Understanding Implications of Social Determinants of Health on Accessing Health Services through the Lens of Identity

Background and Purpose: It is well established that social determinants, such as race, gender, housing, language, and income level, impact the health of communities and individuals ability to access health services. Although public health professionals are recognizing the significance of competing social, cultural, and economic priorities and their effect on healthcare, community feedback and research are still lacking in guiding health policy. The act of intentionally seeking perspectives from communities, particularly marginalized communities, needs to be included in order to understand the depths of social determinants of health, how they shape perception of healthcare, and how best to explain barriers to accessing health services.

This paper furthers the discussion of social determinants of health by examining how various marginalized communities make healthcare decisions and address health care needs based on racial/ethnic, gender, sexual orientation, age, socioeconomic, immigration status, and family dynamics. Importantly, community participants shared their perspectives on how to improve healthcare access and delivery, drawing on their own experiences.

Methods: Forty-five focus groups were conducted with approximately 500 residents of Maricopa County, Arizona (population: 3.8M) between August 2018 and December 2019. Community partners were engaged to assist in the recruitment of residents, utilizing flyers, emails, community boards, and word of mouth to reach diverse communities, with specific consideration of race/ethnicity, gender, sexual orientation, age, socioeconomic, immigration status, and family structures. Gift cards, food, and childcare were offered to incentivize participation. Facilitators and co-facilitators were specifically chosen based on their relationships with communities for each group to establish safety and trust. Community focus groups were audio recorded, professionally translated and transcribed, and coded using NVivo software. Data analysis and reporting were guided by the principles of grounded theory and inductive approach to qualitative analysis.

Findings: Initial results from the focus groups and supplemental questionnaires identified the need for affordable housing (42%), affordable healthy food options (48%), transportation (36%), and access to prevention services (51%) in their respective communities. Lack of/limited health insurance and financial stress were the top barriers to accessing health services across most groups. Participants expressed their perceptions that the healthcare system intentionally discriminated and therefore, denied equal access to health services on the basis of race/ethnicity, age, sexual orientation, immigration status, and/or socioeconomic status (93%). Participants expressed a desire for more healthcare provider education on cultural humility and gender/sexual identities based on personal interactions with healthcare system in Maricopa County. Overall, participants were grateful for the opportunity to share input suggesting the lack of such efforts from the health sector to understand current needs and barriers impacting their overall individual and community health.

Conclusion and Implications: Findings from this Coordinated Maricopa County Community Health Assessment highlight the desire from the community to be included in research that helps inform community and health policies. Additionally, competing priorities, such as housing, food, and financial stability that delay efforts to address healthcare needs. Advocacy for equal access to health services, including affordability and fair treatment, continues to be a need to reduce barriers to care.