Exploring Barriers to Primary Care Utilization in Transition-Age Males in Southern Connecticut

Young men with cell phones

Background

Optimus Health Care is a Joint Commission accredited and a federally qualified health center (FQHC) in Southern Connecticut, which serves thousands of male transition-age-youth per year. Attrition among males moving from pediatric to adult primary care is a nationally recognized issue.

Literature suggests that there are three key barriers to young men seeking care: (1) concerns about confidentiality; (2) embarrassment and discomfort about disclosing their concerns; and (3) concerns about cost and accessibility (location, limited open hours). Studies highlight the importance of examining demographic trends and establishing consensus among transition protocols.

This study seeks to assess the prevalence and magnitude of the young male attrition problem and evaluate transition services available to Optimus patients. This project will focus on the population of male transition age youth (TAY, 18-21 years old) who live within the Southern Connecticut areas (Bridgeport and Stamford) who move from pediatric to adult primary care at any one of Optimus Health Care’s locations.

Methods

Quantitative: used de-identified electronic medical records (EMRs) (n= 874) of male patients ages 16-23 at Optimus Health Care. Chi-square analyses were conducted to analyze the relationship between particular demographic factors and attrition.

Qualitative: in-depth interviews were conducted with community health workers employed by Optimus Health Care (n=4). These interviews utilized a guide that reflected initial quantitative analyses and the preliminary literature review findings.

Key Findings

  • Knowledge-based barriers include lack of information about resources available to them, such as how to obtain and manage their insurance. Or, a fundamental difficulty in understanding the importance of pursuing primary health care and preventive health services.
  • Institutional barriers include distance from the clinics and access to transportation. Others include those related to a lack of other basic needs, such as food, safety and housing. Worries about these resources and needs may overshadow their concerns about accessing healthcare.
>50% of those born outside of the United States stop receiving care at Optimus before 21.   A significant majority of those with high school or college education will stop receiving care at Optimus before 21.     A significant majority of those employed individuals and full-time students stop seeking care at Optimus before 21.

Conclusions and Recommendations

  • Slightly more U.S.-born TAY patients transitioned to adult care at Optimus (54.6%) than foreign-born TAY patients (47.0%), highlighting the importance of considering structural factors that may disproportionately affect youth of differing social and cultural backgrounds in urban centers.
  • Clinic hours and transportation availability may limit who is able to seek health care.
  • For patients residing in or near Bridgeport, the patient’s relationship with their PCP at Optimus and other factors such as knowledge about insurance processes and unmet basic needs may contribute to loss of male TAY patients.
  • Optimus can focus on:
    • Training to improve communication between providers and patients
    • Implementing a text message system for appointment reminders
    • Incentivizing male TAY adherence to care by addressing other TAY needs such as career skills building (i.e. resume development, career fairs, etc.)
    • Identifying non-medical high-risk patients

Limitations

  • Under-reporting of some variables, including % FPL, height/weight, level of education achieved, employment status
  • Community health worker interviews: social desirability may have affected their responses
  • Focus group discussion recruitment: unable to recruit participants

Acknowledgements:

We would like to thank Dr. Alix Pose, Justin Markowski, Nelly Angah, the Optimus Community Health Workers, the transition age youth patient population, and all other contributing members of the Optimus community for their assistance.

Key references:

Betz, Cecily L., Gay Redcay, and Sylvia Tan. “Self-Reported Health Care Self-Care Needs of Transition-Age Youth: A Pilot Study.” Issues in Comprehensive Pediatric Nursing 26, no. 3 (January 1, 2003): 159–81. https://doi.org/10.1080/01460860390223880.

Noone, Jack H., and Christine Stephens. “Men, Masculine Identities, and Health Care Utilisation.” Sociology of Health & Illness 30, no. 5 (July 1, 2008): 711–25. https://doi.org/10.1111/j.1467-9566.2008.01095.x. Walker, Zoe, et al. "Health promotion for adolescents in primary care: randomised controlled trial." BMJ 325.7363 (2002): 524.

Resources:

Refer to Appendix 1 for a full list of resources.
Downloadable PDF file

Objectives

  1. Conduct quantitative and qualitative research methods to Better understand the magnitude of the problems related to TAY transition from primary care services.
  2. Conduct an exploratory assessment of the key motivators of attrition.

I have people come in and [the insurance paperwork is] due tomorrow, and I’m like – how long do you have this? [They say,] Oh I didn’t realize how important it was. [I say,] Really? Because by tomorrow you won’t have insurance. [a lot of] our patients don’t have transportation or they don’t have money to take the bus. Now you see if you’re not working, where are you getting that money from?