distance barriers to access, a majority of subjects
thought that their access to care was worse as a result of
their SES. Many subjects described situations in which they
delayed or avoided seeking care because of cost, which
typically only resulted in worsening of their conditions and
an even more expensive hospital visit.
Subjects also described the challenges they faced in finding providers who were able and/or willing to care for them.
The limited number of physicians and hospitals treating
patients of low SES indirectly created distance and time
barriers, which discouraged them even further from seeking
care initially. Patients at times had to drive over an hour to
find hospitals that would treat them and some had to wait
several months to get an appointment with a primary care
provider. These barriers made it especially difficult for
those who could not afford to pay for gas, lacked reliable
transportation, or required emergency treatment. However,
despite these sentiments, many subjects also expressed how
grateful they were that they had access to care at all.
Impact on Patient-Provider Interaction
While almost all subjects indicated that their physicians
were aware of their SES, they differed on whether or not
that knowledge affected how their physicians cared for
them. Many subjects perceived that their SES had no impact
on the way they were viewed and treated by their physicians
and that they had a good relationship with their provider.
For example, subjects appreciated that their physicians
understood the economic constraints and were knowledgeable about what was covered under the publicly financed
program. In terms of communication, subjects thought that
their providers explained things thoroughly and answered
all their questions; they appreciated how doctors tailored
communication to meet their personal needs.
In contrast, some subjects perceived that physicians
viewed and treated them differently because of their SES.
Frequently reported differences in patient-provider communication included situations in which providers did not listen to what they were saying or answer their questions.
Subjects used a variety of negative words and phrases to
Journal of Primary Care & Community Health 8(3)
describe how they perceived their doctor viewed and treated
them because of their SES, including: a customer, on the
back burner, bottom feeder, bum, another cog in the wheel,
dollar bill, leech, livestock, a number on a file, peasant, and
scum. Whether or not providers actually viewed and treated
these patients in such a manner, subjects noted this perception caused them to feel ashamed of themselves and hesitant
to return for care.
Discussion
Most subjects within our sample believed that their SES
influenced the health care they received. The complex
answers subjects gave to these questions suggests that while
our subjects were able to acknowledge that SES influences
health care for patients in general, many had difficulty
expressing or were reluctant to say that their own personal
health care or providers’ perceptions of them may be inferior because of their SES. This mirrors the findings in the
physician studies; while physicians do as a group perceive
and treat low SES patients differently than those of high
SES,19-23 it may be difficult to identify themselves as contributing to such disparities as they are often unaware of
their own implicit biases.39-41
Subjects described several aspects of their health
care—treatment provided, access to care, and patientprovider interaction—which they perceived to be affected
by their SES. While in some instances, differences in
these aspects, such as fewer tests performed and expensive medications prescribed, improved subjects’ perceptions of the quality of health care they received, the
majority perceived that these differences worsened the
quality of health care they received and contributed to
health care disparities.
Patients’ perceptions that such differences in care exist
due to SES can potentially contribute to health care disparities. Whether or not the limited number of diagnostic tests
and the longer length of time required for their approval
actually worsened health care quality, the perception that
their care was somehow inferior often caused them to lose
trust and confidence in the health care system or their provider. Similarly, whether or not generic substitutes are truly
less effective than brand-name medications, the perception
among these subjects that they are, in fact, inferior could
potentially worsen health care outcomes if it leads to noncompliance with the purchase or use of medications as prescribed. Likewise, the perception that physicians view
them as “second-class,” as described by subjects, could
worsen health care quality if it leads to lower likelihood of
disclosure of important issues or attendance at follow-up
appointments. Perceived health care disparities like the
ones mentioned above and those related to access in particular, even led some to avoid or delay seeking health care
altogether.
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Arpey et al
Consistent with previous studies that described low SES
patient perceptions of health care experiences, subjects in
our study described similar barriers to health care access
and areas of dissatisfaction with their health care. However,
instead of simply confirming the disparities that exist
between low and high SES individuals at the population
level, our study expands on the existing literature by exploring if and how low SES patients perceive this disparity to
affect their health care. Our findings suggest that subjects
are, in fact, conscious of the differences that exist between
them and high SES patients in terms of the care they receive
and can potentially exacerbate these disparities.
Advancing health equity for low SES patients will
require a multifaceted approach that targets both providers
and the health care system as a whole. Educating physicians
about the implicit biases they may have—and how patients
may perceive these biases affect their health care—could
help to reduce these disparities42-44 as it has been shown that
physicians change their clinical decisions when they
become aware of their unconscious bias.44 Regardless of
physicians’ attitudes toward individuals of low SES, providers should be aware of how patients perceive they are
treated based on SES, allowing for increased empathy with
patient’s experiences and identification of potential perceptual barriers to both satisfaction with and adherence to
effective health care management. Policies that increase
Medicaid reimbursement rates and induce more hospitals
and providers to accept patients with publicly financed
health insurance could also help reduce health care disparities. Many of the perceived access barriers that subjects
experienced in our study, including distance and time barriers, stemmed from the number of providers and hospitals
who did not accept patients with such insurance. Recently,
the Medicaid Parity provision of the Affordable Care Act
increased Medicaid reimbursement rates to at least Medicare
levels for 2013 and 2014 in all states with the goal of
increasing the number of providers who accept Medicaid
patients.45-47 It was thought that, by expanding this number,
patients would be able to seek health care closer to home,
reducing the travel costs and wait-times for primary care
appointments. One study found that the Medicaid Parity
provision increased primary care appointments by 7.7%
and that the states with the largest increases in availability
were those with the largest increases in reimbursements.47
Despite its effectiveness, the policy expired at the end of
2014 and was not extended.48
Limitations to this study include it being conducted with
a patient population in one geographic area, limiting its
generalizability to other settings and populations. Also, the
tendency to remember negative experiences more than positive experiences may have skewed patient responses to
interview questions and also affected those who chose to
participate in the study. Finally, the study was conducted
during a time period of many changes in health care
delivery and at 2 sites that differed in the types of coverage
that were accepted, the appearance of the clinic, the providers at the clinic, and the location of the clinic in the academic health center. These factors could potentially affect
how patients perceived their health care experiences and
further influence our results. Bias was limited by asking
participants not only about their current experiences but
also about their past experiences (including experiences at
other hospitals).
Areas for future research include investigating how
patient perceptions are affected by the severity and type of
medical condition for which they are receiving care. For
example, though we did not collect data on the purpose of
the subjects visit, several subjects in our sample felt that
their SES did not affect their health care because they did
not have a serious enough health condition for it to make a
difference. It is possible that perceptions might differ
between a low SES patient who is receiving care for a cold
when compared with a low SES patient who is receiving
care for cancer, for example. Comparing appointment
lengths under private and public insurance coverage and
exploring how differences affect patient perceptions might
also be interesting.
Our findings identify a range of patients’ perceptions
regarding their SES and health care experiences. Most
subjects perceived that the treatment provided by their
physicians, access to health care, and the relationship they
had with their provider were affected by their SES, though
they often avoided saying so directly. Reducing and eliminating health care disparities is a complex, multifactorial
endeavor that will require complex solutions, but increasing physician awareness of implicit biases, patients’ perspective and experiences, and improving access to care
through the expansion of Medicaid and related programs
may be beneficial in advancing equity and patient perceptions of equitable treatment. Further investigation into
how patient perceptions of physician bias impact care of
low SES populations that have received health care coverage due to the Affordable Care Act will be helpful informing these questions.
Authors’ Note
The views and findings discussed in this article are solely those of
the authors and not the University of Iowa.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
174
study was funded through the Carver College of Medicine Iowa
Medical Research Fund.
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Author Biographies
Nicholas C. Arpey, BA, is a third-year medical student at the
University of Iowa Carv
