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Inequitable access to primary care in ethnic minority populations

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Inequitable access to primary care in ethnic minority populations

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Content Inequitable Access to Primary Care in Ethnic Minority Populations
Morgan J. Hawkins
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
December 2023

© Copyright by Morgan J. Hawkins 2023
All Rights Reserved

The Committee for Morgan J. Hawkins certifies the approval of this Dissertation
Aneesah Smith
Jessica DeCuir-Gunby
Cathy Krop, Committee Chair
Rossier School of Education
University of Southern California
2023

iv
Abstract
This qualitative study explores the disproportionate barriers ethnic minorities face in obtaining a
primary care physician. This study navigates the patient’s experience during their pursuit in
establishing or following up with a primary care doctor, where four research questions were
examined:
1. What are the knowledge gaps middle-aged ethnic minorities have, preventing them
from having a primary care provider?
2. What is the motivation that hinders this population from obtaining primary care
services?
3. What organizational roadblocks delay this population from obtaining healthcare
services?
4. What are the recommendations to close the gap of inequitable access to preventive
medicine in middle-aged people of color?
The research questions explored the experiences of eight ethnic minorities between the ages of
45 and 65 who have had different degrees of exposure to a primary care doctor throughout their
life. The interviews conducted revealed seven findings that led to three recommendations:
1. Create a central electronic hub that instructs how to access a primary care doctor.
2. Encourage incorporation of telemedicine into the business practice.
3. Develop an instructional module made available to primary care offices as a guide to
increase community engagement between patient and doctor.
This study is essential as ethnic minorities continue to be disproportionately affected by health
ailments which cause increase morbidity and mortality, which could have been curtailed or
avoided, had they had less barriers and equal access to a primary care doctor.

v
Keywords: primary care, ethnic minority, equitable healthcare, access to medicine

vi
Dedication
To my dad Fred Hawkins, and Stevie Martin, both who, without spoken words, pushed me to
unimaginable levels of hard work and dedication. Dad, your abrupt passing is what fueled me to
choose this research topic. The goal is for less people to experience what you went through.
Stevie, I will always be in awe of you and your desire in the pursuit of higher education. Both of
you are dearly missed.
To my mom, who continues to be the most influential person in my life, thank you for being a
trailblazer for our family, and being the perfect role model.
To my brother and sister, you have been my rocks since I was born. You have never limited what
I can do, and I wholeheartedly appreciate your unconditional love and support.
To my nieces and nephews, you are the true blessings of the family. Your youthfulness inspires
me to want more, and to do more, so that you do not have to experience what we did. Uncle
loves you.

vii
Acknowledgements
I would like to thank my committee chair Dr. Cathy Krop, and committee members Dr.
Jessica T. DeCuir-Gunby and Dr. Aneesah Smith. Thank you for being my role models and
going on this journey with me. I will always appreciate the time you took from your busy
schedules to ensure I reach enough depth to capture something that is meaningful.

viii
Table of Contents
Abstract.......................................................................................................................................... iv
Dedication...................................................................................................................................... vi
Acknowledgements....................................................................................................................... vii
List of Tables .................................................................................................................................. x
List of Figures................................................................................................................................ xi
List of Abbreviations .................................................................................................................... xii
Chapter One: Introduction to the Study.......................................................................................... 1
Background of the Problem ................................................................................................ 1
Organization of Study......................................................................................................... 5
Purpose of the Project and Research Questions.................................................................. 8
Importance of the Study...................................................................................................... 9
Overview of Theoretical Framework and Methodology .................................................. 10
Organization of the Study ................................................................................................. 10
Chapter Two: Review of the Literature ........................................................................................ 12
Role of the Primary Care Physician.................................................................................. 13
Inequitable Access to Healthcare...................................................................................... 19
Factors Contributing to Barriers Faced by Ethnic Minorities........................................... 25
Clark and Estes (2008) Gap Analysis Framework............................................................ 33
Chapter Three: Methodology........................................................................................................ 38
Overview of Methodology................................................................................................ 38
Credibility and Trustworthiness........................................................................................ 45
Ethics................................................................................................................................. 46
The Researcher.................................................................................................................. 48
Chapter Four: Findings................................................................................................................. 50

ix
Participants........................................................................................................................ 50
Research Question 1: What Are the Knowledge Gaps Middle Aged Ethnic
Minorities Have, Preventing Them From Having a Primary Care Provider?................... 52
Research Question 2: What Is the Motivation That Hinders This Population From
Obtaining Primary Care Services?.................................................................................... 58
Research Question 3: What Organizational Roadblocks Delay This Population
From Obtaining Healthcare Services? .............................................................................. 67
Summary........................................................................................................................... 75
Chapter Five: Discussion and Recommendations for Practice ..................................................... 78
Discussion of Findings...................................................................................................... 78
Recommendations for Practice ......................................................................................... 88
Limitations and Delimitations........................................................................................... 97
Recommendations for Future Research............................................................................ 99
Conclusion ...................................................................................................................... 100
References................................................................................................................................... 102
Appendix A: Interview Protocol................................................................................................. 133
Appendix B: Codebook............................................................................................................... 138

x
List of Tables
Table 1: Organizational Mission, Organizational Performance Goal, and Stakeholder
Goal 8
Table 2: Inequality of Healthcare in Ethnic Minorities Is Multifactorial 13
Table 3: Demographics of Participants 51
Table 4: Income Threshold in Dollars for Los Angeles County in 2023 52
Table 5: Connection Between Recommendations and Findings 88
Table 6: Template for Healthcare Community Screening 96
Table A1: Interview Protocol Questions 135
Appendix B: Codebook 138

xi
List of Figures
Figure 1: Gap Analysis Process 36
Figure 2: Assumed Knowledge, Motivation, and Organizational Influences in Ethnic
Minorities 37

xii
List of Abbreviations
WCUMC West Coast University Medical Center
SMART Specific, measurable, attainable, relevant, and time-based
KMO Knowledge, motivation and organization
SES Socioeconomic status
ACA Affordable Care Act
PHS United States Public Health Service
CDC Center for Disease Control and Prevention
HRSA Health Resources and Services Administration
HPSAs Health professional service areas
HHS Department of Health and Human Services
MUA/Ps Medically underserved areas and populations
USC University of Southern California
IRB Institutional review board

1
Chapter One: Introduction to the Study
Ethnic minorities continue to have inequitable access to primary care services when
compared to White Americans. Due to the lack of this preventive healthcare, minorities have
greater instances of hospitalization compared to the ethnic majority for conditions that are
preventable such as kidney dysfunction, uncontrolled diabetes, high blood pressure, asthma, and
bronchitis, all of which disproportionately affect the minority population (Gaskin, 2011). About
32% of the population in the United States are Hispanic, Latino or Black (U.S. Census Bureau,
2020), which also represents the group with the highest high school dropout rate (Cooper, 2018;
Hussar & Bailey, 2011) and incarceration (Federal Bureau of Prisons, 2013) in the United States,
both of which likely contribute to the knowledge gaps about their own short term and long-term
healthcare needs (Smedley et al., 2014). People of color continue to describe multiple barriers in
obtaining preventive health services, some of which include the sense of racial marginalization
(Philbin et al., 2018), low socioeconomic status, history of unfair healthcare practices in the
United States, lack of reliable transportation, or language barriers, all of which can contribute to
the lack of motivation in obtaining a primary care physician (Miranda & Sanchez, 2014; Pabon
& Wisotzkey, 2013; Snowden, 2012; Solomon et al., 2020). This study analyzed some of the
barriers middle-aged ethnic minorities who live at or below the poverty line continue to face in
obtaining equitable access to preventive medicine when compared to White Americans.
Background of the Problem
Ethnic minorities continue to face unequal access in their ability to consistently see a
primary care physician. The inequitable issues when compared to White Americans are
multifactorial, some of which include financial instability, being unhoused, past trauma or
mistreatment within the healthcare system, or even being unclear of the benefits of preventive

2
health due to lack of education (Sherman et al., 2022; Snowden, 2012). Because of these issues,
minorities are less likely to have quality health insurance (Smedley et al., 2014), which can
prevent them from having access to a primary care physician. Sixty percent of those who are
uninsured in the United States are Hispanic, Black, or identify as a person of color (U.S. Census
Bureau, 2020). Most people without health insurance have a high school education or less (U.S.
Census Bureau, 2020). Those who did not complete high school makeup almost 30% of the
uninsured. According to the U.S. Census Bureau (2020), over half of those who are uninsured
are in poverty-stricken areas in the West, South and Southeast, and in communities where there
is a predominance of ethnic minorities. Because they do not have access to preventive services,
chronic issues worsen leading to increased hospitalization rates that could have been prevented,
which generates preventable healthcare costs (E. K. Adams et al., 2003; Gavin, 1996). Minority
children on average will miss more days of school due to preventable illness (D. Adams, 2021)
which can also lead to increased dropout rates amongst this group. Avoiding or delaying
regularly scheduled preventive health services often leads to worsened physical and mental
health problems later in life. Addressing the disproportionate barriers ethnic minorities have such
as financial insecurity, homelessness, and incomplete high school education would reduce
inequitable access to health care, increasing their odds of establishing care and being followed by
a primary care doctor who can address their medical needs (Rhee et al., 2019; Wight et al.,
2012). Addressing these barriers would also decrease healthcare waste by minimizing extensive
imaging in clinic and hospital settings, avoiding overtreatment, and reserving the emergency
department for life-threatening illnesses (Bazargan et al., 2019), all while allowing this
marginalized population the same healthcare access as White Americans.

3
Access to a primary care physician allows a patient and physician to establish and
monitor mutual health goals, assess and treat mental health ailments, prevent medical conditions,
and manage chronic diseases with the objective of curtailing worsening disease that could have
been prevented. However, people of color experience more difficulties than the ethnic majority
in being able to establish care with a doctor (Brown et al., 2016).
Having a primary care physician enables one to monitor their physical, mental, and social
wellbeing. Primary care physicians and their practice of preventive health management focuses
on preventing incidence of disease, avoiding preventable negative health outcomes, and allows
appropriate follow up after complication of a disease so that it does not lead to increased
morbidity or mortality (Crittenden & Fang, 2021). Also, the advantage of having a primary care
physician results in lower healthcare costs to the patient and taxpayers, while generating greater
overall quality of life (Bazemore et al., 2018). In the United States, for every 10 additional
primary care physicians per 100,000 population, there is a 51 day increase in life expectancy
(Basu et al., 2019). Therefore, the more primary care physicians available to the population who
can effectively treat one’s acute and chronic illness, the lower the mortality.
Health disparities continue to exist due to racial and ethnic background, both of which
have historically been directly proportional to socioeconomic status, generational history, and
even education level, all of which can influence the knowledge and motivation of the individual
(Yearby, 2021). There have been many attempts to use biological race to establish and circulate
an ethnic or racial hierarchy which states that Black genes are more inferior to White genes,
which is why Blacks have worsened health outcomes compared to Whites. However, that linkage
has not been proven in the research. Instead, the research shows that when preventive medicine
is a normal part of anyone’s life, regardless of racial background, they have fewer physical

4
ailments, less disease burden, better mental health, and improved quality of life (Salkeld, 1998;
Taksler et al., 2013; Tazkarji et al., 2016). Therefore, it is ideal to eliminate the barriers ethnic
minorities continue to face so that a better quality of life is achieved.
When patients have an established primary care provider, the number of visits to the
emergency department decreases, unnecessary testing and unnecessary treatment decreases,
preventable healthcare costs go down, and patients feel that they have more control over their
health (Tsai et al., 2018; Uscher-Pines et al., 2013). Uncompensated healthcare costs in the
United States between 2015 through 2017 exceeded $40 billion dollars, of which $33 billion in
public funds were used to offset this cost which could have been used in other infrastructure
programs (Coughlin et al., 2021).
The impact of not achieving the goal of breaking down the barrier marginalized ethnic
minorities face in obtaining a primary care physician would result in more uncontrolled disease,
increased premature death, and increased mortality (Corscadden et al., 2018; Maruthappu et al.,
2013; Stone, 2008). The effects are exacerbated when preventable illness causes children to miss
school, or the working class to miss work, both of which can cause short-term and long-term
deficits to society (Assa et al., 2015; Takala et al., 2014).
The research shows that minorities consistently face more barriers in obtaining healthcare
services when compared to other populations (Corscadden et al., 2018). The literature however
has provided limited qualitative analysis on these barriers from the perspective of the minority
person. Additionally, the disadvantages this group face have not been thoroughly studied as it
relates to preventive medicine and the outpatient primary care service. According to the U.S.
Census Bureau (2020), close to 85% of those who are uninsured are between the ages of 19 to
64. The two groups that are most represented are between 26 to 34, and 35 to 44. About 25% of

5
uninsured persons are between 26 to 34, and about 20% are between 34 to 44 (U.S. Census
Bureau, 2020). The age distribution of those who are uninsured generally represent the younger
population. It is during these years, however, that adults gain weight, become less active postgrade school, have families, and are more likely to experience life stressors, all of which can lead
to weight gain, increase caloric intake, and smoking or substance abuse (Arslanian et al., 2018;
Barrington-Trimis et al., 2020; Greaney et al., 2020; Wing et al., 2020). The effect of these
behaviors is cumulative and can often take a decade to show negative health consequences
(Baum et al., 2019; Merrick et al., 2019; Yuan et al., 2020). Therefore, the focus of this study is
on those aged 40–65. Ethnic minorities make up more than 60% of uninsured Americans, where
more than 25% of these ethnic minorities did not complete high school. As such, there appear to
be general knowledge and motivational gaps this population faces. A dedicated analysis of these
issues is important to address to decrease the financial burden of the healthcare system, while
allowing equitable access to a healthcare provider regardless of race, class, education, or
socioeconomic status. This qualitative study examined the obstacles ethnic minorities experience
in obtaining a primary care doctor.
Organization of Study
This study took place at a large county hospital, West Coast University Medical Center
(WCUMC, a pseudonym). It is a 600-bed hospital situated in a metropolitan city. It is operated
by the county’s Department of Health Services, whose annual operating fund exceeds almost $6
million dollars. The hospital system provides inpatient, surgical, and outpatient services.
WCUMC is strategically placed in a community where ethnic minorities (predominantly Black
and Latino) make up the majority of the surrounding neighborhood (U.S. Census Bureau, 2020).
The mission of the medical center focuses on being inclusive, providing equal access to

6
healthcare for all individuals regardless of race, ethnicity, age, sex, gender, citizenship, or
socioeconomic status. The immediate surrounding area of the medical center is made up
predominantly of Black/African American and Hispanic. It has become a common trend to see
this population disproportionately need acute medical services both in the emergency department
as well as requiring admission in the hospital for further treatment. Much of the treatment
involves management of chronic illnesses that have snowballed over the course of months and
years because they have not been addressed in a timelier fashion. Though the hospital system is
conveniently located in a heavily populated area where physicians are within arm’s reach, many
of the residents still are not able to establish care with a physician. This is a problem because
although preventive medicine services exist, there appear to be barriers the surrounding
community face that inhibit access and use of primary care services preventing the hospital
system from completely fulfilling their mission.
West Coast University Medical Center has a robust outpatient primary care establishment
a short distance from the inpatient hospital, as well as satellite offices throughout the region that
can meet the needs of the surrounding community. WCUMC has trained doctors, nurse
practitioners, physician assistants, and care managers to assist patients in their short term and
long-term healthcare goals. They have a variety of specialists to meet all age groups: pediatrics,
family medicine, internal medicine, mental health, and geriatrics. They also have specialists who
have received additional training to assist in the management of other aspects of a patient’s total
health, such as HIV specialists, or even endocrinologists and surgeons who specialize in gender
reassignments.
Given the network of the healthcare team, by December 2025, hospital leadership aims to
have a 5% increase in the new establishment of middle-aged ethnic minorities with a primary

7
care provider. The focus is on those who identify as an ethnic minority—as these groups make
up the dominant ethnicity surrounding WCUMC. Primary care specialties will be queried on the
number of new appointments made over a 6-month period, then over a 12-month period. At the
6-month period, which would be a halfway benchmark, the expectation is to see at least a 2%
percent increase in new adult patients 18 years or older who identify as an ethnic minority. At the
12-month period, that number is expected to be at least 5%. Checkups and well visits are
important, as these encounters allow a patient and their provider to discuss family history of
medical problems, diet, exercise, past illnesses, medications, and other important aspects of their
healthcare (Fleisch et al., 2021).
Because the medical center is operated by the county’s Department of Health Services
and is funded by taxpayer dollars, those without insurance, or those who are underinsured, often
cannot pay for rising healthcare costs, leaving the burden of their healthcare expenses from
hospital visits to the taxpayers. Eliminating this barrier will not only allow the medical center to
be able to fulfill its mission, but also, the residents of the community will allow their tax dollars
to be diverted elsewhere, rather than on preventable healthcare costs. Performance goals are
listed in Table 1.

8
Table 1
Organizational Mission, Organizational Performance Goal, and Stakeholder Goal
Category Statement
Organizational mission To provide inclusive, equitable, compassionate, and innovative
medical care and education to the surrounding community
Organizational performance
and stakeholder goal
By December 30, 2025, West Coast University Medical Center
will see a 5% increase in new adult patients 18 years or older
in the primary care setting who identify themselves as persons
of color.
Purpose of the Project and Research Questions
The purpose of the study was to evaluate the barriers middle-aged ethnic minorities face
when trying to obtain a primary care physician. The study utilized the Clark and Estes (2008)
gap analytical framework to examine their knowledge, motivation, and organizational barriers to
obtaining necessary healthcare services. Four research questions guided this study:
1. What are the knowledge gaps middle-aged ethnic minorities have, preventing them
from having a primary care provider?
2. What is the motivation that hinders this population from obtaining primary care
services?
3. What organizational roadblocks delay this population from obtaining healthcare
services?
4. What are the recommendations to close the gap of inequitable access to preventive
medicine in middle-aged people of color?

9
Importance of the Study
Primary care and preventive medicine began to accelerate in the twentieth century with
the discovery and implementation of vaccinations, medications for infection control, measures to
identify and decrease heart disease, the diagnoses of high blood pressure, and even the
pathophysiology of tobacco and its deleterious effects on the body (Zaza et al., 2018). The
research shows that the ability to first identify, then offer pharmacologic and/or
nonpharmacologic treatment for these issues leads to a decrease in all-cause mortality and
increase in quality of life (Bazemore et al., 2018). However, people of color disproportionately
experience more negative outcomes of systemic disease processes than White Americans
(Ventura et al., 2017), partly due to the continued barriers this marginalized population faces in
obtaining a primary care physician. Rubin et al. (2015) showed that primary care providers who
are located in socioeconomically deprived urban or inner-city areas see more long-term health
problems, more unstable mental health disease, and more combined medical problems than those
who are in economically rich cities. Ethnic minorities also have a longer wait time to see a
primary care physician for regularly scheduled visits, have shorter time with their medical
provider, and are less satisfied with their experience when compared to advantaged White
Americans (Rubin et al., 2015). This combination of factors leads to delayed care where medical
conditions are not diagnosed or are only diagnosed when it causes more severe disease, or when
there is manifestation of symptoms that impede a comfortable daily life, progressive
disablement, or death (Basu et al., 2019; Fleisch et al., 2021; Stott & Davis, 1979).
Undiagnosed, untreated, or mismanaged medical conditions due to the result of not
having consistent primary care services often cause one to need acute medical care in an
emergency department, creating unnecessary burden and increasing healthcare costs that could

10
have been minimized if the patient had stable medical disease (Gavin, 1996). Thus, taxpayers,
healthcare centers, and government entities often must cover costs for uninsured or underinsured
persons (Boggess et al., 2017; Coupet et al., 2018; Galvani et al., 2020). Studies have shown it is
more cost-effective to manage chronic disease than it is to manage acute-on-chronic disease in
the emergency department for which long inpatient hospitalization is often required (Gordon &
Rowell, 2015). Finding solutions that minimize the barriers ethnic minorities face in getting a
primary care physician could have an impact on a person’s quality of life as chronic medical
conditions are addressed, acute-on-chronic conditions are minimized, and healthcare
expenditures are reduced.
Overview of Theoretical Framework and Methodology
This study used the Clark and Estes (2008) gap analytic framework to study the
knowledge, motivation, and organizational (KMO) influences preventing the desired outcome of
middle-aged ethnic minorities seeking primary care services. Gap analysis begins by
documenting the actual performance compared to the desired performance, identifying any gaps
that need to be addressed. The problem of practice presented here will focus on KMO factors
middle-aged ethnic minorities face that hinder them from having a primary care provider. This
study used a qualitative interview-based approach with middle-aged ethnic minority patients who
had received care at a large county hospital, WCUMC. The guiding research questions focused
on person-specific and organizational barriers experienced when trying to obtain a primary care
physician.
Organization of the Study
Five chapters were used to organize this study. This chapter provided the reader with the
background information needed to understand general issues of inequitable healthcare access to

11
primary care services in ethnic minority populations. The research questions were presented, and
a brief introduction to Clark and Estes (2008) gap analysis was discussed. Chapter Two provides
a review of the current literature surrounding the scope of the study on topics of socioeconomic
status, race, language, differential medical treatment, and mistrust of the medical system, and
how these issues continue to perpetuate inequitable access to healthcare in certain populations.
Chapter Three details the methodology in choosing participants, how data were collected, and
how the data were analyzed. In Chapter Four, findings from the data are presented. Chapter Five
offers a discussion of findings from the collected data in the context of literature reviewed and
offers recommendations for practice for closing the gap that has impacted inequitable access to
and use of primary care services among ethnic minority populations.

12
Chapter Two: Review of the Literature
The literature review examined the barriers ethnic minorities face in obtaining primary
care services. First, there is a discussion on the duties of a primary care physician, and their roles
and responsibility to their patients. Next, there is discussion on the benefits and risks of not
having primary care health services, comparing and contrasting the associated medical outcomes.
This leads to a more focused discussion on inequitable access to healthcare among ethnic
minorities, mainly in Black/African American and Hispanic populations, discussing issues of
socioeconomic status, race and ethnicity, and language barriers. The literature then focuses on
issues specific to those experienced in ethnic minority communities such as medically
underserved areas, mistrust of the healthcare system due to previous unethical medical practice
and research, different treatment in the ethnic minority population, and peripheral trauma. The
chapter concludes with a conceptual framework that uses gap analysis (Clark & Estes, 2008) as a
mechanism for understanding what knowledge, motivation, and organizational gaps exist that
prevent ethnic minorities from accessing primary care services so that recommendations can be
given to decrease barriers that are unequally distributed in ethnic minorities. Table 2 shows some
key points and pertinent articles that will be discussed within Chapter Two.

13
Table 2
Inequality of Healthcare in Ethnic Minorities Is Multifactorial
Statement Sources
Ethnic minorities continue to face unequal
access in the ability to consistently see a
primary care physician.
Sherman et al. (2022)
U.S. Census Bureau (2020)
Smedley et al. (2014)
People of color experience more difficulties
than the ethnic majority in being able to
establish care with a doctor.
Crittenden & Fang (2021)
Basu et al. (2019)
Brown et al. (2016)
Ethnic minorities are less likely to have a
primary physician when compared to White
Americans.
Yearby (2021)
Tsai et al. (2018)
Tazkarji et al. (2016)
Uncontrolled disease, premature death, and
increased mortality disproportionately affect
ethnic minorities.
Barrington-Trimis et al. (2020)
Corscadden et al. (2018)
Assa et al. (2015)
Role of the Primary Care Physician
A primary care physician has completed medical training in various subjects including
anatomy, physiology, pathology, and pharmacology that aid in the treatment and evaluation of
medical illnesses in the general population. In the United States, this typically involves a 4-year
education leading to a bachelor’s degree, followed by 4 years of medical school, and at least 3
years in hands-on training in a clinical setting. The education and clinical training is designed for
physicians to apply their medical expertise to a broad range of individuals.
Primary care physicians have the training to manage both simple and complex medical
problems. They diagnose and treat high blood pressure, high cholesterol, diabetes, autoimmune
diseases, skin infections, and respiratory infections (van den Muijsenbergh & van Weel, 2019).
They also diagnose and treat mental health disorders such as depression, anxiety, post-traumatic
stress disorder, social isolation, and eating disorders (McFarlane, 2019; Troya et al., 2019). They

14
aid in smoking cessation, treatment of alcoholism, and other substance abuse. They are also
important in preventive healthcare, which focuses on preventing and avoiding disease processes
through education, diet, exercise, and other lifestyle modifications (van den Muijsenbergh & van
Weel, 2019). The primary care physician is tasked to help individuals prevent serious illness or
disease, but also manage disease processes in hopes of curtailing avoidable morbidity and
mortality.
Benefits of Having a Primary Care Physician
A primary care physician focuses on the mental, physical, and social wellbeing of their
patient. Their goal is to meet the needs of a patient through preventive, curative, rehabilitative
and palliative care approaches. This medical specialist prioritizes one’s health so that it meets the
individual’s needs.
The pillars of primary care are the diagnoses, treatment and management of chronic
disease. A chronic disease is one that is of long duration that is slow in progression, which is not
passed from person to person (World Health Organization, 2014). Researchers from The Global
Burden of Disease, an organization that studies epidemiology, health, and wellness worldwide,
reported an increase of 42.3% years lived from 1990 to 2013 of those who have non-infectious,
non-communicable chronic disease due to implementation of primary care physicians and
medical advances (Murray & Lopez, 2013; Vos et al., 2016). More recently, this same
organization studied Coronavirus-19 (COVID-19), a novel respiratory infection that, coupled
with the chronic illnesses such as obesity, high blood pressure, heart, and lung disease,
substantially increases overall risk of death, illuminating the importance of decreasing these
chronic ailments. Even in developed countries, addressing chronic disease poses a challenge for

15
healthcare systems because they require long duration of supervision, observation and
specialized care.
Coronary heart disease, heart failure and stroke affect more than 20 million Americans.
The prevalence continues to increase, even though mortality has improved with new medical
capabilities and medications. However, about 50% of those diagnosed with these conditions die
within 5 years because they were not previously discovered and managed long-term through a
primary care provider (Baron-Franco et al., 2017). Primary care providers are trained to screen
for these conditions so that they are caught in a timely fashion.
Hospitals are a common place for people to present when they are not feeling well. One
of the most common complaints upon presentation to the hospital is chest pain. Though most
chest pain is not likely due to a cardiac cause, it is often due to another body system (BaronFranco et al., 2017; Hobbs et al., 2007). However, comorbidity with heart issues often exaggerate
the medical illness. Research has shown that a lay person without a primary care provider is
more likely to misinterpret the symptoms of other body organs when compared to those who are
under the consistent care of a doctor (Magnani et al., 2018; Yang, 2019). This has also been true
of other symptoms such as shortness of breath, having to sleep at an incline for comfort, feelings
of heartburn, or even arm or neck numbness which are often early symptoms that aid in
diagnoses of a more serious condition, but are missed due to the lack of seeing a primary care
physician where these alarming symptoms are often discussed (Cagle & Cooperstein, 2018).
Death from heart disease and stroke in Western countries in patients who have a primary care
doctor have decreased because of the management of lifestyle modifications which is the larger
focus in the primary care setting (Nowbar et al., 2019).

16
Metabolic syndrome is another example of how the outcome can be favorable among
those who establish care with a primary care physician. Metabolic syndrome represents an
increased risk of long-term complications of which is diagnosed by having three of five criteria:
high blood pressure, low high-density lipoprotein (“good cholesterol”), high triglycerides,
elevated blood glucose, and increased abdominal fat (Wang et al., 2020). This syndrome
increases risk mainly for cardiovascular disease and diabetes type II, both of which
independently increase all-cause mortality. The prevalence of metabolic syndrome in adults in
the United States is nearly 25%, where between another 30% and 65% are overweight or obese,
respectively, and are estimated to be diagnosed with metabolic syndrome in their lifetime
(Barber et al., 2015). Patients who have a primary care physician are focused on prevention first,
then treatment. These patients are less likely to develop metabolic syndrome as cholesterol is
more controlled, blood pressure is more likely to be below problematic levels, glucose is
normalized, and weight is actively managed by diet and exercise (R. D. Barnes et al., 2014), all
of which would essentially eliminate a diagnosis of metabolic syndrome. Those who do end up
with a diagnosis of metabolic syndrome who also have a primary care physician, are also more
likely to reverse the causes, and have less all-cause mortality (Barber et al., 2015; R. D. Barnes et
al., 2014).
The same correlation of the increased likelihood to reverse, improve, and/or have a
decrease in all-cause mortality if followed with a primary care physician can be seen with other
diseases such asthma and lung disease (Larsson et al., 2020), kidney disease (Fraser &
Blakeman, 2016), liver dysfunction and other gastrointestinal illnesses (Cotter & Rinella, 2020),
autoimmune disease (Giacomelli et al., 2017), and malignancy (Merriel et al., 2018). When
managed with a primary care physician, all these disease processes are more likely to be

17
controlled, and less likely to cause more serious illness or death, than if not managed under the
care of a primary care physician.
Potential Harm of Not Having a Primary Care Physician and Lack of Preventive Health
Services
One of the tenets of primary care is preventive health—measures taken to prevent disease
before it even starts. Patterns of health, sickness, and disease are often influenced by the way
people live; their environment, economic, and social life all play an integral part (Rose et al.,
2008). This implies that at least some disease processes, in theory, are preventable, so long as
one is able to modify one or more of the aforementioned factors. A primary care physician’s role
is to provide knowledge, education, and resources to prevent disease with the goal of sustaining
or improving quality of life for their patients.
Preventive health is thought to be economically efficient. When one is not in good health,
lifetime earning capacity diminishes, which can have a domino effect as lack of economic
growth and decreased finances has the potential to influence oneself, family, relationship, job,
and overall quality of life (Mogilner & Norton, 2016). Reducing the incidence of disease will
also have a positive impact on health service costs since the number needed to treat will decrease
(S. M. Smith et al., 2016). Healthcare costs in the United States continue to rise and are projected
to rise exponentially as Americans are living longer. Since the beginning of the twentieth
century, life expectancy has increased from 50 years to almost 80 in many developed countries
due to more reliable food security, production of medications like antivirals and antibiotics that
cure disease, new diagnostic capabilities like magnetic resonance and computed tomography,
and the field of primary care and preventive medicine where the goal of prevention, diagnoses,

18
maintenance and treatment of chronic disease is one of the main goals of this medical specialty
(Bazemore et al., 2018; Tricoli et al., 2017).
Having a primary care physician has the benefit of preventing disease, decreasing
severity of disease, increases lifespan, and generally improves quality of life. Those who are not
under the consistent care of a primary care physician are more likely to be diagnosed with a
medical condition that could have been prevented, more likely to have severe uncontrolled
disease that could have been lessened, and more likely to experience premature death at a higher
rate, when compared to those who do have a primary care doctor (Morelli, 2017; Troya et al.,
2019). The most efficient lifestyle modification strategies are through a team-based approach
that involve the patient, and the patient’s primary care physician, where both can review one’s
risk factors, and the physician can offer strategies that may influence an individual’s health
(Arnett et al., 2019). The American College of Cardiology and the American Heart Association
are national organizations made up of clinicians and scientists who conduct research and follow
clinical trials to advise the medical community and general public how to maintain
cardiovascular fitness. One of their top 10 directives for middle aged adults 40–75 years old is to
always have consistent primary care visits for prevention of heart disease and, if diagnosed,
management, to increase lifespan and quality of life (Arnett et al., 2019; Lloyd-Jones et al., 2019;
Rich et al., 2016).
As heart disease is the leading cause of death in the United States in those aged greater
than 75 (Rich et al., 2016), the leading cause of death in adults 18–74 years old is cancer
(Wender & Wolf, 2020). If caught early and before a cancer has spread to other organs, many
cancers can be treated, and even induced into lifelong remission. If cancers are left undiagnosed
or untreated however, there is a greater likelihood of multi-organ system involvement, which can

19
lead to more serious illness or a hastened death (Zaorsky et al., 2017). Because a primary care
doctor focuses on both prevention and treatment, they are tasked with guidelines to ensure ageappropriate screening is done. Screening for cancer with a primary care physician or with a
cancer specialist, who, in the United States, must first be trained in primary care, has led to
substantial reductions in death from many cancers, and is the most cost-effective interventions in
preventive measures (Zaorsky et al., 2017). Not having a primary care physician causes one to
miss screening measures designed to diagnose cancer and cancer-related illness, which can
increase likelihood of developing cancer when it is in advanced stages leading to an increase of
more serious illness (Weir et al., 2015).
Not having a primary care doctor would miss the benefits of regularly scheduled
checkups where screening protocols are in place, not being able to obtain updates on the latest
health information by a medical professional, and the inability for the parties involved to
communicate their shared goals of having a healthy lifestyle (Grad et al., 2017). Though not all
disease processes can be mitigated, many can be prevented or recognized early if under the care
of a primary care doctor.
Inequitable Access to Healthcare
Access to healthcare is not equally attainable to all population groups. In the United
States, the healthcare system has a disproportionate impact on certain groups such as those who
identify as lesbian, gay, bisexual, transgender and queer (LBGTQ), unhoused persons, those who
lack abundant financial resources, and those whose race, ethnicity and language differ from the
majority (Taylor, 2019). This inequity can have downtrace effects as these groups are more
likely to not have insurance or have gaps in insurance, have less access to other ancillary health
services like nutrition, physical or occupational therapy, wound care or home health, and often

20
lack access to prescription medication for treatment for their acute and chronic disease, all of
which contribute to poorer health outcomes (Mullachery et al., 2016).
The Impact of Socioeconomic Status
Socioeconomic status (SES) can play a role in the availability and ease of how one
receives healthcare. SES is the combination of a person’s financial resources including income,
assets and debts, occupation, and formal or informal education (Baker, 2014). In 2018 and with
the same anticipated trend over the next 5 years, White Americans had a median household
income of $70,462, compared to Hispanic or Latino at $51,404 and Black or African Americans
at $41,361 (U.S. Census Bureau, 2020). African Americans and Latinos continue to make less
than Whites even while having the same job, which has historically contributed to unequal pay
and a gap in overall household income (Darity et al., 2018). Income can be a major factor in a
family’s ability to obtain a primary care doctor and other healthcare services, as it can increase
household spending in relation to out-of-pocket costs and high insurance premiums.
Accumulating wealth that can be passed down to generations is also a way to provide a
head start on maintaining wealth and health throughout one’s lifetime. On average, White
families have almost 10 times more wealth than African American families (Hanks et al., 2018).
Wealth gap is a negative predictor of overall accumulation of wealth, which can influence other
aspects of one’s life. Hanks et al. (2018) has shown that the impact of a wealth gap for African
Americans makes it more difficult to own homes or build retirement savings. Though ethnic
minorities generally have less debt than whites, this group is also more likely to have higher
interest debt obligations and payments. The combination of wealth gap, high payments to
debtors, gaps in medical insurance, and unpredictable medical bills can affect the ability to
eliminate and reduce overall debt, while being more likely to have inadequate primary care

21
health services, an increase in unmanaged chronic medical problems, and the inability to
generate and pass down wealth to subsequent generations, thus creating a cycle of unmet needs
(Darity et al., 2018; Fontenot et al., 2018; Hanks et al., 2018).
Unpredictable medical bills in uninsured and underinsured persons can cause a budgetary
crisis. The average family spends about 11% (or $8,200) per year on out-of-pocket medical costs
such as prescription drugs, office copays, and health care premiums, which can decrease
financial security of families (Kaiser Foundation, 2019). The Kaiser Foundation (2019) found
that the annual cost for health care premiums is nearly 20% of the average income for African
Americans and Latinos, which can be a detriment to some households when considering income
inequality in this demographic. In 2019, there were 27.5 million people that lacked insurance,
where almost all stated it was due to cost (Kaiser Foundation, 2019). The Commonwealth Fund
(2019) shows that 87 million adults aged 19 to 65 are underinsured, which leads to higher out-ofpocket costs that strain personal finances and increase debt. Of these 87 million adults, more than
20% are African American or Hispanic.
Ethnic minorities are more likely to experience poverty in their lifetime when compared
to White Americans. According to the Bureau of Labor Statistics (2019), this demographic is
also less likely to have workers in the home that have full-time employment. Their findings
further show that the poverty rate in ethnic minorities in years 2018 through 2020 was greater
than 20%, which is more than double the poverty rate for White Americans. Poverty has also
been correlated with toxic physical and mental stress, which can ultimately impact one’s health
due to factors such as poor appetite leading to poor diet and nutrition, depression, anxiety and
other mental health problems causing unsatisfactory quality of life (Gundersen & Ziliak, 2015).

22
Therefore, addressing the impact of socioeconomic status in ethnic minority populations may
decrease the disproportionate healthcare outcomes this group faces.
Race and Ethnicity
Race and ethnicity play an integral part in the interactions with primary care physicians,
which can affect one’s overall health. While “race” and “ethnicity” are commonly used
interchangeably, they have different demographic attributes. Ethnicity involves having a shared
cultural identity, while race is a biological and genotypical trait (Pan et al., 1999). A person can
be characterized by either race or ethnicity, or by both. For example, there are non-Black
Hispanics, and there are Blacks. Evidence has shown that there are multifactorial economic and
social inequalities ethnic minority people face—including racism—which contributes to ethnic
inequalities in health (Chouhan & Nazroo, 2020; Del Pino et al., 2019).
Health of ethnic minorities are different across conditions. Many illnesses however
disproportionately affect this demographic at higher rates when compared to Whites. There are
higher rates of diabetes, heart disease, and high blood pressure in Blacks, Caribbean, and
Hispanics, higher rates of admission into psychiatric hospitals with psychosis in Asian and
Blacks, and higher rates of suicide attempt in Black and South Asian Americans (Assari, 2018;
Cagle & Cooperstein, 2018; Forte et al., 2018; Rich et al., 2016). Though this is often viewed
solely as a description of health amongst ethnic minorities, it also highlights the complexity of
health inequalities these ethnic minorities face in their healthcare throughout their lifetime
(Chouhan & Nazroo, 2020). Notably, analysis of disproportionate healthcare outcomes based on
race and ethnicity has shown that disease in ethnic minorities is not always independently
explained by cultural, genetic, and biological differences (Drewniak et al., 2017; Kinney, 2000).
Instead, it is conglomerate of issues, exacerbated by being an ethnic minority where this

23
population faces increased poverty, financial instability, housing insecurity, homelessness, and
poor nutrition (Babitsch et al., 2008; Cox et al., 2012; Grad et al., 2017; Gundersen & Ziliak,
2015; Hanks et al., 2018). Therefore, key drivers of ethnic differences in health outcomes does
not appear to be solely genetic or behavioral, but also includes social and economic differences
that affect ethnic minorities in different ways than Whites.
Those of different race and ethnicity when compared to the majority are more likely to
face a difference in healthcare delivery. Ethnic minorities consistently report experiences with
racial harassment and discrimination in primary care settings, resulting in the belief that
healthcare in general is against ethnic minority people (Wallace et al., 2016). This idea has a
downstream effect as it is passed down through generations, likely exacerbating disproportionate
illness in this population.
The Affordable Care Act (ACA) was a federal statute in the United States signed in 2010
which represented healthcare regulation with expansion of already existing government
healthcare programs such as Medicaid and Medicare, which has helped to ensure healthcare
coverage for millions of Americans, especially ethnic minorities. The rate for uninsured African
Americans, Latinos, and Asians declined after its implementation. While more than 20 million
people gained coverage at its origination, close to three million were African American, four
million were Latino, and more than four million were Asian American and Pacific Islanders
(Statista Research Department, 2022). Even still, ethnic minorities are still more likely to not
have insurance, or have insufficient insurance coverage compared to Whites (Fontenot et al.,
2018). Medicaid programs which are funded by both state and federal governments are often
thought to be the lifeline for low-wage Americans, the elderly, pregnant persons, and those with
disability. From August 2019 with similar projection through 2021, it is estimated that more than

24
68 million people will be covered under a Medicaid program, with African Americans making
up 20%, Hispanics making up more than 30%, and Asian and mixed races making up 10%
(Kaiser Foundation, 2019). Race and ethnicity have shown that a correlation with overall health
outcome exists, while other factors such as income, job security, and lack of wealth unequally
influence ethnic minorities when compared to Whites (Hanks et al., 2018), ultimately leading to
health inequity.
Language Limitations
Ethnic minorities continue to face disparities with access to health care, leading to
worsened health outcomes and mortality. Lack of access in this population is due to additive
issues of lower socioeconomic status, education, lack of resources, and even miscommunication
due to language barriers. Drewniak et al. (2017) conducted a thematic analysis from four
literature indexes studying barriers in healthcare. One of their top six conclusions was that when
a language differs from the majority, there is less access to a healthcare professional, increase of
preventable medical disease, decrease in general physical and mental health, and increase in
overall death. Language and communication between patients and their healthcare provider have
historically shown to be persistent problems in obtaining equitable health care in both the acute
and chronic medical setting (Babitsch et al., 2008; Cox et al., 2012; Jensen et al., 2011).
Language barriers impact the cost and quality of healthcare. A language barrier is when
the patient and the healthcare provider do not speak the same native language. Standard of
medical care, however, is to deliver high quality healthcare irrespective of difference of
language, as medical care is typically thought of as a human right (Kinney, 2000). Language
barriers have been shown to negatively impact the quality of care, while also decreasing patient
safety, and decreasing patient satisfaction of their medical team and overall healthcare goals.

25
Many healthcare organizations have utilized interpreter services to address this issue, but these
services increase healthcare cost and length of treatment, which indirectly raises the cost of the
medical visit to an already vulnerable population where finances are not abundant (Fontenot et
al., 2018; Gundersen & Ziliak, 2015; Hanks et al., 2018).
Communication between patient and their medical team is vital for overall satisfaction of
both patient and medical provider. Physicians and nurses who do not speak the same language as
their patient and do not have interpreter services often lead to wrong diagnosis, incorrect
prescription medications, and mismanagement of diseases (Al Shamsi et al., 2020). One study
showed that with patients who received treatment from a medical provider who did not speak the
local language, 30% did not understand the medical instructions given to them by their doctor,
30% had questionable reliability of medical information as perceived from their doctor, and 50%
of the physicians surveyed believed the language barrier would contribute to otherwise
preventable medical errors (Al-Khathami et al., 2010; Kale & Syed, 2010). Given the diversity,
ethnic minorities in the United States are more likely to have a different primary language, and
thus experience more inequitable access to healthcare.
Factors Contributing to Barriers Faced by Ethnic Minorities
Inequitable access to a primary care provider in ethnic minorities is complex, and often
involves multiple areas that need to be addressed. Finances, education, housing security, stable
employment and transportation are just some of the issues that, on average, lack in this
population (Cox et al., 2012; Fontenot et al., 2018; Gundersen & Ziliak, 2015; Jensen et al.,
2011). Furthermore, racial or ethically targeted events can have long-lasting health implications
on those who were not directly targeted. The feelings that continue to indirectly affect the
population is known as peripheral trauma (Alsan et al., 2020). Police brutality, mass

26
incarceration, genocide, and medical exploitation are a few reasons of ongoing peripheral
trauma. Research has shown that population-effects in ethnic minorities where ethicality was
diminished during medical care and research, continues to show a disproportionate rise in
mortality and medical mistrust in ethnic minorities (Klitzman, 2022; Vernon, 2020).
Primary Care Provider Shortages in Ethnic Minority Communities
Not having healthcare access within a reasonable distance of one’s community can be a
significant hindrance in establishing care with a primary care provider. This issue is often due to
residential segregation. Residential segregation is the disproportionate domicile separation
between ethnic minorities and Whites (Tehrani et al., 2019). Historically, this type of segregation
is often the blame of imbalanced, inequitable resources in favor of the ethnic majority, while the
ethnic minority is forced to either go without, or have to make additional strides for the same, but
often fewer desirable services (Charles, 2003; Massey & Denton, 1988). Residential segregation
is often influenced by economic status, which has effects on the establishment and location of
public assistance buildings, grocery and retail stores, shopping malls, schools, and health care
services.
Because of residential segregation, ethnic minorities are more likely to lack health care
providers, access to hospitals, and access to primary care providers (Gaskin et al., 2011; Thomas‐
Hawkins et al., 2019). Therefore, where one lives, which is often influenced by other factors
such as education level and socioeconomic status, matters. When primary care physicians are
located in predominantly Hispanic and African American neighborhoods, they are often of lower
quality when compared to those in White communities (Lin & Sripipatana, 2018; Streeter et al.,
2020; Xue et al., 2019). Ethnic minorities are often left heavily relying on overworked and
understaffed community health centers and emergency rooms for routine outpatient care, because

27
there is a lack of available mental health and primary care providers within their own geographic
areas (Taylor, 2019). To reach better quality providers, this population must travel outside of
their immediate area; but even this can be challenging with issues of lack of access to reliable
transportation. Furthermore, costs and time associated with traveling farther in a population that
is already more likely to have limited income cannot be understated.
Residential segregation has been a notable problem for decades with the ethnic minority
community, leading to governmental regulatory bodies to address the shortcomings. The Health
Resources and Services Administration (HRSA), an agency within the Department of Health and
Human Services (HHS), is a government organization in the United States that defines Health
Professional Shortage Areas (HPSAs) by geography and population. With this information, they
make recommendations to city, state, and federal governmental health service agencies on where
and how to allocate healthcare funding and resources (Lin & Sripipatana, 2018). The HRSA
makes designations in the health disciplines of mental health, dental health, and primary care.
After receiving information from HRSA and U.S. Census Bureau, federal regulators then
calculate the ratio of the population to that of the provider, to determine areas that need increased
healthcare services. From 2018 to 2020, there has consistently been almost 20,000 areas within
the United States—mostly areas that are heavily populated with ethnic minorities—where there
are still not enough healthcare providers to meet the needs of the population; mental health and
primary care disciplines were of the shortest supply (Streeter et al., 2020; Xue et al., 2019).
HRSA is also responsible for determining Medically Underserved Areas and Populations
(MUA/Ps), and the healthcare issues that surround this population. Their goal is to identify
geographic areas where there is specifically a lack of primary care providers and provide
recommendations to decrease this gap (Taylor, 2019). The HRSA has identified MUA/Ps mostly

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of which consists of unhoused persons, those who are eligible for Medicaid but often have
insurance gaps, Native Americans, African Americans, Hispanics and farmworkers. This
population is often found to be below the federal poverty level. The health ailments identified in
MUA/Ps that continue to disproportionately affect this population are heart disease, stroke, high
blood pressure, increased infant mortality rate, increased maternal mortality during childbirth,
mental health disorders, drug and substance abuse, and suicide (Del Pino et al., 2019; Forte et al.,
2018; Gaskin et al., 2011; Lin & Sripipatana, 2018). This shows that the unequal access to
primary care services based on location is often a barrier of ethnic minorities in poverty, which
can lead to decreased quality of life, worse overall health outcomes, and increased premature
death.
Distrust of the Healthcare System
Medical distrust in the ethnic minority population is often a deterrent to establishing care
with a primary care provider. Distrust is the notion that a person or organization is not deemed
reliable, and thus, cannot act in the best interest of the stakeholder (Webb Hooper et al., 2022).
These feelings can lead to skepticism, fear, or increased vigilance. Purposefully providing
substandard healthcare and inappropriate and unethical biomedical research among ethnic
minorities has long been a problem in the United States (Klitzman, 2022). African Americans
have consistently reported more physician distrust and poorer patient-provider experiences when
compared to White adults (Webb Hooper et al., 2022). This is important to note because the
distrust in the medical profession can cause one to forego age-appropriate and symptomappropriate establishment and follow up with a primary care provider. Continued distrust in the
healthcare system can allow for skipped cancer screenings, ultimately leading to untreated and
undiagnosed metastatic cancer, causing premature death. Not getting examined for other

29
symptoms such as chest pain, shortness of breath, or back pain, can lead to worsening coronary
artery disease, end-stage lung diseases, or untreated pathologic fractures, respectively, all of
which can decrease both quality and quantity of life.
Research has shown that negative experiences are easier to recall than positive ones
(Kensinger et al., 2006; Levine & Bluck, 2004; Mittal et al., 1998). The Tuskegee Study in the
United States became an example of mistreatment and neglect in African Americans. Covering
40 years, between 1932 and 1972, the United States Public Health Service (PHS), a precursor of
what is now known as the Center for Disease Control and Prevention (CDC), followed mostly
poor, African American men in Tuskegee, Alabama, most of which had syphilis, for the purpose
of trying to understand the natural course and progression of the disease (Alsan & Wanamaker,
2018). A cure for the disease, penicillin, was already known to be effective (Spellecy & Busse,
2021). These men however were asked not to seek medical care outside of the physicians who
were involved in the study, to further prohibit their knowledge and access to curative medicine.
The participants had frequent invasive monitoring such as taps in the spinal cord, blood draws,
and autopsies once they were deceased. They were either told they were healthy, or they had
“bad blood,” which the patients then believed they were getting treatment for given the frequent
medical visits and testing (Alsan & Wanamaker, 2018; Spellecy & Busse, 2021). It was not until
1972 that a journalist with the Associated Press detailed the narrative of the past 40 years of
medical mistreatment to these poor African American men. Many ethnic minorities point to this
history of mistreatment as the cause of why they still do not seek medical care in the United
States (Alsan et al., 2020).
Unethical research has also stifled programs that could aid in more effective treatment in
ethnic minorities. In October 1951, Dr. Howard Jones, a physician at Johns Hopkins, announced

30
on television that he had discovered a major breakthrough in cancer research. He and a
researcher, George Gey, had spent years trying to grow cells outside of the human body. Prior to
this, human cells would only stay alive for a few days at most. Keeping cells alive outside of the
body for an indeterminate amount of time however would allow unprecedented research in cell
biology and oncology, hopefully leading to advanced therapeutics. A 31-year-old African
American woman named Henrietta Lacks was under the treatment of Dr. Jones at Johns Hopkins
for cancer, and unbeknownst to her, was isolating her cancerous cells for his research (Vernon,
2020). George Gey had observed that Mrs. Lacks’ cells differed than what he had previously
studied: her cells divided multiple times without ever dying. Mrs. Lacks later succumbed to her
illness, where soon after Gey went to the morgue and took additional tissue samples without the
knowledge of Mrs. Lacks’ family. This started a cell line from Lacks’ sample which was able to
divide repeatedly without dying. The cells are essentially immortal. This cell line became known
as HeLa cells, named after the first two letters of Mrs. Lacks’ first and last name. Since these
cells divide indefinitely, many researchers felt they can provide value into their research and as
such, were sent to scientists around the globe and used in medical breakthroughs in biomedical
research (Malcom, 2018; Vernon, 2020). The family of Henrietta Lacks never gave permission to
use her cells and has not received financial contribution (Klitzman, 2022) even while her cell line
has resulted in medical breakthroughs.
Mistrust in the medical system is still very present. Severe acute respiratory syndrome 2
(SARS-CoV-2 or “COVID-19”) is a respiratory virus that has affected essentially all countries of
the world with more than 600 million cases and over 6 million deaths as of November 2022
(World Health Organization, 2022). Vulnerable and marginalized populations such as Blacks,
Hispanics, Asians, and indigenous people, and those who are of low socioeconomic status have

31
been disproportionately affected (Greenaway et al., 2020). In the United States, as of June 2020,
Latinos and Black Americans made up 33.8% and 21.8% of all COVID-19 infections, yet only
make up 18% and 13% of the population, respectively (Tai et al., 2021). In New York City,
Black Americans and Latinos were also found to be twice as likely to die from COVID-19 when
compared to Whites after age adjustment (Tai et al., 2021). In the United Kingdom, Blacks and
Asians were more likely to die from COVID-19 even after adjusting for age and prior medical
history (Williamson et al., 2020).
Mistrust of COVID-19 vaccines remain widespread among ethnic minorities. As of 2020,
only 18% of Black Americans and 40% of Latino Americans trusted that the COVID -19 vaccine
will be effective or safe (Opel et al., 2021). As of May 2021, fewer than half of Black Americans
intended to get vaccinated against COVID-19 (Opel et al., 2021). Such hesitancy is thought to be
multifactorial, rooted in public health experimentation and unethical medical treatment
previously conducted by governmental organizations in the United States (Klitzman, 2022; Opel
et al., 2021; Vernon, 2020). This suggests that ethnic minorities continue to exhibit
psychological harm due to the mistreatment experienced by earlier generations.
The implementation of review boards mainly established in developed countries has
helped curbside such instances, but ethnic minorities still continue to face substandard medical
practice which can lead to further doubt and apprehension, contributing to the notion that the
medical profession cannot be wholly trusted (Lincoln et al., 2021; Quinn et al., 2019). Unethical
trials have been reported in India, Argentina, Russia, Brazil and Nepal, mainly in marginalized,
ethnic minority communities with low socioeconomic status (Vernon, 2020). This continues to
perpetuate uncertainty and wariness in this population, leading to overall decreased healthcare
establishment and follow up.

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Differential Treatment of Patients of Color
Patient-provider interactions contribute to healthcare disparities in people of color.
Cultural health capital is defined as the way healthcare professionals use their cultural skills,
possess attitudes, behaviors, and prejudices towards certain groups that result in either a buildup
or breakdown of the doctor-patient relationship (Shim, 2010). Studies have shown that ethnic
minorities continue to have lower quality of medical care, lower patient satisfaction, and lower
levels of medical services when compared to Whites (Tesema & Braeken, 2018). Cultural health
capital argues that not every doctor has the cultural competency and skills to effectively engage
their patient. This has led to inequitable healthcare treatment to ethnic minorities as a long-held
belief is that these racial groups are inferior to the White majority (Nelson, 2002; Shim, 2010;
Young et al., 2003).
Ethnic minorities continue to experience different, substandard medical treatment. For
example, inequitable pain assessment in people of color when compared to Whites in the United
States has led to undertreatment and mismanagement of pain, causing undue and avoidable
suffering that has disproportionately affected ethnic minorities (Hoffman et al., 2016). A study
showed that Latino patients who presented to a large, academic emergency department in Los
Angeles with long-bone fractures only received half of the same regimen of pain medications as
non-white Latinos with the same fracture at the same emergency department (Todd et al., 1993).
A similar study showed that Black patients with long-bone fractures were less likely to receive
opioid medication when compared to White patients, and significantly more likely not to receive
any analgesics while in the emergency department (Todd et al., 2000). These instances shed light
on the persistent mistreatment people of color have faced during their healthcare journey.

33
Differential treatment to ethnic minorities has devastating after affects, which create what
many believe to be a justifiable reason to avoid healthcare altogether. Black women in the United
States are nearly four times more likely to die during childbirth. The mortality rate for Black
women is about 41 per 100,000 compared to 11 per 100,000 in White women (Dekker, 2017).
Dekker (2017) also showed that Black women are more likely to have pre-term birth at a rate of
16% compared to Whites at a rate of 10%, and Black women are more than twice as likely to
have an infant with low birth rate, 13% compared to 7% in women. The death rate for Black
babies is about 11.5 per 1,000 compared to 5 out of 1,000 in White women. These numbers
equate to one Black infant dying before they are one year old, even after controlling external
factors such as food, environment, and mother’s health (Attanasio & Hardeman, 2019; Dekker,
2017).
Ethnic minorities have historically been subjected to unequal healthcare treatment. This
Chapter has shown that this mistreatment has had devastating generational outcomes which has
swayed ethnic minorities away from the healthcare system, which undoubtedly puts them at
increased risk for worsened medical disease and illness. The trauma they have faced with not
having competent, culturally sensitive medical care further exacerbates the mistrust they
continue to have in their pursuit of the healthcare system. Though there are several layers that
continue to breed this sentiment, this study focused on three areas Clark and Estes (2008)
identified as the root causes that if not addressed, will undoubtedly lead to poorer outcomes.
Clark and Estes (2008) Gap Analysis Framework
Gap analysis is a tool to understand the divide, or gap, between what is occurring and the
desired goal. Clark and Estes (2008) identified three elements that are paramount to understand
and address to close the divide: knowledge, motivation, and organization (KMO). Performance

34
almost always comes down to deficiency in one or more of these three areas (Clark & Estes,
2008). Knowledge gaps occur when individuals do not know or understand how to do something,
or how to effectively complete a task. Knowledge includes questions that address what, how and
why; it illuminates the declarative, procedural, and conceptual issues respectively (Krathwohl,
2002). Krathwohl (2002) describes four different types of knowledge: (a) declarative or factual,
which represent the facts and information; (b) procedural knowledge, which are the tools needed
to know how to complete a task; (c) conceptual knowledge, which is the information given that
is specific to a framework; and (d) metacognitive knowledge, which is knowing the processes
that are necessary for gaining, processing, and analyzing the knowledge.
Further, a person or organization may not feel confident with their current tools to be
successful, which can lead to a lack of motivation (Clark & Estes, 2008). Self-efficacy, or the
belief in one’s ability to accomplish something to a desired end-goal, is the foundation of
motivation (Bandura, 2000, 2005). Lastly, an organization may experience setbacks because of
their lackluster, outdated, or irrelevant policies, procedures, or practices, tainting their goal.
Clark and Estes (2008) states that an organization’s cultural models and settings, leadership, and
resources need to be thoroughly examined to better understand an outcome that falls short of the
goal. Many of these aforementioned KMO issues may not be known or apparent to the individual
or organization, straying away from the desired outcome. The KMO gap analytic framework
focuses on identifying the issues that affect performance in each of these areas.
Since the desired performance goal of eliminating barriers to obtaining primary care
services among ethnic minorities has not yet been reached, this study will examine specific
knowledge, motivation, and organizational influences that may underlie the problem, and then
offer solutions with the expectation of meeting the desired performance. Though there have been

35
few dedicated qualitative studies addressing inequitable healthcare access in primary care, many
other studies have identified that minorities do not receive the same standard of care compared to
White Americans (Adebayo et al., 2022; Misir, 2022; Wilson et al., 2021). This issue is
multifactorial, with likely knowledge gaps in the minority population, lack of motivation due to
the history people of color have faced in mismanagement of medical issues, racism, prejudices in
healthcare previously experienced in the United States (Gavin, 1996), and organizational
roadblocks that were put in their way. Through a qualitative methodological approach, this study
tells the story through the lived experiences of middle-aged ethnic minority patients to
understand the issues this population face in obtaining primary care services. Recommendations
for practice will be offered to increase access to primary care services and make access to
healthcare fairer. Figure 1 illustrates the gap analysis process. As shown, the desired goal is what
one desires to achieve. To reach this goal, there must be an assessment of the knowledge,
motivation, and organizational issues that has prevented this goal from being reached. Once the
issue has been identified, recommendations will be given to close the shortcomings, where
execution of these recommendations would ultimately yield the desired goal.

36
Figure 1
Gap Analysis Process
Note. This figure illustrates the continual recursive nature of the processes used in gap analysis.
Figure 2 shows assumed influences that ethnic minorities, specifically Black/African
American, Hispanic, and Asian populations continue to have in accessing primary care services.
They may not know the importance of treating their disease, and how substandard treatment can
be consequential later in life. They also may not have the tenacity to be on the forefront of their
health, or may simply have misguided expectations on the duties of the primary care doctor.
Desired Goal
Knowledge
Assessment
Motivtion
Assessment
Organizational
Barriers
Gap
Identified
Recommendations
Execution

37
Figure 2
Assumed Influences in Ethnic Minorities
Note. The figure illuminates the assumptions that prevent ethnic minorities from establishing or
following up with primary care.
Cultural Model: Inclusivity of patients from different ethnic backgrounds, age, lifestyle and
sexual orientation.
Cultural Setting: The ability for ethnic minorities to have access to a primary care physician.
Knowledge Motivation
All persons understand
declarative/conceptual
knowledge. However, ethnic
minorities must be taught what
chronic illnesses are, and why
it is important to have a
primary care physician.
Procedural knowledge is
common sense. However, some
ethnic minorities may not
understand how to navigate the
healthcare system.
Self-efficacy is inherent:
However, some ethnic
minorities may not be aware of
their own ability to execute
necessary behaviors.
Everyone acknowledges their
own expectancy value:
However, many people must be
taught what factors in their
long-term health should
motivate them for consistent
follow-up with their doctor.
dd

38
Chapter Three: Methodology
Chapter Three presents the research design and methodology for data collection and
analysis to examine the barriers ethnic minorities face in obtaining a primary care physician.
Specifically, this research study sought to understand the knowledge, motivation, and
organizational (KMO) influences that continue to disproportionately affect this population in
obtaining primary care services when compared to the ethnic majority.
Four research questions guided this study:
1. What are the knowledge gaps middle-aged ethnic minorities have, preventing them
from having a primary care provider?
2. What is the motivation that hinders this population from obtaining primary care
services?
3. What organizational roadblocks delay this population from obtaining healthcare
services?
4. What are the recommendations to close the gap of inequitable access to preventive
medicine in middle-aged people of color?
Overview of Methodology
This study used Clark and Estes’s (2008) gap analysis framework to understand the KMO
influences preventing ethnic minorities from obtaining a primary care physician. Gap analysis
examines current performance compared to the desired performance to identify gaps that need to
be addressed. To change from the current state to the desired state requires identification of
shortcomings in areas of knowledge, motivation and organizational influences. This study was
conducted using a qualitative approach. Because qualitative research shows relevance,
feasibility, importance of outcomes, and acceptability, it is often a method of choice on issues of

39
equity that affect a particular population (Flemming et al., 2019). This approach allowed the
participant to tell their unique story, as not everyone’s background is the same (Babchuk, 2016;
Merriam & Tisdell, 2015). This qualitative study included eight participants in one-on-one phone
interviews using 14 open-ended questions. Open-ended questions are often found to yield the
most well-rounded answers when compared to surveys (Roberts, 2020). The recruitment site was
at WCUMC located in a metropolitan city, where the county has a racial demographic of 51%
White, 8% Black or African American, 14% Asian, and the remainder of the population being of
mixed race (U.S. Census Bureau, 2020). The immediate surrounding area of WCUMC consists
mainly of Black/African American and Hispanic populations. Given these demographics, this
healthcare center is an ideal location to hear the stories of the local residents and their
interactions with primary care access and services.
Interviews
The primary data collection method was by telephone interviews. Participants were
recruited after being treated and discharged as an inpatient at WCUMC where they recently
underwent medical treatment. Prior to starting the interview questions, there was a brief
introduction of the study, detailed in Appendix A. Then, the participant was asked if they were
comfortable conducting the interview in English. All of the participants were able to understand
English, and none were excluded on the basis of language barrier. They were then asked for their
consent to be recorded. After receiving permission to record, the 14-question interview began.
Participants
The target population for this study was middle-aged ethnic minorities, 40–65 years old.
This is typically the age range where chronic medical conditions have gone uncontrolled for
more than 2 years and have created conditions that require acute medical care and hospitalization

40
(Cunningham et al., 2021). Ethnic minorities were chosen for this study because this group
continues to be disproportionately affected by health ailments in the United States (Alsan et al.,
2020; Magnani et al., 2018; Tai et al., 2021; Yuan et al., 2020) when compared to White
Americans.
This study included eight participants. The demographic makeup was five men and three
women, with an age range of 40–65 years old. Black/African Americans represented half of the
participants, followed by Hispanic/Latino and Asian, each of which represented 25%. The ethnic
diversity was representative of the surrounding population at WCUMC.
Instrumentation
This qualitative approach was done through recorded phone interviews, which lasted an
average of 50 minutes. This method was chosen for easier access to and comfort for the
participants. At the beginning of the interview, rapport was established in an effort to create a
comfortable environment. Then, an introduction of the study was given so that the participant
was aware of the questions that followed. The introduction and interview questions can be found
in Appendix A. This was a one-on-one meeting, with 14 open-ended questions followed by
demographic questions. The interviews were semi-structured to allow for follow-up, probing
questions, as needed, and to explore the participants’ answers further. The questions were
developed based on the Clark and Estes (2008) gap analysis framework to examine knowledge,
motivation, and organizational influences that may be deterrents in obtaining a primary care
physician. Approximately three to four questions focused on each of these areas of influences.
Some of the questions were worded to discuss both knowledge and motivation, or motivation
and organization, or another combination of any of the three.

41
Data Collection Procedures
The recruitment method was done by purposeful sampling. Over a one-week period, I
recruited 12 individuals who fully qualified for the study, with the goal to interview until
saturation was reached. An initial goal of 12 was chosen in case some of the participants were no
longer willing to be interviewed, or if they were otherwise unavailable. Eight to 10 interviews
were a guesstimate of when saturation of responses will occur. If responses were not saturated
after interviewing eight participants, the interview count would have exceeded eight until
saturation has occurred. Out of the 12 participants recruited, two became unreachable by phone;
two voicemail messages were left for each, without receiving a call back. It is unclear why they
were unreachable, but it could have been because they were no longer interested in the study, had
medical mistrust due to prior occurrences with medical staff, had questionable legal status and
were afraid of legal ramifications such as the threat of deportation, or had worsening physical
health requiring medical treatment and re-hospitalization. Saturation occurred at eight
participants, which is the number included in this study. The interviews took place over 7
consecutive days.
Prior to recruitment, a partial HIPAA authorization form approved by the University of
Southern California’s Institutional Review Board (IRB), as well as an approved authorization
form granting site access was provided by the city’s Department of Health Services, which
allowed me to access to the hospital’s electronic medical record (EMR) for research purposes.
The EMR was opened with my username and password where the first page (splash page) has
the following information: patient’s name, age, sex, and ethnicity, all of which is self-reported by
the patient upon registering at the medical center. The splash page also lists the location in the
hospital where the patient is located, along with their illness severity from least stable to most

42
stable (unstable, watch, stable, discharging), and diagnoses. A patient’s preferred language was
also often noted in the EMR. Patients who met the age criteria of 40–65 years old, whose illness
severity is “stable” or “discharging,” and who are an ethnic minority met the study criteria.
Those whose disease severity was identified as “unstable,” or “watch” did not qualify for the
study as they were currently undergoing medical treatment. An illness severity of “stable”
sometimes means the patient is discharging, though they still may be waiting on prescription
medications from the pharmacy, family notification, transportation, their belongings to arrive at
bedside, or are waiting for final paperwork from their medical team. If a patient is listed as
“stable” and is discharging, it is noted in their medical record from the patient’s medical team.
An illness severity of “discharging” means transportation has been set up, the patient has
everything they need from their medical team, and the patient is in a holding area ready to leave
the hospital. Only those who were “stable” with a plan to discharge the same day, and those
whose chart noted “discharging” were included in the study. All others were still receiving
medical care in the hospital setting, and thus did not qualify to participate.
After participants met the criteria based on age, ethnicity, and illness severity, their
location in the hospital was reviewed. Once identified, I went to the location, usually a holding
area inside the hospital while they were awaiting pickup and approached the potential
participants. I introduced myself by first name, and verbally stated that I was a physician. I also
added that I was not involved in their medical care and instead am speaking to them as a
researcher. I asked if it was okay to continue. After getting permission, I reiterated that I was a
physician, but also a student, currently conducting research on the barriers of obtaining a primary
care physician, and I was looking for participants to share their story. I asked if they would be
amenable to a recorded phone conversation not earlier than 5 days after they leave the hospital.

43
A 5-day waiting period was used so that the participant can continue focusing on their healing
and management of their disease process while at home. After the participant agreed, I reviewed
the informed consent with them. After reviewing the consent, I gave time for them to ask
questions. After all questions were answered and they were agreeable to the interview, they
signed the consent form. They were also given a copy of the informed consent. Additionally, I
told them I will obtain a verbal consent at the time of the interview. They were also informed
that they may have a follow-up phone call after the initial interview, if they agreed to one, to help
verify my interpretation of the data collected (member checks). In addition, I explained that their
identity will be de-identified. The participant then provided me their telephone number, where
they were contacted between 5 and 10 days after leaving the hospital.
I contacted the participants by telephone at the agreed upon time. After the introduction
of the researcher and the study, and after obtaining verbal consent to be recorded, I reminded the
participant they can terminate the interview at any time, and for any reason. Once they
acknowledged understanding, they were asked if they were comfortable conducting the interview
in English. All participants were able to speak English fluently. The voice recording began, and
the interview started. During the interview, I took notes on key phrases and used quotation marks
to delineate the direct words from the participant. The qualitative phone interview took on
average of 50 minutes. At the conclusion of each interview, I immediately summarized the key
findings.
Once the interview was completed, the voice recording and the transcript were kept on a
secure password-protected USB drive that was locked with a key in a cabinet. This method was
chosen over storage on a password protected computer in case the computer would be misplaced,
stolen, or become non-functional. The transcripts were de-identified by assigning random names

44
using an online name generator. The transcript will be erased 60 days after acceptance of the
final dissertation.
Data Analysis
The data were analyzed using thematic analysis, which identifies, analyzes and interprets
patterns of meaning (Castleberry, 2018). This approach evaluates qualitative data for themes or
perspectives (Creswell, 2014). Thematic analysis looks closely for repeated topics or ideas. This
method goes beyond counting only specific words or key phrases to make meaningful themes, as
is used in other types of analyses. Instead, it explores the meanings across the data set, and
involves meticulously evaluating data to determine similarities (Castleberry, 2018).
After the conclusion of each interview, the data was transcribed. After the transcription
was complete and checked for errors, I began the coding process with a software program
(NVivo, Version 20). Coding was done line-by-line for each transcribed interview, as this
method is often used because it allows for thorough analysis and often finds more significant
new findings when compared to other forms of coding (Khandkar, 2009). I used open coding,
which involves naming and categorizing the data. Open coding allows the identified data to be
closely examined, where the similarities and differences can more easily be compared. I coded
the data to the research questions with the assumptions of knowledge, motivation, and
organizational influences, and then analyzed the data for themes within those categories.
Appendix A provides a crosswalk between the research questions, category addressed, and
interview questions for the research questions and the corresponding category chosen for each.
One week after the interview, each of the study participants was contacted again to review my
findings. The participant was given the chance to correct and/or clarify any of my findings. After
such clarifications, the codebook was finalized, which is shown in Appendix B.

45
Credibility and Trustworthiness
Acknowledging the researcher’s positionality is essential to ensuring credibility and
trustworthiness of the study (Babchuk, 2016; Merriam & Tisdell, 2015), as the researcher will be
the primary data collector. The researcher must also be aware of their past experiences,
knowledge, and upbringing, as all of these can be an important factor in mitigating biases and
misinterpreting data to suit one’s current state of mind (Creswell, 2014; Creswell & Clark, 2017;
Merriam & Tisdell, 2015). I, as the researcher, actively reflected on my preconceived notions
and biases that may alter the objective findings and analysis of data. I acknowledge that I was
tasked with ensuring that the credibility and trustworthiness of the study meets the standard of
quality research-gathering and analyses (Merriam & Tisdell, 2015). I was also aware to not
prematurely summarize data during the data analysis process. Instead, all the data were analyzed
strategically, where the objective findings were clearly stated, without regard to my positionality.
I systematically reflected on my positionality throughout the data-gathering and analysis
processes, as this was vital to ensuring unbiased conclusions of the study (Babchuk, 2016;
Creswell, 2014; Creswell & Clark, 2017; Merriam & Tisdell, 2015).
Credibility or internal validity is how close the findings are to reality. A credible study
must capture findings that closely resemble the true state of the issue (Merriam & Tisdell, 2015).
Merriam and Tisdell (2015) states that the analysis of data can vary; studies will often show
people’s construct of their reality can change from person-to-person. However, internal validity
through qualitative findings uncovers the complexity of data, allowing the researcher to make
well-educated conclusions.
There are several ways to increase credibility. This study used member checks, also
called respondent validation (Merriam & Tisdell, 2015). Through this strategy, the researcher

46
solicits feedback from the preliminary findings from the people interviewed (Merriam & Tisdell,
2015). One of the most important ways of ruling out the possibility of misinterpreting data from
a participant is to verify with the participant your interpretation after the data is analyzed by the
researcher (Maxwell, 2013). The process of member checks is to take the preliminary analysis
back to some of your participants and ask if your interpretation is an accurate representation of
the participant’s thoughts. Member checks do not have to be performed on every participant but
should reach a number where the analysis of the data and the member’s agreeance of that
interpretation reach a threshold where both are at least more than partially congruent (Babchuk,
2016; Maxwell, 2013; Merriam & Tisdell, 2015).
A credible study is where, through member checks, the participant is able to recognize
their experience of events through the researcher’s interpretation. The participant can also finetune the interpretation as needed. Member checks can be done at the conclusion of all analysis,
or throughout the study (Merriam & Tisdell, 2015). This research study performed member
checks throughout the study, with all the participants who were interviewed. Interpretation of
data was mostly congruent between the researcher and the participant.
Ethics
Prior to collecting data, this research study went through a thorough review process with
the University of Southern California (USC) Institutional Review Board (IRB), while also
undergoing a separate review process with leadership at WCUMC. These processes were in
place to ensure ethical treatment of the participants.
The process first started with leadership at WCUMC being contacted. An email
introducing myself, description of the research study and methodology, and how the research
would be used was sent first to the medical center’s department administrator, followed by a

47
nursing representative, and lastly, the lead at the primary site of the hospital ward. This is a
formal process already in place at WCUMC, prior to starting any research. A pre-populated
document requesting such signatures was obtained by the researcher from WCUMC, ultimately
granting site access to interview hospitalized patients, and to access the medical center’s
electronic medical record (EMR). The next step was to submit to USC IRB for their review and
approval.
A partial Health Insurance Portability and Accountability Act (HIPAA) authorization
waiver was submitted to the Institutional Review Board (IRB), as this allowed me to review
patient’s name, age, and discharge diagnoses in the EMR at West Coast University Medical
Center. I received approval both from WCUMC and USC IRB in March 2023 after which the
data collection began.
It is important to protect the confidentiality of each participant. Further, participants
deserve to be well-informed of how their contribution to research will be used (Brazell, 1997).
Obtaining informed consent is paramount to information gathering and regulation of research
(Bhutta, 2004). Each participant was assigned a random name by use of an online name
generator, which simply provides as many random names as one desires. This was done to
protect the identity of the participant. I reviewed a hard copy of the informed consent during the
recruitment phase while the participant was discharging from the hospital. I allowed the
participant to ask questions, while I provided clarification. Upon agreeance to participate, the
study participant signed the informed consent form, and was also given a copy of the form before
leaving the hospital. The participants were ensured that their personal information abides by
HIPAA governing laws. Based on the study’s findings, recommendations to increase access to

48
primary care services are provided in Chapter Five and will be presented to WCUMC for their
review and further action, as this is an important ethical obligation of a researcher.
The Researcher
I decided to study this patient population because this is the population I identify with in
my own family structure. During my formative years and well into adulthood, I observed my
immediate family’s lack of seeing a consistent primary care doctor, and lack of motivation to get
one. My parents and siblings are Black Americans. My father did not have a formal postsecondary education, while my mother obtained one late in my teenage years. Research has
shown that educated people are healthier, have less physical and mental health disease, and live
longer than those who are less educated (Davies et al., 2018). Furthermore, my parents were
raised in the rural parts of Mississippi, at a time where mistrust of the medical system began to
form due to mismanaged healthcare by the U.S. government (Alsan et al., 2020; Vernon, 2020).
As a Black American, I saw firsthand how socioeconomic status and the lack of sufficient
financial resources can affect health (Sherman et al., 2022). My family was also not privy to the
many options that were available such as free or low-cost healthcare. We also did not feel as if
any of the surrounding healthcare organizations would be able to empathize with our previous
indiscretions. Now, as a Black physician, I understand how the lack of awareness can cause one
to defer their own healthcare, contributing to more complicated disease processes (Jaeger et al.,
2019; Sherman et al., 2022). In my daily workplace, I remain aware of the motivational issues
that people of color continue to face, because I have faced many of them myself. I also
understand the importance of community healthcare organizations to have capable outreach
efforts to build comradery and trust with the ethnic minority community (Mullins et al., 2018).
Though I believe I understand many of the barriers minorities continue to face in having

49
consistent preventive medical services, I also recognize that people may have their own different
experiences why they are not under the care of a physician. This can range from past issues such
as experienced or observed medical malpractice, death of a loved one, language barriers, or the
concern about immigration issues. Paying note to my own biases allowed me to remain openminded and objective, giving each participant to share their individual story.

50
Chapter Four: Findings
This study’s objective was to examine the knowledge, motivation, and organizational
barriers middle-aged ethnic minorities face in obtaining primary care services. The study aimed
to obtain lived experiences from ethnic minorities and how they have experienced and continue
to experience barriers in obtaining consistent care by a primary care physician. The research
questions were developed to obtain a deep understanding of the many roadblocks ethnic
minorities have faced throughout their healthcare journey. The interview questions were
specifically designed to gather in-depth responses that tell the story from the patient’s
experiences. Four research questions guided this study:
1. What are the knowledge gaps middle-aged ethnic minorities have, preventing them
from having a primary care provider?
2. What is the motivation that hinders this population from obtaining primary care
services?
3. What organizational roadblocks delay this population from obtaining healthcare
services?
4. What are the recommendations to close the gap of inequitable access to preventive
medicine in middle-aged people of color? This will be discussed in Chapter Five.
Participants
This qualitative study consisted of eight participants. A pseudonym for each participant
was given to maintain confidentiality and anonymity. The study included five men and three
women, aged 40–65 years old. Black/African Americans made up 50% of the participants
interviewed, followed by Hispanic/Latino and Asian, each of these groups representing 25%.
Table 3 provides demographic information for the participants. All participants resided on the

51
West Coast of the United States and were considered low-income based on their adjusted gross
income and family size as determined by the California Department of Housing and Community
Development (2023). Table 4 shows the income threshold for Los Angeles County.
Table 3
Demographics of Participants
Pseudonym Ethnicity Sex Age (years) Income ($) Family size
Andy Black Man 45 <45,000 2
Crowley Asian Woman 64 <45,000 2
Dianne Black Woman 65 <45,000 1
Fordy Asian Man 62 <60,000 4
Fred Black Man 40 <45,000 1
Ross Black Man 41 <30,000 1
Matty Hispanic Woman 54 <45,000 3
Willy Hispanic Man 60 <30,000 1

52
Table 4
Income Threshold in Dollars for Los Angeles County in 2023
Income category Number of persons in household
1 2 3 4 5 6 7 8
Acutely low 10,350 11,800 13,300 14,750 15,950 17,100 18,300 19,450
Extremely low 26,500 30,300 34,100 37,850 40,900 43,950 46,950 50,560
Very low 44,150 50,450 56,750 63,050 68,100 73,150 78,200 83,250
Low 70,650 80,750 90,850 100,900 109,000 117,050 125,150 133,200
Median 68,750 78,550 88,400 98,200 106,050 113,900 121,750 129,600
Moderate 82,500 94,300 106,050 117,850 127,300 136,700 146,150 155,550
Research Question 1: What Are the Knowledge Gaps Middle Aged Ethnic Minorities Have,
Preventing Them From Having a Primary Care Provider?
This first research question sought to examine the knowledge gaps ethnic minorities face
that have hindered them from having consistent healthcare with a primary care doctor. This
question was addressed with the participants detailing their ability to access healthcare services,
when they were first introduced to the necessity of a primary care doctor, and explanations of
what role they believe primary care physicians have in their overall health goals. The
participants’ responses yielded two key findings:
1. Inadequate exposure to preventive health services during childhood leads to an
unknown role of a primary care physician.
2. Ethnic minorities do not know how to access primary care services.

53
Finding 1: Inadequate Exposure to Preventive Health Services During Childhood Leads to
an Unknown Role of a Primary Care Physician
All eight participants stated they did not see a primary care doctor until they reached
adulthood. This lack of exposure resulted in these participants not having the wherewithal and
understanding of the necessity of a primary care doctor and the preventive health services this
specialty has in their overall long-term health. This was demonstrated by Crowley who said:
I wasn’t educated about this as a child. I was always taught to go to the doctor when
something is wrong. I didn’t know to go to the doctor when things were going right. I
could have prevented this [health] issue from becoming debilitating. Now I can barely
walk.
Not having sufficient interactions with a primary care doctor as a child led to not understanding
the role this doctor has in the prevention and maintenance of disease. Ross, similar to Crowley,
stated, “The main issue I have is probably ignorance, followed by lack of education. As the
saying goes, I don’t know what I don’t know. No one told me the importance of seeing a doctor.”
This sentiment resonated with many of the participants in that they were never exposed to, or
informed about, the role of primary care. Due to this lack of exposure, the role of this doctor was
not fully understood. Fred discussed this lack of understanding when he said:
It took several decades for me to learn what a primary care doctor does, and how they are
really a champion for your physical and mental health. I wish I knew this is what they did
earlier in my life, but I was really never taught on what a primary care doctor does.
Not being able to interact with a primary care doctor prior to adulthood led to uncertainty of the
primary care physician’s role. Matty immigrated from Mexico with her parents and younger
brother when she was 9 years old. Matty recalled her father not feeling well when he used to take

54
her to grade school during her pre-teen years. Matty remembers asking her dad why he will not
see a doctor. Matty said her father’s answers were never direct, and he always assured her he
would be okay. Her father eventually passed away due to complications of diabetes when Matty
was in high school. It was not until Matty was almost 18 years old did she ask her mother why
her dad never sought medical care. Her mom told Matty that their family had to avoid medical
visits because they did not have legal status in the United States. Matty’s mom told Matty that
they always believed seeing a doctor would put the family at risk for deportation, and they would
only see a doctor when it is absolutely dire. Matty’s father got very sick and he finally went to
the emergency room where he succumbed to his ill health only a few days later. As a child, then,
Matty never saw a reason to see a primary care doctor unless absolutely needed. Matty said:
The doctor wants to treat all of your medical issues when they happen. When you get
sick, you go to the doctor. I don’t think there’s a reason to see a doctor any other time. I
never did as a child. My parents never did unless they had to. Some people see the doctor
when they are healthy; I never understood why.
A primary care doctor not only treats acute illnesses as they arise but they are also tasked
with providing health maintenance to prevent disease from even occurring. However, the study
participants did not understand this role of primary care as they were never accustomed to their
role prior to adulthood. Andy said, “When I was healthy, I didn’t see the need of having
consistent follow up care. No one thinks of seeing a doctor when you are healthy.” The role of
primary care then is not intuitive. It must be taught and integrated into one’s life.
When ethnic minorities gain exposure to primary care, they are able to understand the
importance of preventive medicine and consistent follow up. Crowley, a native of South Los
Angeles, said he grew up in a poor household. He believed his parents worked hard, but never

55
seemed to have anything tangible to show for it. Crowley recalls growing up where his parents
often dissuaded him from playing sports in high school because if he got hurt, they would not be
able to afford any medical bills. Crowley was eventually able to play basketball in high school,
in lieu of football as he had wanted, because basketball had less contact. He recalls his mom
telling him not to get hurt because there was not enough money to pay for any extra bills.
Crowley said that this had trained him to avoid doctors, until he was seen by a primary care
doctor for high blood pressure and weight gain. When he met with his doctor for the first time,
he was impressed by the visit, and was amazed at how thorough his doctor was. Crowley said:
[The doctor] took time to listen to my medical issues, examined me, and gave me a
diagnosis. They also told me about things I can do to make my issues better, and how to
prevent other diseases from happening. I was surprised they did all of this.
Primary care doctors aim to prevent disease, but when disease does present itself, the
doctor is crucial in diagnosing and implementing medical treatment. Sometimes, however,
unfavorable diagnoses to the patient unevenly skews the patient’s ideas of what their primary
care doctor does. This may be particularly true when someone does not have early knowledge
related to the role of a primary care doctor and exposure to a primary care doctor only later when
they are sick. Fordy suggested this when he said, “The purpose is for them to tell you everything
that is wrong. I don’t think they give good news, right? They only tell you the problems.”
Crowley similarly added, “No one likes going to the doctor. They always give you bad news. I
want to hear good news, not bad news.” Though medical issues arise in one’s life, it is often
more advantageous to be properly diagnosed so a treatment plan can be presented. However, not
having the proper exposure and developing good relationships with a primary care doctor can
lead to knowledge gaps and can be devastating to one’s health.

56
Finding 1 showed that the lack of exposure to primary care services in the ethnic minority
population during childhood often leads to not knowing the role of a primary care doctor. Late
exposure in adulthood can lead to misunderstandings, avoidance, and poor health outcomes.
Prevention of medical illness and maintenance of disease processes is not fully understood as the
relationship between the patient and primary care doctor has not been established. Study
participants showed that they were not given the scope of how primary care plays into their life
when they were children, which led to knowledge gaps that had not been addressed until proper
exposure occurred later in life when medical issues arose.
Finding 2: Ethnic Minorities Do Not Know How to Access Primary Care Services
Obtaining primary care services in the United States is not always intuitive. Unlike other
countries, the United States does not have socialized medicine where the government owns and
operates healthcare facilities and is responsible for the medical expenses of the citizens. Instead,
one often needs to know the specialty of the doctor they are looking for, if this doctor’s office
takes their insurance, and if the patient does not have insurance, where can they go for assistance
so they can be seen by a physician.
Establishing care with a primary care doctor often requires a lot of steps with minimal
guidance, and it can be difficult to know where to start. The United States Preventive Taskforce
Services (USPTF) recommends seeing a primary care doctor twice a year, and sometimes more
often if one has certain diseases, or is at risk of certain diseases through lifestyle or family
history. They also publish additional guidelines like when to see a gastroenterologist for routine
colonoscopy for evaluation of gastrointestinal cancer, or when to see a lung specialist for
evaluation of lung cancer in those who have or had a smoking history, all of which start with the
assessment by a primary care doctor. There are many nuances to their guidelines, but it is

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difficult to follow unless you are formally taught. Dianne said, “It is not always easy trying to
figure out what or who you need in terms of healthcare services. Of course, there is a primary
care doctor, but there are also many other specialists that you might need too.” The role of the
primary care doctor is to advocate for the prevention of disease, as well as refer to appropriate
specialists so that patients receive more individualized medical care if needed. All assessments
start with primary care, who is designed to be at the forefront of one’s medical needs.
As suggested by the participants, not understanding where or how to access primary care
services can be distressing. Sometimes, it can lead to a delay in care, or for one to feel ostracized
by the medical community. Fred suggested this type of distress when he said:
I would just give up on trying to see primary care because no one tells you where to start.
If I have something I need to talk to a doctor about, there is no Step 1, do this, Step 2, do
this. I don’t know where to begin any of this.
The lack of a clear stepwise approach to finding a doctor can lead to uncertainty and even
avoidance of establishing care. Furthermore, not knowing how to access preventive health
services may cause one to inappropriately rely on emergency services for a condition that could
have been seen, evaluated, and managed by a primary care doctor. While this reliance on the
emergency department for non-emergent issues causes overfilled emergency rooms, long wait
times, and improper use of the emergency healthcare system, several participants reported the
use of emergency services for issues that could have been addressed through a relationship with
a primary care doctor. For example, Fred said:
On one hand, I want to avoid using the emergency room as my first visit to a doctor, but
on the other hand, the wait time, insurance, and other healthcare bureaucracy it takes just
to see a primary care doctor in the office setting is daunting. If I go to the emergency

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room, I know I will be seen the same day. If I had a starting point to establishing care
with a primary care doctor, then I wouldn’t be in this mess. But the whole process is
confusing.
Relying on the emergency room for preventive health services has been an increasing problem,
especially for ethnic minorities, as this group is the most disproportionately represented group
for emergency room visits (Bazargan et al., 2019). However, as suggested by the study
participants, it is often the only method they know how to navigate. Dianne said, “I would like to
think that getting healthcare is easy to do when in fact, that is not the case, but the emergency
room is always there.”
The study participants who were low-income, ethnic minorities did not understand the
many approaches to finding a primary care doctor. In practice, this can be done by various
methods such as calling a toll-free county help line that directs patients to such physicians even
without insurance, calling their insurance company who will guide them to a primary care doctor
in their approved health plan or network, or using the many free online tools that will also assist
those in search of a primary care doctor. The above approaches exist, but a central hub to find
this information has not been well established, and study participants were unaware of resources
available to access primary care services. Not knowing how to access these services left several
participants feeling distressed and, ultimately, using emergency care services instead.
Research Question 2: What Is the Motivation That Hinders This Population From
Obtaining Primary Care Services?
This second research question sought to examine the motivational roadblocks ethnic
minorities face in establishing continuity with a primary care doctor. This question was
addressed with the participants telling the specific barriers they have encountered when seeking

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preventive health services. Their responses uncovered two main categories of motivation: task
value, where motivation and performance are enhanced if one believes the task in question is
valuable, and expectancy outcome, where one believes the behavior will or will not lead to a
given outcome. The first finding relates to decreased task value, while the other two findings
relate to decreased expectancy outcome.
1. Healthcare concerns are not valued.
2. Primary care doctors are not thorough enough.
3. There is inadequate time spent with the primary care doctor.
Finding 1: Healthcare Concerns Are Not Valued
When patients believe their primary care doctor does not value their medical and
psychiatric complaints, they begin to believe the time they spent with their doctor is futile.
Patients expect their doctor to address all their medical needs, however big or small they may
seem. However, the participants in this study experienced situations where their doctor appeared
to have either ignored or minimized their complaints, which led the participants to not want to
return to their medical appointments.
Patients are encouraged to establish care with a primary care doctor as early in their life
as possible. This creates a healthy doctor-patient relationship that can be beneficial from a very
young age. Patients expect to entrust their doctor during some of their most vulnerable and
potentially embarrassing times in life. However, when the patient believes their doctor does not
listen to them, it has the potential to ruin the relationship between doctor and patient. Andy
expressed this effect on his relationship with his doctor when he said, “It didn’t seem like he [the
doctor] listened to any of my complaints. It feels like my issues weren’t important enough to
him.” Andy believed that his primary care doctor did not listen to his medical issues as

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intuitively as he had expected. He felt as if the doctor either did not want to address his issue or
did not have any interest in his issue. This dissuaded Andy from returning to his primary care
doctor as he no longer felt this was a valuable experience worth his time.
When a patient visits their primary care doctor, they expect to be able to discuss both
acute and long-term issues that are affecting their health. Primary care doctors are trained to ask
introductory questions querying why the patient came to the visit, and if the patient has any
concerns that need to be addressed. These statements are meant to encourage the patient to
discuss any outstanding issues that are important to them. However, patients sometimes feel like
the responses from the doctor are dismissive, as was expressed by Willy who said:
I also didn’t feel like my doctor listened to all of my problems. I would mention a
complaint, and it seemed like he just brushed it off and didn’t ask more questions about
it. I don’t understand why he asked me a question and didn’t bother to even listen to me.
The term “medical gaslighting” has been coined to define the dismissive nature of
doctors as it relates to patients’ complaints. This term is also used when a patient believes their
doctor is criticizing their complaints, doubting their patient’s complaints, being accusatory to a
patient in the belief that the patient is making something up, or simply refusing to participate and
discuss a patient’s issue. Matty expressed this sentiment when she said, “I never felt enthusiastic
about returning to my previous doctor because she seemed too dismissive. What is the point of
me going if my issues aren’t grand enough for them to address?” Matty felt like her first two
primary care doctors did not invest enough time into the issues she thought were important to her
long-term health. She wanted to discuss weight loss and nutrition on several visits but was only
repeatedly told to continue going to the gym and eat fruits and vegetables. She never felt as if her
doctors took any real interest in this topic that concerned her as she comes from a family of

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obesity and obesity-related issues. Matty, however, did eventually find a primary care doctor
where she believed her concerns were acknowledged. She said, “I do not have many health
problems, but it was good that my new doctor took the time to explain elements of nutrition to
me.” She added that during this visit, she has increased her satisfaction with her new doctor, and
said her newfound professional relationship is refreshing. Matty’s experiences with three
different primary care doctors highlight the importance of task value, and how this shapes future
actions. Matty’s first two experiences did not go as she had liked. She felt as if her concerns were
ignored which has led her to not value the task of returning these doctors. She left her
appointments unsatisfied and incomplete. She did eventually find a primary care doctor who
thoroughly explained the issues that were important to her. She placed a high task value on these
visits as she felt this doctor was cognizant of what was important to her. Because of this
association, Matty continues to see the physician who she says has continued to show mutual
interest in ensuring she remains healthy.
Finding 2: Primary Care Doctors Are Not Thorough Enough
Primary care doctors are responsible for the maintenance and treatment of acute and
chronic illness of their patients. Therefore, the expectations patients have for them is to be
efficient yet pay attention to detail when appropriate. Patients rely on their expertise to be
competent, accurate and comprehensive, from their medical workup of medical illness to the
explanations they give to their patients. Six out of eight participants in this study stated that they
were unimpressed by the lack of detail they were provided by their primary care doctor, which
caused them to lose motivation and the desire to return.
When a patient reports a physical or mental complaint to their primary care doctor, the
expectation is that their doctor asks relevant questions, explains the workup of their issue,

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reviews the key findings of that workup, and explains it to them in a way that the patient can
comprehend. By contrast, Andy explained how he visited his primary care doctor for a complaint
of a non-healing wound on his foot. He decided not to go to the doctor for several years as he
assumed the wound would heal itself. When it began to have a pungent smell, leaked blood, and
became more painful, he decided to establish care with a doctor. Andy said his doctor did blood
work and got an X-ray of the foot, but when he returned for the results, he was dissatisfied with
the explanation he was given. Andy said:
I didn’t understand all of the tests they ran on me. I felt the doctor wasn’t thorough
enough. I only wanted her to discuss each of the results with me. Prior to that visit, they
took a lot of blood tests, but didn’t tell me in enough detail what those results were.
After that visit, Andy was so frustrated with the lack of thoroughness he decided not to return to
the doctor. He said he felt as if he knew the same information before the appointment as he did
after, since the results of the findings seemed to be “glossed over.” After several months of the
wound getting worse, Andy later presented to a local emergency department where he was
hospitalized for a severe infection in his blood, which started from the wound in his foot. When I
asked Andy why he decided not to return to his primary care doctor, or any other doctor before
the wound got worse, he said, “the information they gave me wasn’t thorough enough. That’s not
fair to me.”
When patients feel as if they are not given enough detail to the reason of their illness,
steps to diagnose, or explanation of the diagnosis, they have feelings of being lost or abandoned
by one of the persons who they trust with their sensitive information. Ross said, “I wish the
doctor would have taken time to explain things to me more thoroughly. By the end of the
conversation, I felt like a neglected child in foster care. Yes, it was that bad.” Ross explained that

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the doctor provided ideas of what he thought would be the cause of his medical problem but
failed to explain why he thought of these causes, and what would be required to determine which
of these would be the most likely diagnosis. Ross said he felt as if the conversation was not
complete, and he left with more questions than answers. Ross added, “I could have used an
online search if I wanted to find a bunch of words that didn’t make sense.” Ross switched his
primary care doctor more than two times for similar issues. He said he finally found one who
gave more detailed answers and explanations. During this switch however, his medical condition
worsened which required him to be hospitalized—something he was trying to avoid. However,
he believes the time and effort it took to switch doctors was worth it in the long run.
When participants believed their doctors provided thoughtful, detailed explanations, they
were more satisfied with that visit and more likely to return. Participants appreciated it when
their primary care doctor took time to provide answers and gave detailed explanations when
warranted. Dianne’s first time being evaluated by a primary care doctor was when she was
pregnant with her first child in her early twenties. Dianne was raised in the south where she says
it was almost taboo to go to the doctor unless something was “very serious.” She says the south
has deep-rooted hatred towards those in the medical profession because of how medical doctors
treated people of color. She described situations of racism and prejudice she observed when
accompanying her parents to medical visits when she was a young child in the 1960s. Because of
this, she generally avoided doctors, which she says was almost customary during that time.
When she got pregnant, however, she was afraid and had a lot of questions she needed answers
to. Dianne was thankful that her first experience of seeing a primary care doctor was a good one.
Dianne said:

64
My first experience was surprisingly a good one. I had questions and my doctor had
answers. The doctor explained what to expect during the pregnancy, and the vitamins I
need to take. She also explained complications I can have throughout the pregnancy. I
remember leaving shocked because the doctor exceeded my expectations. However, most
of my friends and family had quite opposite experiences. I was lucky and continued
seeing the doctor throughout my pregnancy.
A visit with a primary care doctor is supposed to be a trusted space where patients come
to bring a wide range of health issues that they believe require appropriate attention. That
appropriateness includes attention to detail and being meticulous and comprehensive. When
participants felt that their issue did not get enough attention as it deserved, they had less interest
in returning. When the doctor, however, did give sufficient time and detail to the patient’s
sensitive needs, the participant was more likely to return, strengthening the rapport between
patient and doctor.
Finding 3: There Is Inadequate Time Spent With the Primary Care Doctor
When patients want to discuss their past, present or future health conditions, the
expectation is that they have adequate time allotted to convey their issues to their primary care
doctor. However, seven of the eight participants stated that the face-to-face time with their doctor
was insufficient. They believed that they were not able to discuss their issues in the limited
amount of time they were given. The visits were often cut short and left the participants with
unanswered questions they thought would be addressed. Leaving the appointment unfulfilled
created an additional barrier in the participants not having the desire to return.
The average primary care visit with a physician is about 16 minutes (Overhage &
McCallie, 2020). Within this timeframe, the physician and patient usually discuss relevant past

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medical history, any current issues that need to be addressed, and execution of preventive
measures such as vaccine administration or blood draws. To this point, Andy said, “The
appointment went too fast. I waited a very long time to see the doctor, but the appointment only
lasted a few minutes. There wasn’t enough time for me to explain all of my issues.” Often,
patients wait an extended time between setting up the doctor’s visit and seeing the doctor. The
average wait time from appointment to visit is generally 3 months, sometimes longer (ChidoAmajuoyi et al., 2023; Martinez et al., 2019). Within this wait time, medical issues can snowball
and worsen, requiring more time and attention at the in-person visit. When these issues are not
addressed, patients believe their medical problems worsen. This was the situation with Andy
who added:
I had questions and expected answers but wasn’t even able to address any of the
questions I had related to the tests they ran. I really believe not being able to spend time
with the patient delays care, ultimately to have my medical issues mismanaged.
The participants noted that the time to wait for an appointment and the time spent with
their primary care doctor did not appear to be aligned. Dianne said she was extremely nervous at
her first primary care interaction. She did not know what to expect with the pregnancy and since
this was her first time seeing a doctor, she thought the visit would last more than 10 minutes. She
was surprised that the visit went much quicker than anticipated. She was disappointed that she
had a lengthy pre-appointment wait time, only to see the doctor for a few minutes. Dianne said:
When I actually saw the doctor, it was a fast conversation, mainly about the pregnancy
and further checkup I would need in the future. I remember feeling it was too brief. I
spent forever waiting for an appointment only to have a few minutes with the doctor.

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Many of the participants were displeased at the time spent with their doctor. Fred, a social
worker, continued to be dissatisfied with the minimal time he has been able to talk with his
doctor. This has questioned his desire to return. Fred said:
The actual time with the doctor was only about 10 minutes. It’s bizarre. All of the waiting
boiled down to 10 minutes to discuss my health. Sometimes I think, “What’s the point of
doing all of this?” Maybe I just shouldn’t go.
Because of the short time with the doctor, Fred has mostly avoided seeing his primary care
physician. Instead, he goes to the local emergency department for his issues. He believes that
since it is in an emergency setting, the doctors seem to take more time with him as they have to
be thorough. He believes the opposite is true when seeing his primary care provider; because he
is stable, his current issue is not as concerning, thus the short time with his doctor. Ross, too,
stated that he rarely visits his primary care doctor due to similar dissatisfaction. He said his
recent visit with his primary care doctor went too quickly. He expected the visit to “go slower,”
because there were important test results he wanted to discuss. However, the visit lasted less than
10 minutes and he believed the visit was incomplete. Ross said:
I wish the doctor would have taken time to explain things to me. Everything seemed very
rushed. I know they are busy and there are a lot of patients, but my visit with the doctor is
important too. There needs to be better balance with ensuring patients get the most out of
their visit. Otherwise, why bother coming?
It is essential that patients feel as if their time spent with a primary care doctor is
commensurate with issues they would like to discuss. However, the participants repeatedly said
they often have several questions or are seeking explanations to past and current medical issues
but do not have enough time for such discussions. When the appointment times are too short, it

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can lead one feeling as if the time spent was inadequate, which contributes to the lack of
motivation in the desire to return. The patient is then lost-to-follow up, which in the medical
community means a patient was previously seen but has not returned. Because patients do not
return, future diagnoses are not made, and/or their previous medical issues begin to worsen.
When patients do feel as if their visits are fruitful, they are more likely to have good rapport with
their doctor and more likely to return. In the case of the study participants, expectancy value was
diminished. The participants expected to have thorough conversations about their health, but the
actual time spent with the doctor was far less than anticipated. This created negative associations
with the participant and their doctor visits.
Research Question 3: What Organizational Roadblocks Delay This Population From
Obtaining Healthcare Services?
This third research question sought to examine the organizational obstacles ethnic
minorities face in developing a healthy relationship between themselves and their primary care
doctor. Though the doctor is important, the business practices of the medical facility are also
important. One cannot solely exist without the other. The two must have a symbiotic relationship
in order for the patient to have a positive experience. Patients want to feel safe and comforted
and have some level of familiarity with their doctor and doctor’s medical facility. There were
two organizational issues the participants said needed to be addressed:
1. Excessive wait times are a major hindrance to establishment and follow up with a
primary care doctor.
2. There is a general lack of community presence leading to patient unfamiliarity with
the doctor and their medical practice.

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Finding 1: Excessive Wait Times Are a Major Hindrance to Establishment and Follow Up
With a Primary Care Doctor
One of the first steps in seeing a primary care doctor is setting up an appointment. This
typically involves calling the medical office and speaking to a front desk representative. Often
times, this representative is trained to multi-task: they answer phones, check patients in and out
of the office, and are responsible for filing, faxing, scanning, and doing additional work on the
computer. The representative who can multitask is advantageous to the organization but may not
be as advantageous to the patient who is attempting to schedule an appointment as phone wait
times are often quite lengthy. After the appointment is set up, the pre-appointment wait time can
be several months before one is able to see their doctor. The combination of these two events had
led participants to deter establishing care and following up with a primary care doctor.
Phone Wait Times Are Too Long
To schedule an appointment with a doctor, most medical offices require the patient to call
and schedule an appointment. During this call, the patient’s availability is matched with the
doctor’s availability. When both agree, an appointment can be made. More than half of the
participants interviewed expressed discontent during this process. Andy said:
Sometimes it just takes too long for them to answer the phone. There have been many
times where I would call just to be put on hold. I sometimes wait 10 or even 15 or 20
minutes before someone talks to me.
Andy said this has often been the case with multiple doctors he has visited. He expressed
frustration at the process of trying to see his doctor. He added that after waiting on the phone for
extended periods of time, he no longer thought it was worth the wait and would “give up.” The
first time Dianne saw a primary care doctor was when she was in her early twenties. Dianne is

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from Mississippi, and she said the medical community is generally not trusted due to past issues
of medical negligence and experimentation that was done on people of color. However, her first
pregnancy prompted her to get medical advice. Dianne says that from then until now, almost 40
years later, the time it takes to schedule an appointment is about the same. She recalls attempting
to set up a primary care visit in the 1980s, only to be on hold for almost an hour. Around early
January of 2023, she needed to visit her doctor but after waiting on hold for 20 minutes with the
scheduler, she gave up and hung up the phone. Dianne said throughout her life, she has
continued to experience very long hold wait times to do “this simple task.” Fordy expressed a
similar sentiment when he said, “The time holding on the phone can easily exceed 10 minutes. If
I have to wait that long, sometimes I just hang up.” Matty echoed this when he said, “I would
call to make an appointment, and the phone rings for a few minutes. Then someone answers and
puts you on hold for several other minutes. I don’t understand it.”
Excessive wait times on the phone with front desk staff had led study participants to not
want to follow through with their commitment in seeing their doctor. Fred said he often bypasses
his primary care doctor and chooses an urgent care center or emergency department because with
the time it takes to wait on the phone, he could be seen in-person, albeit a doctor who does not
know much about him or his medical history. But Fred said it was worth not having to wait for
extended periods. He added, “you just show up at urgent care, sign your name on the line, and
wait to be called.” Wait times on the phone appeared to be quite problematic amongst those who
were interviewed, and even after they had endured the wait time and an appointment was finally
established, the pre-appointment time to see a doctor was yet another barrier that this group of
low-income ethnic minorities continued to face.

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Pre-Appointment Wait Times Are Lengthy
On average, it takes about 3 months from the time an appointment is established to the
time one can have an in-person visit with their primary care doctor. Oftentimes, patients expect
to have this visit within 2 weeks. However, this is not feasible for most outpatient medical
practices. The long pre-appointment wait times led to further deterrence for study participants
who wished to visit their primary care doctor. Ross, for example, said that around the time of the
coronavirus-19 outbreak in 2020, he became more inclined to address some health problems that
he put on hold for several years. Once the pandemic improved around 2022, he wanted to
establish regular cadence with a primary care doctor so that he would have an advocate for his
health since he had never had a doctor in the past. He called to schedule an appointment but was
told there were no available appointments for the next 5 months. He called a different primary
care doctor and was told it was a 4-month wait. Though he did wait the 4 months, he
acknowledged that the wait was almost “inhumane.” Ross said he was blessed to be generally
healthy, but he empathized with those who are sick and have multiple medical issues stating,
“what happens to them, they have to wait 4 months too? This is very sad.” Matty said over the
years, she had become strategic with her medical visits. Because the wait time is generally 4 to 5
months, she would schedule her appointment with the expectation that she would go to an urgent
care facility midway through. Before leaving her in-person visit at her doctor’s office, she would
schedule her next appointment so that she was not on hold “forever,” and did not have to wait
more than 5 or 6 months to be seen again. Matty has chronic lung problems that often flare up to
the point where she needs breathing treatments. She can get breathing treatments during her
medical visits, but once every few months, she said, is not enough. Matty would instead go to
urgent care for her breathing treatments. When urgent care had a long wait time, she would go to

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her local emergency department. Matty said she is always chastised in the emergency room
because they know she has a primary care doctor who can provide this treatment for her, but she
rebuts and says, “It takes too long to see my doctor. What am I supposed to do, suffocate at
home?” Fred also said he had relied on the emergency room as an alternative to waiting several
months to see a doctor. Fred said he has had issues with indigestion for several months. The
indigestion was worsening to the point it was difficult for him to sleep. This was affecting his
daily activities as he was often routinely awakened in the middle of the night with a burning
sensation in his stomach and throat. Fred called his primary care doctor for assessment and
treatment but was told the wait would be 3 months. Fred recalled the time he had these
symptoms and said he was quite miserable. He said he could not endure these symptoms for
another 3 months and instead went to the closest emergency department on his day off of work.
While at the hospital, he waited several hours to be seen by a doctor, but said the doctor
diagnosed his issue and gave him a prescription to suppress the acid. Fred said the issue was
taken care of within a day, and although he wanted his doctor to be abreast of the situation,
waiting several months would have left him “debilitated.” Fred said, “We have to do better with
these extended wait times. They do not benefit me or anyone else really.”
This finding showed that wait times, both on the phone trying to schedule an
appointment, along with the time needed to wait after the appointment has been established,
continue to dissuade low-income ethnic minorities from seeing a primary care doctor. Their
medical issues that could be addressed by a primary care doctor are instead being seen in the
emergency room, thereby creating an influx of non-emergent stable conditions that are
inappropriately routed to an emergency room physician. However, participants felt as if this
alternative was the only feasible one given the time it took to set up and see their doctor. The

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times needed to wait for their appointment were yet another hindrance for these ethnic minorities
in pursuit of establishing a relationship with and following up with their primary care doctor.
Finding 2: There Is General Lack of Community Presence Leading to Patient
Unfamiliarity With the Doctor and the Services They Provide
A primary care doctor is often seen as one who is intertwined in a patient’s life as they
age. They are trained to see those starting from early adulthood until geriatric age. Because these
doctors often see patients during some of their most vulnerable times, the expectation is that
primary care doctors are pillars of one’s community. The profession of medicine is one that is
highly respected and as such, primary care doctors are believed to have a duty and obligation to
be leaders and advocates for their patients and for their community. However, this is not often
the reality. In fact, many study participants believed primary care doctors have not done enough
to show the community they are vested in their lives. Andy, for example, said he continued to be
dissatisfied by the lack of presence of his past and current primary care doctors. Andy had been
living in the same area for more than 2 decades and believed the medical facilities around him
had done close to nothing for the community. He added that this is even more important in the
inner-city of Los Angeles where he lived as the residents are predominately people of color who
already have mistrust in the medical system. Andy said:
The primary care offices need to remind us they exist. They should do more blood drives,
or educational seminars for people in the community. The medical staff needs to get out
of the office, and venture into the community. How else are we supposed to establish
comradery if we are sitting at home, and the medical staff is sitting in their offices?
Andy believed there was a growing disconnect between community and medicine, and this
disconnect perpetuates indifference to primary care physicians. Crowley expressed similar

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discontent. He said, “Healthcare organizations need to increase their presence outside of the four
walls where they practice. People belong to a community, so showing up in the community is
important.” He further suggested that primary care doctors or their representatives should be seen
in their churches, block parties, and shopping centers. He would like them to do community
health fairs where they can get guidance on general health-related issues. Andy believed this
would establish rapport with those in the community. Dianne said that although she was
generally healthy for her age, she believed primary care doctors have not done enough to let the
community know that they are there to be advocates for their health. Also, living in an area
where the population is predominantly people of color should be an area of extra concern.
Dianne said:
I would just like to add that we do need more consistent outreach particularly in lower
income areas. I’m speaking primarily of the black race right now. We need more
information about what services our primary care doctor is supposed to provide.
Sometimes I feel oblivious, which is not a good word to describe how I feel about my
doctor.
Dianne acknowledged that primary care doctors do more than diagnose and treat. Dianne said
she was surprised at her last visit with her primary care doctor, because she was informed they
had a nutritionist to review her diet and provide recommendations for healthier balanced meals.
She asked how long this office had a nutritionist, and she was told many years. Dianne had been
to this doctor several times over the past 5 years and never knew there was a nutritionist. She felt
that if her primary care doctor’s office also focused on educating the community on the services
they provide outside of the clinic, she would have been privy to these services offered by her
doctor. Dianne recalls going to a healthcare fair with her son in a neighboring, predominantly

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White community. Dianne’s son had been looking for a heart specialist to discuss the family’s
history of coronary artery disease. During this fair, she noticed many of the community’s
medical offices were in attendance. Dianne was impressed at how the healthcare organizations
advertised all the services that were available in that medical facility. Dianne said prospective
patients were able to sign up with a mental health therapist, get a therapist for school-aged
children, and had other services available such as nutritionists, chiropractors, and even personal
trainers. Dianne says she was perplexed that other medical facilities show everything they offer
during community fairs, but her doctor does not, even though they have similar services. Dianne
believes the latter highlights how important it is to educate outside of the clinic walls so that
patients have an understanding of what is available to them. In similarity to Dianne’s experience,
Fred found out there was a medical social worker he had access to because of his establishment
with a primary care doctor. Fred had been recently diagnosed with high blood pressure, but he
often had trouble getting his medication due to lack of insurance. The medical social worker was
able to connect Fred with city resources, where he was now able to get his blood pressure
medication for only $5. Fred said it had been a tremendous help to utilize the additional services
his primary care doctor has, but admittedly was angry that no one told him about this benefit
even after seeing this doctor in the past. He said he had spent hundreds of dollars on medications
and even had gone months without, because he did not know the additional services his doctor
provided. He advised primary care doctors to further explain everything they offer so that
patients can use these benefits. Fred’s experience mirror’s Dianne’s where neither of them had
the wherewithal of the services their doctors have. Fred’s sentiment was similar to Dianne’s,
where he believed the lack of community education has been detrimental. He acknowledges the
obligations primary care physicians have in going out into the community to create a more

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welcoming environment. He believes medical care is not confined to the walls of a doctor’s
office but must encompass the surrounding community and neighborhood where the patients are
eager to develop a doctor-patient relationship. He also believes that there has been lackluster
effort with bridging the medical community to those who live in it. Fred said:
I think primary care doctors can do a better job with advertising their services, and
hosting events like blood drives, free blood pressure checks, and healthcare screenings.
They just need to have their brand present throughout the community, especially in the
inner city.
Ross had similar feelings and said, “Having community fairs or advertising services offered
would help in the long run.” Having a larger presence in the community could promote solidarity
between primary care physicians and the patients that they serve, especially in low-income
communities of color such as the one in this study.
Summary
The purpose of this study was to examine the knowledge, motivation, and organizational
barriers middle-aged, low-income ethnic minorities continue to face in obtaining primary care
services. Through this qualitative study, I was able to gather their lived experiences and the
roadblocks they endured in pursuit of a healthier lifestyle. Eight participants were interviewed
and gave their account on experiences they had while trying to establish or follow up with a
primary care doctor. There were clear knowledge gaps among study participants. Those
interviewed had not been exposed to preventive health and a primary care doctor during
childhood. This lack of exposure led the participants to not know the role of how a primary care
physician plays in one’s life and health. They also did not know how to access a primary care
doctor. Many of the participants said they were unsure where to start.

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Further, the participants claimed that many of the primary care doctors they had seen as
adults did not appear to value their concern and/or did not provide enough detail in the workup,
diagnosis, and management of their illness, leading to a lack of motivation to see a primary care
doctor. The participants stated that they often left their visits with more questions and less
answers. They were also dissatisfied with the face-to-face time they had with their doctor. They
stated that it was not the length of time they had expected, and it was far too short to discuss their
medical needs and be of value. All these factors had at some point dissuaded them from
continuing to pursue visits with their primary care doctors.
The interviews also explored organizational factors that might have delayed or dissuaded
them from obtaining a primary care doctor. One of those factors was that to make an
appointment, they had to call the office, where they oftentimes experienced long wait times
while on hold, upwards of 30 minutes. Once the appointment was established, there was also a
waiting period to be seen and evaluated by the doctor that, on average, took 3 to 4 months. The
excessive phone wait times and pre-appointment wait times continued to be an issue and
prevented pertinent follow-up. Lastly, participants stated that primary care offices had not shown
a consistent presence in the community. Patients believed the medical community and the
residents of the community had no comradery with each other and were stand-alone entities. The
participants saw this as an organizational barrier that prevented them from having a primary care
doctor as primary care doctors’ establishment in the community plays an integral part in building
a relationship and obtaining care. Chapter Four showed the multifactorial barriers in the areas of
knowledge, motivation, and organization that middle-aged ethnic minorities had experienced
with their primary care doctor that delayed them from obtaining their services. Chapter Five will

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provide recommendations to minimize these barriers with the goal of making healthcare more
accessible to middle-aged ethnic minority populations.

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Chapter Five: Discussion and Recommendations for Practice
This study examined the barriers middle-aged ethnic minorities face when establishing
care with a primary care doctor. The study used Clark and Estes (2008) gap analytic framework
to explore the knowledge, motivation, and organization influences that has led to the study
participants’ experiences. This chapter will discuss the pertinent findings within the context of
reviewed literature, then make evidence-based recommendations for practice based on the
experiences faced by this special population. The following research questions supported this
study, with Research Question 4 addressed in this chapter:
1. What are the knowledge gaps middle-aged ethnic minorities have, preventing them
from having a primary care provider?
2. What is the motivation that hinders this population from obtaining primary care
services?
3. What organizational roadblocks delay this population from obtaining healthcare
services?
4. What are the recommendations to close the gap of inequitable access to preventive
medicine in middle-aged people of color?
Discussion of Findings
This section discusses the study’s findings and how each connects to the literature and the
Clark and Estes (2008) gap analysis framework.
Research Question 1: What Are the Knowledge Gaps Middle-Aged Ethnic Minorities
Have, Preventing Them From Having a Primary Care Provider?
This first research examined the knowledge gaps that have hindered ethnic minorities
from obtaining healthcare services from a primary care doctor. Possessing knowledge, or

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knowing what to do and how to do it, is crucial in obtaining positive performance, meeting or
establishing goals, and achieving satisfactory benchmarks for oneself (Clark & Estes, 2008).
Clark and Estes (2008) also state the opposite is true. Not having the wherewithal,
understanding, or dexterity to initiate or complete a task will inevitably leave one to be
outperformed by another; the one with knowledge will almost always surpass one who is bliss.
Finding 1: Inadequate Exposure to Preventive Health Services During Childhood Leads to an
Unknown Role of a Primary Care Physician
Knowledge is the practical understanding of knowing what to do and how to do it. It is
the foundation of initiating, engaging, and completing a task (Clark & Estes, 2008). The study
participants recollected their experiences during their childhood. Out of the eight participants,
only one had exposure to a primary care doctor as a child. The other participants do not recall
seeing a doctor until disease manifested later in their third and fourth decade of life. Because the
study participants did not have such exposure, they were unable to identify the role a primary
care doctor has in being integral in their life. During childhood, they were never taught the
importance of preventive health, and how a primary care doctor is trained to set benchmarks and
goals for their patients in pursuit of a healthy lifestyle, which Fleisch et al. (2021) suggests as
critical to establishing primary care. Also, during their childhood and adolescent years, they
never had a doctor to discuss with them the importance of health, and how their physical, mental,
and social well-being is essential to establish and maintain starting from a young age. Previous
research suggests that this sets the precedent of their baseline health when getting older
(Crittenden & Fang, 2021; Kokkinos, 2012). Studies have also shown that when one does not
have the proper exposure to start or complete a task, a knowledge deficit will exist until the
deficit is unveiled and a plan is in place to overcome the gap in knowledge (Clark & Estes, 2008;

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Paduch et al., 2017; Rich et al., 2016). When one has sufficient exposure starting from a young
age, the gap in knowledge is more likely to be diminished (Thakur et al., 2020), giving one the
tools to be more successful later in life. As was found in the study’s participants, this exposure
was lacking at a young age, leading to a critical gap in knowledge in adulthood.
Finding 2: Ethnic Minorities Do Not Know How to Access Primary Care Services
Not understanding how to complete a task can have harmful and unwanted effects on the
outcome. Conversely, one is more likely to be successful and reach goals if one knows how to
navigate a situation irrespective of external help (Bandura, 2000, 2005; Greenaway et al., 2020).
Krathwohl (2002) describes four different types of knowledge: (a) declarative or factual, which
represent the facts and information; (b) procedural knowledge, which are the tools needed to
know how to complete a task; (c) conceptual knowledge, which is the information given that is
specific to a framework; and (d) metacognitive knowledge, which is knowing the processes that
are necessary for gaining, processing, and analyzing the knowledge. The participants’
acknowledgement that one barrier they have had while trying to get a primary care doctor is most
consistent with what Krathwohl describes as the lack of procedural knowledge; they do not
understand nor believe they have the tools necessary to access primary care doctors. Ethnic
minorities continue to be disproportionately affected by the complications of high blood
pressure, diabetes, high cholesterol, and lung diseases (Baum et al., 2019; Graham & Cataletto,
2014; Larsson et al., 2020; Runions et al., 2020). Though the ethnic majority has similar
diagnoses, they are also more likely to be under the care of a primary doctor because they were
taught by friends or family members how to navigate the healthcare system (Young et al., 2003).
The ethnic majority then, on average, has a better grasp of procedural knowledge when in search

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for a primary care doctor than ethnic minorities which has yielded them more favorable, yet
inequitable health outcomes.
Research Question 2: What Is the Motivation That Hinders This Population From
Obtaining Primary Care Services?
This second research question examined the motivational influences that have hindered
ethnic minorities from having consistent care with a primary care doctor. Studies have shown
that health disparities in ethnic minorities exist due to multiple issues such as socioeconomic
status, generational history, and education level (Corscadden et al., 2018; Stone, 2008; Yearby,
2021). However, there are also social factors that contribute to these disparities such as mistrust
of medical professionals, and the social dynamic between patient and physician that has gone
unnoticed and/or unrepaired (Higgins et al., 2021; Stone, 2008). Though the participants showed
a combination of the above, more than 75% acknowledged and stressed the social dynamics
between themselves and their primary care doctor. They believed healthcare concerns did not
appear valued to their doctor, their doctor was not thorough enough, and there was inadequate
time spent with their doctor, all of which amounted to decreased motivation. When a person does
not feel valued, they are less likely to be motivated and often do not accomplish the goal they
previously set (Clark & Estes, 2008). Bandura (2000) notes that this also leads to issues with
self-efficacy, or the belief in one’s ability to accomplish something to a desired end-goal, which
is the foundation of motivation.
Finding 1: Healthcare Concerns Are Not Valued
If a person does not find fulfillment in a task, they are less likely to have the desire to
repeat the task, irrespective of how favorable or unfavorable the end result may be (Clark &
Estes, 2008). Motivation, the reason(s) one has for acting, reacting, or behaving in a particular

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way, is often due to external influences, and how these influences either agree or disagree with
one’s internal influences, morale, and ethics (Bandura, 2000, 2005). The participants in this
study believe that when they mention issues related to their physical or mental health, they
expect for their physician to have empathy and to express a certain level of concern. This does
not appear to be the case. The participants state that when they do mention their issues, their
doctor often seems unimpressed, or does not show a suitable level of attention that the patients
would like to see. Medical gaslighting occurs when a patient raises an issue to a medical
professional, but that issue is ignored, dismissed, or appears to have been inappropriately taken
lightly (Sebring, 2021). It is a complicated phenomenon with the exchange of one’s belief and
shared knowledge, and how this interaction is downplayed by an authoritative figure in respect to
someone else’s experiences (E. Barnes, 2023). Sidelining such experiences often has detrimental
effects on the patient-physician long-term relationship, many of which end abruptly (E. Barnes,
2023; Sebring, 2021). Such gaslighting disproportionately affects black, indigenous, and other
people of color (Witvliet, 2022). The unequal dismissive nature of medical professionals to
ethnic minorities has been shown during the COVID-19 pandemic where the symptoms
experienced by ethnic minorities were dismissed more often than white Americans, during
emergency room visits where ethnic minorities get substandard or delayed pain medication even
though it is clinically warranted, and during childbirth when women of color continue get
delayed care during labor, resulting in more preventable fetal death when compared to whites
(Dekker, 2017; Hoffman et al., 2016; Witvliet, 2022). Because the patients feel as if their past or
present issues are dismissed, they do not seek care or return for follow-up visits, often making
their medical issues worsen.

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Ensuring follow-up with a primary care doctor is a task, as it requires the patient to take
certain steps to set up and attend the next appointment (i.e., making an appointment, scheduling
time away from work, arranging transportation). But when one does not find the value in the
task, then there is no motivation to complete it (Eccles, 2020). Motivation is paramount to
initiating and completing a task (Clark & Estes, 2008). When one is motivated, the given task
and the end-goal are symbiotic, creating levels of pride, satisfaction, and even continued interest
which leads to persistent pursuit of other attainable goals (Fishbach & Woolley, 2022). The end
result is continued positive reinforcement as goals continue to be sought after, which are fueled
by one’s own motivation. The lack of motivation however has opposite effects, as seen in the
study participants, where the goal is no longer sought after, and often viewed as unwanted or
unattainable.
Finding 2: Primary Care Doctors Are Not Thorough Enough
People will have the desire to go after the end result only after having weighed how such
results will impact their life. Motivation is then predicated on the desire to achieving the goal if
the pros outweigh the cons, if it is more advantageous than disadvantageous, and if the positive
outcome exceeds the negative (Bandura, 2005; Clark & Estes, 2008; Fishbach & Woolley,
2022). The study participants said that they do not believe their primary care doctor gave enough
attention to detail into their medical issues. They often sought thorough explanations to their
complaints and the required workup needed to establish a diagnosis. The study participants
wanted details in how their disease started, and how it would impact their day-to-day living.
They also desired a roadmap of how to co-exist with their disease and wanted explanations of
what to do when things go awry. These desires however were often unmet. Instead, the
participants left their appointment feeling incomplete, and not having all the knowledge they had

84
hoped they would gain during that visit. This led to more questions than answers and feelings of
uncertainty and ambiguity. The result left many of the study participants unfulfilled by the end of
their interaction with their primary care doctor. Feelings of being incomplete or inadequate are
often the cause of, or the contributors to, the lack of motivation (Clark & Estes, 2008). Starting
and completing a task requires one to stay motivated so that goals are continually met. The study
participants acknowledged that not having a thorough explanation into their complaints, illnesses
and treatment course made them question the utility of returning to the primary care setting.
They did not have the motivation to continue seeing their doctor because they did not feel as if
they always received thorough and comprehensive justifications.
Finding 3: There Is Inadequate Time Spent With the Primary Care Doctor
Completing tasks often requires multiple levels of sacrifice. These sacrifices can be direct
or indirect, and can include some degree of time, money, sleep, or trade-off with enjoyable
things like hobbies, just to name a few. When people lose these indirect sacrifices without
equivalent gain, they become less likely to offer such sacrifice again later in life (Jasko et al.,
2019). Motivation is said to be directly correlational with sacrifice; when motivation goes up, so
does the tendency for one to sacrifice more as the favorable outcome is much more beneficial
(Schwarz et al., 2020). The study participants do not believe they spent enough time with their
primary care doctor. They claim that their visits were often too short to have meaningful
conversations regarding their issues. This led to conversations that were not complete, or the
patient feeling too rushed to discuss other issues they had. Because of insufficient time with their
doctor, the study participants lacked the desire to re-establish care, or return to their doctor in the
future as they believed the time sacrificed did not equate to an outcome that was worth it. This

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led to diminished motivation, which had ultimately affected the doctor-patient relationship and
the consistency of their subsequent visits.
Research Question 3: What Organizational Roadblocks Delay This Population From
Obtaining Healthcare Services?
The third research question focused on the organizational roadblocks ethnic minorities
have experienced during their pursuit of having a primary care doctor. Clark and Estes (2008)
states that an organization’s cultural model and settings, inclusive of its leadership and resources,
should always be thoroughly examined if a goal is not met. When there are setbacks, the default
is often to blame one or a few individuals. This however does not solve the problem, as it is
usually many individuals who collectively move an organization to areas that are not fruitful to
its stakeholder (Clark & Estes, 2008). To thoroughly elucidate a gap in performance then,
organizational roadblocks must be examined just as thoroughly as the individuals who make up
that organization.
Finding 1: Excessive Wait Times Are a Major Hinderance to Establishment and Follow up
With a Primary Care Doctor
Healthcare valued by patients is, by default, patient-centered. Part of this experience
includes the willingness to wait while scheduling an appointment, but the wait time required for
a face-to-face visit with a primary care doctor is exceedingly long. All of the study participants
acknowledged dissatisfaction with the time required to wait to see their primary care doctor.
They said it was too lengthy and was one reason they chose to either skip their appointments or
opted to be seen sooner in a non-primary care setting such as an urgent care facility or the local
emergency department.

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The lengthy wait times created negative associations between study participants and their
primary care doctor. Long wait times have been shown to decrease overall patient satisfaction,
and lower return rates for follow-up care (Anderson et al., 2007) which increases patient
sickness, psychiatric complaints, and unmanaged or mismanaged medical illnesses (Davies et al.,
2018; Maruthappu et al., 2013; Snowden, 2012). Ethnic minorities are disproportionately
vulnerable to these negative outcomes because their disease process on average is often more
advanced when compared to the majority (Calvin et al., 2003; Magnani et al., 2018; Nowbar et
al., 2019; Rich et al., 2016; Young et al., 2003). The lengthy amount of time needed to either
wait on the phone to schedule an appointment, or the time needed to wait between in-person
visits, is due to several factors including an organization’s staff availability, business practices,
available building space, money, or the organization’s efficiency. All of these factors establish an
organizational culture and climate with the expectation that long wait times are inevitable (Dirani
et al., 2020; Malik et al., 2020; Werdhiastutie et al., 2020). The COVID-19 pandemic that spread
at alarming rates in 2020 was catastrophic not solely because of the nature of the virus, but due
to the lack of available resources needed such as emergency transport, hospital staff (janitorial,
nurses, doctors), medical building space, information technology infrastructure and medical
equipment (Dirani et al., 2020). Those with lower socioeconomic status and people of color who
at baseline already had lower access to healthcare services were exponentially affected at higher
rates when compared to the White majority (Dirani et al., 2020). When there is a discrepancy
with the current state compared to the desired state, it is imperative that the affairs of the
organization are closely examined as the organization and its practices can be a major deterrence
in reaching the desired state (Clark & Estes, 2008). In this case, excessive wait times were a
major deterrence to participants’ obtaining primary care.

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Finding 2: There Is a General Lack of Community Presence Leading to Patient Unfamiliarity
With the Doctor and Their Medical Practice
An organization’s participation in the community is paramount in developing a healthy
relationship between a patient and their doctor. Community participation has been shown to have
significant positive outcomes at both the organization and individual level (Haldane et al., 2019).
For an organization to be viewed as important and needed by its stakeholders, it is imperative for
the organization to show genuine interest in the community they serve (Clark & Estes, 2008).
The study participants did not believe their primary care doctors showed significant
presence in their communities. They yearned to meet their doctor in a setting where they could
be educated on various issues related to healthcare such as disease processes, nutrition,
advancement of technology, and preventive strategies that would improve the quantity and
quality of their life. Several of the participants said they did not even know they had access to
social workers or dieticians, even after they had previously been to the same medical facility.
They blamed this on the discontinuity of community presence and organizational practice. The
participants believed that primary care in general has lacked hands-on educational experiences
such as healthcare screenings such as blood pressure and glucose checks, screening for mental
health disorder, obesity, or thyroid disease; many of the diseases that would have been managed
by a primary care doctor. As advances in healthcare increase and Americans are living longer,
the burden of chronic disease has also proportionally risen (Feinstein, 2019; Truby & Rogers,
2020). Studies have shown that to keep the aging population sustainable, it is important to
engage the community with their medical doctor (and/or their proxy) in more out-of-office
experiences, as this has been shown to increase follow up with a primary care doctor which leads
to more controlled disease burden (Haldane et al., 2019; Narain, 2011). The study participants

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acknowledge that they often hear about such experiences in other cities, but not in the ones
where they reside, where a majority of the residents are low-income ethnic minorities. This has
led them to feel left out, while further highlighting how the lack of community presence has
created an organizational barrier that has unfavorable consequences with the relationship they
desire to have with a primary care doctor.
Recommendations for Practice
This section will address recommendations for the knowledge, motivation, and
organization gaps that continue to be barriers in the ethnic minority community in their attempt
to obtain a primary care physician. Table 5 shows the recommendations that correspond to the
study’s findings identified in Chapter Four.
Table 5
Connection Between Recommendations and Findings
Recommendation Findings
Create a central electronic hub
that provides guidance on
how to access a primary
care doctor
Ethnic minorities were unaware of how to find a primary
care doctor.
Study participants are frustrated because there is no unified
place to find a doctor.
Participants are overwhelmed at the process of finding a
doctor.
Incorporate telemedicine into
the business practice
Pre-appointment wait times are too long.
In-office wait times are lengthy.
Simple medical issues can be addressed more efficiently.
Develop an instructional
model to increase
community engagement
There is general unfamiliarity with the local medical
practice.
There is lack of presence resulting in the belief that the
primary care doctor is not invested in the community.
Not enough education is provided at the community
outreach level.

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Recommendation 1: Create a Central Electronic Hub That Provides Step-by-Step
Instruction on How to Access a Primary Care Doctor
This study showed that ethnic minorities were unaware of how to find a primary care
doctor. More than 75% of the study participants said that finding a primary care doctor was
daunting, time-consuming, and confusing. The study participants often felt overwhelmed on how
to initiate this process. Knowledge gaps occur when individuals do not know or understand how
to initiate or effectively complete a task. Procedural knowledge, defined as knowing how to do
things, is one of the first steps to achieving a goal (Clark & Estes, 2008). Not knowing how to
start, execute, or finish a task often leads to lackluster results and the end goal not achieved
(Clark & Estes, 2008).
A central hub that will provide a step-by-step process on how to access a primary care
doctor has not been well established. To minimize the questions that address what, how and why,
it is imperative to strategically design a product that is accessible to the population at question,
keeping in the forefront special populations (Krathwohl, 2002). In 2018, more than 95% of
Americans owned a cell phone; that is an increase in smartphone ownership between 2010 and
2016, where ownership increased from 35% to 77% (A. Smith, 2017), meaning a majority of the
population now has access to the internet. There are more than 7 million applications available
for smartphones, and more than 2,000 new applications created every day and available to
download onto a smartphone (Koetsier, 2021). Having a dedicated hub in the form of an
application to access primary care service is not an insurmountable task, as smartphone and webbased applications continue to grow in popularity and efficiency.
Creating this electronic resource would allow for increased access to primary care
services, and less reliance on the emergency department because of one’s unfamiliarity with the

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former (Bazargan et al., 2019; Tsai et al., 2018; Uscher-Pines et al., 2013). This application
would be a multidisciplinary effort with the local health officials, medical organizations, and
information technology specialists, as the multidisciplinary approach has often showed greater
success than one single entity during innovation (Berardi et al., 2020). A list of available medical
clinics would be compiled electronically, inclusive of the physician’s name, address, and
telephone number, and be made available on an easy-to-use web platform accessible by
computer, tablet, or mobile device. This platform will allow the user to apply filters based off
location, patient rating, and even sex and ethnicity of the medical provider to remain culturally
sensitive to the diverse ethnic population. Additional filters could also be applied if a patient is
insured or uninsured, and would provide the results based on the prospective patient’s selections.
As GPS locations are often used on searches such as Google, this would be available on this
application as well to ensure the results match close to one’s neighborhood if desired. Alternative
locations by zip code could be provided should the patient want a doctor in another area.
Establishing a central place where resources can be found could limit the frustration the
study participants expressed as they did now know where or how to look for a primary care
doctor. When patients are established with a doctor, they are less likely to overuse the emergency
room, are more likely to have stable disease and appropriate follow up care, and are more likely
to avoid preventive injuries and premature death (Corscadden et al., 2018; Graham & Cataletto,
2014; Jaeger et al., 2019; Uscher-Pines et al., 2013). This application would be an easily
accessible way to decrease the procedural knowledge gap of the uncertainty of how to establish
care.

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Recommendation 2: Encourage Incorporation of Telemedicine Into the Business Practice
Insufficient face-to-face time with a primary care doctor has led the study participants to
question if the visit was worthwhile. Because the primary care doctor addresses a wide degree of
issues, some visits will require longer time with the doctor than others (Chen et al., 2009).
Shorter primary care visits will include simple things such as medication refills, review of
laboratory work and radiology imaging, or a discussion around anticipated need of medical
equipment such as wheelchairs, nebulizers, or special medical-grade beds. Longer visits with a
primary care doctor may address one’s recent hospitalization, mental health issues, or a new
illness that requires medical workup. It is standard however for most medical visits to be of the
same length, regardless of the complexity (Rao et al., 2019). This has led to many patients to
believe they have inadequate time with their doctor, leaving them unmotivated to return for
follow-up care (Nathan et al., 2017; Rao et al., 2019).
Telemedicine is using the technology of telecommunication and an internet connection to
interact with a patient. A doctor and their patient can use audio/video technology to have much
of the same discussions as a face-to-face visit (Hailey et al., 2002), with the main limitation of
the doctor not being able to perform a physical exam. Telemedicine can be useful in being a
resource for a much wider geographic area than what can be accomplished by the current
standard of going to a doctor’s office (Zeltzer et al., 2023). It has been shown to enhance both
the access to primary care and specialty care, as well as improve the quality of care a patient
receives as appropriate time can be more easily allocated to patients who need it most (Potter et
al., 2016).
One of the more notable advantages of telemedicine acknowledged by both the patient
and physician is that the appointment times can be more tailored based on the complexity of the

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issue (Rao et al., 2019; Zeltzer et al., 2023). During telemedicine visits, medication issues can
often be rectified in minutes; so too can minor medical issues such as non-complex headaches,
common respiratory illnesses, the medical management of a rash, or other simple questions a
patient may have (Haleem et al., 2021). These shortened telemedicine visits could allow the
physician to redistribute time to other patients who require longer face-to-face or telemedicine
interactions with their doctor, thereby increasing patient satisfaction and task value.
In addition to the flexibility of being able to reallocate time to patients based on their
reason of visit, telemedicine has other benefits. Caffery et al. (2016) showed that after
implementing telemedicine into the business model, there is a statistically significant
improvement in wait times to see a doctor. With the use of telemedicine, the evaluation of a heart
specialist decreased from 25 days to 3 days, the wait time to see an eye specialist was reduced
from 14 weeks to 4 weeks, and to see an ear, nose and throat doctor was reduced from 4 months
to 3 months (Caffery et al., 2016). The Veteran’s Health Administration which is responsible for
the ongoing care of U.S. veterans saved close to $3 million dollars in travel reimbursements by
implementing electronic consultations with their primary care doctors and specialty clinics
(Caffery et al., 2016; Jacobs et al., 2020; Morland et al., 2013; Russo et al., 2016). Telemedicine
visits often lasted less than 10 minutes, compared to face to face visit averaging 16 minutes; even
with shorter interaction with the doctor, the patient still expressed greater satisfaction as the need
to drive to a location, check in and out at a front desk, and waiting in a lobby had all been
avoided (Caffery et al., 2016).
Encouraging the use of telemedicine to primary care offices will occur strategically. Data
will be collected by the state’s Consumer Affairs Division (or similar state entity), where patient
complaints are reported. This information is usually publicly available. The complaint of wait

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times or similar access issues will be aggregated. Those facilities who have a higher number of
these types of complaints and who do not currently have telemedicine options will be selected to
receive educational material that discusses the advantages of incorporating telemedicine into
their practice. Because access and follow up care is important, a local health liaison would be
used to discuss its implementation further and provide next-step guidance. Ultimately, it would
be up to the medical facility to review their capabilities and determine if they have the resources
to implement telemedicine into their business practice. Supporting research data will be used to
encourage the doctor’s office to evaluate their current model and determine if telemedicine can
address the complaints made against them with the hope of decreased wait times and more
appropriately allocated time with their doctor based on the patient’s need, which would likely
lead to improved patient motivation and follow-up care.
Recommendation 3: Develop an Instructional Module for Primary Care Offices to Use a
Guide to Increase Community Engagement Through Healthcare Fair
The study participants believed their primary care doctors had not shown enough interest
in the community where they offer their medical services. They continue to be dissatisfied by
this lack of presence as they believe there should not be a disconnect between patient care and
community. The healthcare system has shown to be more productive for both patient and
physician when there is effective community and patient engagement (Webb Hooper et al.,
2022). Organizations have a responsibility to meet the needs of their stakeholders if they want to
remain relevant and successful (Clark & Estes, 2008). Failure to do so often leads goals halffilled or unattainable (Clark & Estes, 2008). Developing an instructional module will not only
address an organizational need, but also a knowledge need as most of the study participants

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lacked exposure to a primary care doctor as child or young adult. Establishing consistent
community outreach can allow the generational knowledge deficit to be broken.
Community engagement can be a powerful tool to increase comradery and establish or
improve relationships with patient and physician. Cyril et al. (2015) conducted a systematic
review of community engagement programs where they showed that well-planned programs
inclusive of collaborative partnerships, the exchange of information between those involved, and
having workers representative of the diverse community, leads to improved health outcomes
among ethnic minority and other disadvantaged populations. O’Mara-Eves et al. (2015) reviewed
131 community public health initiatives where disadvantaged communities were engaged. They
found substantial improvement in health behaviors and increased self-efficacy when compared to
not having such community engagement. Engagement must be specifically designed for ethnic
minority and diverse populations as studies have shown that community engagement project
strategies designed for populations that are not ethnically diverse often fail, as the path to the
desired outcome likely differs among the two groups based off of their cultural needs (GarciaDominic et al., 2010). Designing a curriculum with this in mind can lead to substantial
improvement where ethnic minorities will have a tangible way of knowing their community
physician is vested in their health.
Doctors are generally not trained on business practices as the majority of their schooling
is centered around the diagnosis and management of disease. Most community-based primary
care offices are run by a single or a group of physicians who learn how to operate the medical
practice on-the-go and without any formal didactic training. This has led to a steep learning
curve and organizational unfamiliarity of how to properly engage the surrounding community; a
learning curve that is often overlooked (La Forgia, 2023). The organization however still has a

95
duty to ensure its stakeholders are satisfied with not only the services they provide, but must also
show re-investment into the community so that the stakeholders know the organization values
them (Clark & Estes, 2008). Creating a module that can be easily accessible online to these
community-based healthcare centers can be used as a guide in creating community engagement.
The online module could be designed as a skeleton framework of the pieces needed to
start a program such as a healthcare screening fair, as this is what the participants in this study
repeatedly said has lacked in their community. The model would be divided into a pre-health
portion, which is what should be considered before the healthcare screening, the day-of-event,
which is what should be considered when going live, and the post-health fair, which are the
actions to take when the health fair has concluded. Table 6 shows each of the three stages, along
with actional descriptions.
This study identified knowledge, motivation, and organizational barriers ethnic minorities
face during establishment and follow up of primary care. This chapter provided
recommendations to address KMO aspects, all of which are paramount to minimizing gaps that
impede the desired end state of equitable access to primary care doctors (Clark & Estes, 2008).
However, the recommendations will not capture or even be relevant to all ethnic minorities as
there are additional special populations even within the same ethnic group that will likely require
more specialized initiatives. Extreme poverty, disability, and advanced age are just some
examples that will require additional consideration so that they too can experience unhindered
medical care with a primary care physician. The recommendations presented here are designed to
encompass some, but hopefully many, of those who with inequitable access to preventive health.

96
Table 6
Template for Healthcare Community Screening
Step Getting site and
sponsor
Logistics/backup
plan
Manpower Publicity Supplies
Pre-health fair
1 Meet with site
organizers.
Determine
community need.
Meet with
alternate
organizers early
on.
Determine
manpower based
on prospective
participants.
Reach out to
local
organizations
for press
release.
Have
inventory
of supplies
needed.
2 Obtain health fair
approval/site
permission.
May need to
involve local
health officials.
Sketch a drawing
of the site
inclusive of
tables/chairs/
pertinent layout.
Confirm
participants.
Always send at
least two
reminders.
Post
information
on websites.
Develop a
financial
play for the
supplies.
3 Discuss cosponsorship.
All agreements in
writing.
Discuss weather
contingencies.
Ensure staff/
volunteers have
HIPAA
certification if
needed.
Advertise in
newspapers,
magazines
and social
media.
Have
educational
material
readily
available.
4 Solidify a date and
time.
Consider
refreshments for
staff and/or
participants.
Meet with
volunteer prior to
going live.
Handout flyers
at local
businesses or
churches.
Gather
needed
office
supplies.
Day of event
Have name tags for
staff.
Ensure welllighted signs to
the event are
strategically
placed.
Consider
uniformity (tshirts) to identify
staff.
Keep site clean.
Post-health fair
Send thank you
notes to those
who staffed the
event.
Perform a debrief
and discuss
what went well
and what did
not.
Summarize the
discussion and
write the
summary to store
in a safe place.
Tentatively
provide a
time frame
for the next
event.
Note. HIPAA = Health Insurance Portability and Accountability Act.

97
Limitations and Delimitations
Limitations are the aspects of the study that the researcher cannot control, while
delimitations are those that the researcher can control by the nature of the study design
(Creswell, 2014). The gap analysis framework was chosen in this study so that the current state
of ethnic minority populations obtaining primary care could be compared to the desired state,
identifying any gaps in between (Clark & Estes, 2008). The study was designed to hear the
stories from participants who have experienced barriers as they navigated the healthcare system.
One of the limitations is the actual responses of the participants. Their accurate responses
were crucial, as their truthfulness ultimately resides within them. The study’s interview questions
were designed around specific experiences the study participants may have encountered.
Participants may have been inclined to answer questions to please the researcher and make the
answers more socially desirable to fit the tone of the questions. To mitigate this, different
questions were asked around the same topics of knowledge, motivation and organization, in case
these would yield different responses.
An additional limitation was the language of the participants. Inclusion criteria was
understanding conversational English, as interpreter services were not available. Those who do
not speak English likely represent a different ethnic group and as such, may have different, more
complex experiences to the United States healthcare system.
A further limitation was that several prospective participants simply declined to be
included in the study or, after they accepted, were not able to be reached. Some reasons for
declining or those who were otherwise loss-to-follow up could be due to past experiences with
medical professionals, mistrust in the medical system, past or current feelings of racial prejudice
and injustice, or other systemic issues they faced during their childhood or adulthood. Out of the

98
three prospective participants who declined, two of them said they simply did not want to be
contacted without giving further explanation, and one of them said they did not want issues with
immigration. I assured them their information would be de-identified, but they expressed that
they did not want to continue.
Other delimitations of the study were the sample size and location of the study. There
were eight participants interviewed during this study in one metropolitan city. Because sample
size is important to reduce the probability of error and improve generalizability to the population
at question, a larger size may be of some benefit. The sample size chosen for this study may not
represent the ideas of all ethnic minorities. Instead, it may only reflect a minutia of the target
demographic, and from one geographic setting. Therefore, there may be differences of opinions
should the participant number increase and participants in other areas of the country and different
community settings are included.
Resources at WCUMC were limited and, as such, were also influential in the number of
participants who qualified for the study. This, combined with some participants who did not
respond when attempting to conduct the interview, also affected the sample size. Lack of
willingness to participate could be multifactorial, inclusive of medical mistrust, past experiences
with medical professionals, concern for immigration, and lack of task value and their sentiment
that they do not believe their past or present experiences with primary care doctors were
valuable. The study, however, was designed to get the most accurate, honest experiences from
the participants in the community surrounding WCUMC.
Lastly, age, gender, financial status, education and one’s upbringing can all play a crucial
role in how one experiences or does not experience barriers in healthcare. This study did not look
at the intersectionality of these factors and how they may affect one’s ability or motivation in

99
obtaining a primary care doctor. This paper did discuss medical gaslighting, and although it
likely occurs in many populations, it is more profound and experienced with ethnic minorities.
This is likely multifactorial and may be difficult or even impossible to subclassify ethnic
minorities’ experiences based on factors such as income or gender for example, and how they
experience more or less gaslighting when compared to others in the same ethnic group. Instead,
this study focused on ethnicity, particularly, Black/African American, Hispanic, and Asian
populations. Additional time would have allowed for more broader critique and analysis of the
data.
Recommendations for Future Research
As a result of this study, recommendations for future research includes further
examination of how the intersectionality of race, gender, age and sexual orientation influence
equitable access to primary care. Though the participants in this group represented low-income,
middle-aged Black, Asian and Hispanic ethnic groups, other groups such as Pacific Islander,
Arab, or American Indian may have different experiences as their culture’s approach to medicine
has been historically different. The idea of cultural competence also comes into play as those
patients that are culturally diverse would inevitably have different needs and a different outlook
on what healthy means to them. Research has shown that inequalities and access to healthcare
historically exist in the United States. As cultures remain diversified, so too would be the
strategies needed to effectively communicate with those of different backgrounds to establish
and continue a healthy, long-term doctor-patient relationship. It is then important to not only
examine the population, but the primary care physician also needs introspection in how to
express their professional opinion in a way that is culturally sensitive. Further examination of

100
this interplay is necessary to properly address the needs of patients with different ethnic
backgrounds.
Those of advanced age of greater than 65 or younger ages less than 40 years old may also
have different experiences as the level of knowledge and motivation of those dichotomies will
likely differ. Further research should also include an analysis of how socioeconomic status may
play a role in either increased or decreased access to a primary care doctor. Lastly, this study was
conducted in a large metropolitan area. Ethnic minorities in a rural setting may face other unique
barriers in obtaining a primary care doctor.
Though this study was designed to hear the lived experiences through the patients’ point
of view, it may be of benefit to hear the experiences from the physicians themselves. Their
experiences would be especially important to know as this study has shown that organizational
barriers are very influential in how ethnic minorities navigate the healthcare system. Physicians
who run their organizations may face obstacles that are not apparent to the public but are
undoubtedly passed down to them which can affect the patient’s perspective of healthcare, and
their access to preventive medicine.
Conclusion
This study examined the knowledge, motivation, and organizational influences middleaged ethnic minorities face in obtaining a primary care physician. Ethnic minorities have
historically had more negative health outcomes when compared to White Americans, as this
population has experienced more barriers in access to healthcare services. Inner-city areas where
ethnic minorities dominate continue to be deprived of equitable access to preventive medicine.
The downstream effect is having more physical and mental health problems, both of which
disproportionately increase morbidity and mortality when compared to White Americans. This

101
study has shown some important key findings: (a) ethnic minorities are not exposed to the utility
of a primary care doctor at a young age, and thus remain unaware of how a doctor can beneficial
as they age; (b) ethnic minorities do not know how to properly navigate the healthcare system,
(c) they do not believe their primary care physician always values their concerns, (d) primary
care doctors are not thorough enough, (e) inadequate time is spent with the primary care doctor,
(e) wait times to establish and follow up with a primary care doctor are excessive, and (f) there is
a lack of community presence leading to patient unfamiliarity with the doctor and their medical
practice. The combination of these findings has highlighted multiple barriers ethnic minorities
have in their pursuit to establishing and following up with a primary care doctor. When
compared to White Americans, ethnic minorities have a longer wait time and are, on average,
less satisfied with their medical visits. Economically rich cities where Whites are the majority
have better, more efficient access to primary care, where they get earlier diagnoses and treatment
of their medical illness, thereby improving their overall quality of life.
All persons regardless of race or ethnicity, socioeconomic status, and age, deserve to
have equitable access to a primary care doctor who will follow them throughout their lives.
Those who routinely follow with a primary care doctor are generally healthier, as prevention of
disease rather than only diagnosis and management of disease is the core of this specialty.
Ensuring equitable access to preventive medicine and healthcare services would allow all ethnic
groups to have the same level of competent, culturally sensitive primary care services so that
everyone can reap the benefits of having a healthier life.

102
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Appendix A: Interview Protocol
Thank you for agreeing to talk to me today. Your input will be valuable. My name is
Morgan Hawkins. I am a doctor, who specializes in Internal Medicine. I am also a student
conducting research for my dissertation. For the purposes of this interview, I am speaking to you
as a student-researcher, and not as a doctor. I am honored that you took time to meet with me
today to answer some of my questions. The interview will last approximately one hour. It will
consist of 12 questions. Depending on your answer however, there may be a follow-up question
so that I am sure to capture your complete thoughts. I might also contact you in the next several
weeks to share my conclusions about your interview. I do this to make sure that your view is
properly stated and not misinterpreted by myself.
I would like to discuss the overview of this study. My study is looking at potential
barriers certain ethnic groups face in accessing a primary care doctor. Those who I will interview
are adults who have been recently discharged from West Coast University Medical Center
(WCUMC). This interview will help me study knowledge, motivation and organization
influences that have either propelled, stalled, or hindered your access to obtaining a primary care
doctor.
Everything you say today will be confidential. Your participation is voluntary, and you
can stop the interview at any time or choose not to answer questions. Your name or telephone
number will not be included in the study, as your privacy is of utmost importance. As I stated
before, view me as a researcher, and not as a doctor. I encourage you to be as candid as possible.
Do you have any questions about my role, your role, or anything about this interview?

134
If you develop questions or need clarifications during the interview, please do not hesitate
to stop me and ask. If you do not feel comfortable talking to me about this study and would
prefer to talk to someone else, please email irb@usc.edu, and reference IRB# UP-23-00215
After the introduction, recording will begin. The day, date and time will be mentioned at the
beginning of the recording.
Interview Protocol
Four research questions guided this study:
1. What are the knowledge gaps middle aged ethnic minorities have, preventing them
from having a primary care provider?
2. What is the motivation that hinders this population from obtaining primary care
services?
3. What organizational roadblocks delay this population from obtaining healthcare
services?
4. What are the recommendations to close the gap of inequitable access to preventive
medicine in middle-aged people of color?
Prior to beginning the interview, I will attempt to establish rapport so that the participant
is comfortable. General conversation starters can include, but not be limited to the current or past
weather, any plans for the upcoming summer, their job/career, activities they enjoy, recent books
read, their favorite travel destination they dream about, and other like subjects. This conversation
will be tailored individually.

135
Table A1
Interview Protocol Questions
Interview questions Potential probes Research question
(RQ) addressed
Key concept
addressed
Tell me about your first
experience seeing a
doctor.
What did you like
about it?
What did you dislike
about it?
RQ2 and 3 Motivation
Organization
Tell me about your last
experience seeing a
doctor.
Was this experience
different than
your first
experience? If so,
how?
RQ2 and 3 Motivation
Organization
Tell me about your
ability to access
healthcare services.
Have you found it
difficult? Have
you found it easy?
RQ1, 2, and 3 Knowledge
Motivation
Organization
Do you have a primary
care doctor?
What age did you
first have a
primary care
doctor?
When were you
introduced to the
necessity of a
primary care
doctor?
RQ1 Knowledge
What role do you
believe a primary care
doctor has in your
overall health goals?
What are your goals
you would discuss
with your doctor?
RQ1 Knowledge
What would you say is
the number one issue
preventing you from
consistently seeing a
primary care doctor?
RQ1 and 3 Knowledge
Motivation
Organization
What financial burdens,
if any, have you faced
in obtaining a primary
care doctor?
Potential prompts
based on
response: This can
include issues
with co-payments,
imaging, or seeing
specialists.
RQ2 and 3 Knowledge
Motivation
Organization

136
How have you been
able to overcome
these burdens?
What language barriers,
if any, have you
experienced while
navigating the
healthcare system?
How have you been
able to circumvent
these language
barriers?
RQ2 Motivation
Organization
Has there been a time
where you did not
trust the advice or
recommendations
from your primary
care doctor?
If so, briefly
describe why you
did not trust their
advice.
What was the
outcome?
Have there been
previous
influences that
made you feel you
cannot trust their
recommendations
?
RQ2 Motivation
Describe transportation
issues, if any, that
hinder you from
having a primary care
doctor.
How has this
affected your
appointments with
your doctor?
RQ3 Organization
Have you had any issues
with obtaining
prescription drugs
from your primary
care doctor?
If so, describe what
happened.
How has this
impacted your
health?
RQ3 Motivation
Organization
How would you describe
your interactions with
your doctor’s office
staff (i.e., receptionist,
scheduler)
Have those
interactions
hindered you from
seeing your
doctor?
If so, has this
contributed to a
delay in your
healthcare goals?
RQ3 Organization

137
How can healthcare
organizations be more
present in the
community?
What do you believe
is the ideal way to
show their
presence?
RQ4 Organization
What can medical
professionals do to
ensure middle-aged
ethnic minorities 40–
65 years old
consistently see a
primary care doctor?
RQ4 Motivation
Organization
The following questions may or may not be present in the patient’s electronic medical
record. If it is absent, these will be asked during the interview.
1. What gender do you most identify with (woman, man, both, neither)?
2. What is your race or ethnicity?
3. Is your annual income less than $30,000? Is it greater than $45,000?

138
Appendix B: Codebook
Name Description Files References
Knowledge
Difficulty accessing
healthcare
Unable to obtain a primary care doctor. 7 7
Inadequate exposure Minimal to no exposure as a child. 6 14
Unknown role of primary
care
The primary care doctor’s duties are not
known.
7 20
Motivation
Concerns not valued Participants believe their doctor does not
value their medical issues.
7 9
Inadequate time Doctor visit times are too short. 7 13
Lack of thoroughness Information from the doctor is not detailed
enough.
6 8
Patient expectation Expectancy value not met. 7 10
Transportation issues Lack of reliable transportation. 4 7
Organization
Improvement in business
practices
Participants believe businesses need general
improvements.
7 16
Lack of communication Inconsistent reminders about appointments. 6 9
Lack of community presence Participants want to see their doctors in the
community and providing out of office
education.
6 8
Long pre-appt wait times Wait times to see a doctor is very long. 6 10
Phone wait times Wait time so the phone is very long. 5 9
Staff concerns Staff are sometimes not professional or
knowledgeable.
4 9
Unknown healthcare services It is unclear what services medical offices
have.
4 7

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Asset Metadata

Creator Hawkins, Morgan Jonathan (author)

Core Title Inequitable access to primary care in ethnic minority populations

School Rossier School of Education

Degree Doctor of Education

Degree Program Educational Leadership (On Line)

Degree Conferral Date 2023-12

Publication Date 01/16/2024

Defense Date 12/01/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag access to medicine,equitable healthcare,ethnic minority,OAI-PMH Harvest,primary care

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Krop, Cathy (committee chair), DeCuir-Gunby, Jessica (committee member), Smith, Aneesah (committee member)

Creator Email mjhawkins@alumni.usc.edu,morgan.hawkins@med.usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113803846

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