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The role of healthcare volunteers in addressing social determinants of health

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The role of healthcare volunteers in addressing social determinants of health

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The Role of Healthcare Volunteers in Addressing Social Determinants of Health
by

Carmin MacMillan

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 2021

© Copyright by Carmin MacMillan 2021
All Rights Reserved

The Committee for Carmin MacMillan certifies the approval of this Dissertation

Robert Filback
Jennifer Phillips
Kimberly Ferrario, Committee Chair

Rossier School of Education
University of Southern California
2021

iv
Abstract
In Texas, nearly one in five adults lacks basic medical insurance. This gap has created an
increased demand for safety-net services provided by free and charitable clinics. Factors such as
lack of employment, inadequate housing, unreliable transportation, and food insecurity also
impact health for those of low socioeconomic status (SES). To improve health outcomes, it is
important that free clinics provide resources which also address these social determinants of
health (SDH). Volunteer healthcare providers in free clinics are uniquely positioned to assess
patient needs and to help navigate them to the additional resources. Twelve volunteers with the
Texas Mission Clinic were interviewed in this qualitative study to assess how volunteer
knowledge, motivation, and organizational strategies impact patient access to SDH resources.
The data determined that the volunteers are motivated to help low SES patients gain access to
resources, but they lack knowledge of available resources and the adequate tools and processes
to make referrals. The study also revealed language and cultural gaps between volunteers and
patients. These gaps hinder the depth of discussion between volunteer and patient as well as
navigation to culturally appropriate resources. Based on this research, it is recommended that the
organization create appropriate tools and processes to establish quick wins regarding patient
access to resources, however, a more comprehensive diversity, equity, and inclusion strategy is
necessary to ensure that all patients receive care equitably. These changes are important in order
to improve health equity for low SES adults in the organization’s region.

v
Acknowledgements
I would like to thank my chair, Dr. Kimberly Ferrario, for her guidance and support
throughout this process. Thank you to my committee members, Dr. Jennifer Phillips and Dr.
Robert Filback, for your insightful feedback and support. I could not have asked for a better
committee to push my thinking and writing to produce what I hope will be a useful resource to
the organization and the sector.
Thank you to my family for your encouragement and patience as I processed ideas related
to my research. I am blessed to have you in my corner, and your confidence in me gave me a
boost just when I needed it most. Thank you to my friends for your help in this journey,
especially Jim, for reading and giving feedback on many, many, versions of this paper.

vi
Table of Contents
Abstract .......................................................................................................................................... iv
Acknowledgements ......................................................................................................................... v
List of Tables ................................................................................................................................. ix
List of Figures ................................................................................................................................. x
Chapter One: Introduction .............................................................................................................. 1
Context and Background of the Problem ............................................................................ 1
Organizational Context ....................................................................................................... 2
Organizational Performance Goals ..................................................................................... 4
Purpose of the Project and Research Questions .................................................................. 6
Importance of the Study ...................................................................................................... 6
Overview of Theoretical Framework and Methodology .................................................... 6
Definition of Terms............................................................................................................. 7
Organization of the Dissertation ......................................................................................... 9
Chapter Two: Review of the Literature ........................................................................................ 10
Social Determinants of Health (SDH) .............................................................................. 10
Self-Efficacy in Managing Health .................................................................................... 13
Generational Effects of Low SES and Poor Health .......................................................... 14
The Role of Free Clinics ................................................................................................... 15
Clark and Estes’ (2008) Knowledge, Motivation, and Organizational Influences
Framework ........................................................................................................................ 20
Stakeholder Knowledge, Motivation, and Organizational Influences .............................. 20
Components of Conceptual Framework ........................................................................... 27
Summary ........................................................................................................................... 28
Chapter Three: Methodology ........................................................................................................ 30

vii
Overview of Design .......................................................................................................... 30
Research Setting and Participants ..................................................................................... 31
The Researcher.................................................................................................................. 33
Data Source ....................................................................................................................... 35
Validity and Reliability ..................................................................................................... 39
Credibility and Trustworthiness ........................................................................................ 40
Ethics................................................................................................................................. 41
Summary ........................................................................................................................... 41
Chapter Four: Findings ................................................................................................................. 42
Participants ........................................................................................................................ 42
Findings............................................................................................................................. 44
Research Question 1: What Knowledge Is Required for Healthcare Volunteers to
Provide SDH Resources to a Patient? ............................................................................... 45
Research Question 2: What Motivates Healthcare Volunteers to Provide Patients
With SDH Resources? ...................................................................................................... 60
Research Question 3: What Organizational Resources and Systems Improve or
Diminish a Volunteer’s Ability to Provide SDH Resources to Patients? ......................... 65
Summary ........................................................................................................................... 71
Chapter Five: Discussion and Recommendations......................................................................... 74
Discussion of Findings ...................................................................................................... 74
Recommendations for Practice ......................................................................................... 78
Integrated Recommendations............................................................................................ 84
Limitations and Delimitations ........................................................................................... 87
Recommendations for Future Research ............................................................................ 88
Implications for Equity ..................................................................................................... 88
Conclusion ........................................................................................................................ 89

viii
References ..................................................................................................................................... 90
Appendix: Interview Protocol ..................................................................................................... 101

ix
List of Tables
Table 1: SDH Resources Offered by TMC ..................................................................................... 4
Table 2: Organizational Mission and Department Goals ................................................................ 5
Table 3: Knowledge Influences, Types, and Assessments for Analysis ....................................... 22
Table 4: Motivation Influences and Assessments for Analysis .................................................... 24
Table 5: Organizational Influences and Assessments for Analysis .............................................. 26
Table 6: Participant Breakdown According to Credentials .......................................................... 33
Table 7: Interview Protocol .......................................................................................................... 36
Table 8: Participant’s Length of Experience Volunteering Services to Low SES Adults ............ 44
Table 9: Concern for Diabetic Patients ......................................................................................... 47
Table 10: Patient Nutrition Barriers .............................................................................................. 48
Table 11: Barriers TMC Patients Encounter Concerning Exercise .............................................. 51
Table 12: Working Conditions Relevant to Health Management ................................................. 53
Table 13: Transportation Challenges and Health .......................................................................... 55
Table 14: Volunteer Knowledge of SDH Resources Offered by TMC ........................................ 57
Table 15: Volunteer Performance Barriers Due to Language and Culture Differences ............... 58
Table 16: Volunteer Motivation to Care for Low SES Patients ................................................... 61
Table 17: Motivation Factors Which Influence Whether Volunteers Provide SDH
Resources ...................................................................................................................................... 64
Table 18: Organizational Processes Barriers for Connecting Patients With SDH
Resources ...................................................................................................................................... 67
Table 19: TMC Volunteer Efforts Do Not Always Align With the Organization’s Mission ....... 70
Table 20: Summary of Knowledge, Motivation, and Organizational Themes and Findings ....... 71
Table 21: Applying the McKinsey 7S Framework to Successfully Implement
Recommendations ......................................................................................................................... 85
Table A1: Interview Protocol…………………………………………………………………...102

x
List of Figures
Figure 1: Conceptual Framework ................................................................................................. 28

1

Chapter One: Introduction
In spite of spending more on healthcare per capita than any other nation, adults in the
United States have worse health outcomes than those in other countries (Ratcliff, 2017). One’s
health is impacted by a variety of factors. While some health conditions are genetic, many are
due to factors relevant to the socioeconomic status (SES) of the individual. These are factors
such as income, education, housing, transportation, and social networks (Ratcliff, 2017). The
World Health Organization describes these non-medical factors as social determinants of health
(SDH). Providing healthcare is only the beginning; addressing the SDH is the path to providing
better health for low SES adults.
After adjusting for age, the rate of health-related deaths in low SES populations is more
than double that of the U.S. population as a whole (Phelan et al., 2010). Studies regarding the
health of low SES adults revealed that those who were the poorest and the least educated were
the least healthy (Braveman et al., 2010). Low SES adults often experience mental stress due to
inadequate income (Phelan et al., 2010; Santiago et al., 2011). Income, housing, and
transportation are distinct issues that are intricately connected to poor mental and physical health
for low SES adults (Phelan et al., 2010; Thornton et al., 2016). The U.S. Department of Health
and Human Services (2021) organizes SDH into five domains: economic stability, education,
health and health care, neighborhood and built environment, and social and community context.
To make a meaningful difference, healthcare for low SES adults must be managed in a holistic
manner, which includes improving their access to SDH resources.
Context and Background of the Problem
In this paper, I am addressing the role of healthcare volunteers in helping low SES
patients improve conditions related to their SDH. Unless needs related to SDH are met, the
2

health of low SES adults will continue to decline (Santiago et al., 2011). Volunteer healthcare
providers are uniquely positioned to provide a different kind of care to help change that
trajectory. Free healthcare clinics often depend on volunteers to offer their skills and expertise at
no cost in order to provide free clinic visits and other services. During the patient intake process,
volunteers have conversations with patients which glean insights relevant to SDH. Volunteers
well versed in SDH and knowledgeable about relevant services have the opportunity to make a
significant impact in both short-term and long-term health outcomes.
Free health clinics play an important role by providing a safety net for low SES adults
who are medically uninsured and who most likely would not have access to health care otherwise
(Darnell, 2010). The need for free clinics has increased dramatically since the 1970s due to rising
numbers of uninsured adults in the United States (Gertz et al., 2010). Free primary care clinics
are especially important in Texas due to the large gap in healthcare coverage for low SES adults.
The Affordable Care Act (ACA), introduced in 2010, expanded Medicaid in order for
states to leverage federal funds and expand coverage to help those earning less than 138% of the
federal poverty guidelines. Unfortunately, Texas did not opt in for the expanded Medicaid
option. Nearly 18% of adults in Texas have no health insurance, the most in any state, and the
numbers continue to increase (U.S. Census Bureau, 2018). As health outcomes in the United
States continue to deteriorate and health costs increase, free clinics in Texas are under more
pressure to meet increased health needs in the communities they serve.
Organizational Context
The Texas Mission Clinic (TMC) is a pseudonym that will be used to keep the
organization of study anonymous. TMC is a nonprofit organization that provides free health care,
along with resources to address SDH for low SES adults in North Texas. However, the
3

organization did not begin with a health care focus. When the organization was founded in 1979,
it was a nonprofit with the purpose of providing benevolent financial help to community
members in need. TMC has provided financial help, educational resources, and free food for low
SES families in the area for nearly forty years. In 2019, the organization merged with a free
healthcare clinic and changed its name. It has been through the lens of having added the
healthcare services that TMC has come to identify its prior work as activities which support the
SDH. TMC now offers many services and resources which support whole person wellbeing, the
quality of which has been recognized with awards from leading hospital networks and local
foundations.
A member of both the National Association and Texas Association of Free and
Charitable Clinics, TMC benchmarks itself against other similar sized organizations throughout
the country with regards to patient care standards, financial transparency, and legal practices.
TMC has been awarded the Gold Standard from the National Association of Free and Charitable
Clinics, as well as the Platinum Seal by Guidestar, a national organization which ranks
nonprofits according to their financial transparency and demonstrated commitment to measuring
community impact. TMC also participates in the federal government’s Federal Tort Claims Act
free medical malpractice insurance plan and fulfills required operational policy and procedure
obligations to maintain this coverage annually. These accreditations and standards of excellence
help support the high quality of medical care the organization strives to offer and instills
confidence in donors that their investments will make a difference in the community TMC
serves. Table 1 provides an overview of the SDH resources, medical and otherwise, that TMC
offers the community.
4

Table 1
SDH Resources Offered by TMC
Economic
stability
Housing Education Food Healthcare
Employment
coaching
Housing search GED program Free food market Free primary
care
Job skills
training
Temporary
shelter referral
College
scholarship
program
SNAP benefits
enrollment
Free medical
labs
Financial
coaching
Eviction
prevention
program
ESL program Pet food market Specialist
referrals
Free tax
preparation
Prescription
enrollment
program
Interest-free
loans
Fitness
memberships

Note. All patients who receive medical services from TMC are also eligible for the full menu of
services addressing SDH needs.

Organizational Performance Goals
TMC has a three-year strategic plan created and endorsed by its staff and board of
directors. Performance goals are created each year to align program planning and activities to the
overarching strategy. Each organizational department has a performance dashboard which
describes goals on a quarterly basis. Dashboards are updated quarterly with results and variance
explanations. The dashboard reports are presented at quarterly staff and board meetings. For the
purpose of this study, I am focusing on the goals of TMC’s Community Impact department,
5

which encompasses the medical and SDH resources provided to the community. Table 2 outlines
TMC’s organizational mission and goals of the Community Impact Department.

Table 2
Organizational Mission and Department Goals
Organizational mission statement
Motivated by Christ’s love for all, we promote comprehensive wellbeing so that all who live in
our community can thrive.
Community impact department goals
Goal 1: By October 1
st
2022, TMC will equip all clinic volunteers with the appropriate SDH
education and resources to meet the needs of low SES patients.

Goal 2: By December 31
st
2022, volunteer healthcare providers will demonstrate proficiency
in providing SDH resources to all low SES patients.

Note. TMC’s organizational goals indicate their intentionality in leveraging the role of healthcare
volunteers in connecting low SES patients with helpful SDH resources.

6

Purpose of the Project and Research Questions
The purpose of this project is to identify gaps in volunteer knowledge and motivation, and
gaps in organization resources and systems, in order to better provide low SES patients with
SDH resources during a healthcare visit.
My research questions are as follows:
1. To what extent do healthcare volunteers have the knowledge needed to provide SDH
resources to patients?
2. What motivates healthcare volunteers to provide patients with SDH resources?
3. What organizational resources and systems improve or diminish a volunteer’s ability
to provide SDH resources to patients?
Importance of the Study
There is promising evidence to show that improving SDH for low SES patients improves
their long-term health outcomes (Fenelon et al., 2017; Ratliff, 2017). TMC has resources which
can improve SDH needs for patients. This study is designed to learn more about the role of
volunteers in leveraging these resources for patients, as well as organizational systems which
facilitate these resources. The results from this study will be used to improve upon strategies that
deepen and expand TMC’s impact in the community.
Overview of Theoretical Framework and Methodology
I am using the Clark and Estes gap analytic framework to identify gaps in the knowledge
and motivation of volunteers and organizational barriers to volunteer performance in providing
SDH resources to TMC’s patients. The gap analysis framework identifies performance gaps
resulting from knowledge, motivation, and organizational causes (Clark & Estes, 2008).
Applying gap analysis can help address additional training needed for volunteers so they may
7

develop greater understanding of their patient needs in a holistic manner and implement the SDH
resources and referrals effectively. Gap analysis may also help discover what volunteers
understand to be additional SDH resources patients need but that TMC may not currently offer.
The method used to collect data was qualitative in nature. The target population for
interviews was healthcare volunteers who had served more than twice in the six months prior to
the interview period. Physicians, physician assistants, nurse practitioners, and nurses who meet
these criteria were invited by the Clinic Director to participate in the study. Twelve volunteers
were interviewed for the study.
Definition of Terms
Federal Poverty Limit: The Federal Poverty Limit is a measure of income determined by
the Department of Health and Human Services which helps the government and social services
agencies determine eligibility for benefits and services (Healthcare.gov, 2021).
Free Medical Clinic: As defined by the American Health Lawyers Association, free
medical clinics are “a health care community safety net that is established, operated and
maintained for the purpose of providing primary care to socioeconomically and geographically
underserved patient populations […] and personnel includes dedicated volunteers and/or paid
staff […]” (AHLA, 2016).
Health Disparity: The Center for Disease Control (CDC) defines health disparities as
“preventable differences in the burden of disease, injury, violence or opportunities to achieve
optimal health that are experienced by socially disadvantaged populations” (CDC, 2020).
Health Insurance Portability and Accountability Act (HIPAA): The Health Insurance
Portability and Accountability Act of 1996 (also known as HIPAA) is a federal law that required
8

the creation of national standards to protect sensitive patient health information from being
disclosed without the patient’s consent or knowledge.
Social Determinants of Health (SDH): The World Health Organization (WHO) defines
social determinants of health as “non-medical factors that influence health outcomes. They are
the conditions in which people are born, grow, work, live, and age, and the wider set of forces
and systems shaping the conditions of daily life. These forces and systems include economic
policies and systems, development agendas, social norms, social policies and political systems”
(WHO, 2020).
Socioeconomic Status (SES): The American Psychological Association (APA) defines
Socioeconomic status as “the social standing or class of an individual or group. It is often
measured as a combination of education, income and occupation. Examinations of
socioeconomic status often reveal inequities in access to resources, plus issues related to
privilege, power and control.” SES refers to the social disadvantage one experiences and is often
measured by lack of income, education, social connections, and wealth (APA, 2020).
Supplemental Nutrition Assistance Program (SNAP): The Federal SNAP benefits
program assists eligible individuals and families with food purchases based on household income
and family size. SNAP benefits in Texas are credited to a card account, similar to a credit card,
called the Lone Star Card (Texas Health and Human Services, 2021).
Volunteer: A volunteer is defined by the U.S. Bureau of Labor Statistics as “persons who
did unpaid work (except for expenses) through or for an organization” (U.S. Bureau of Labor
Statistics, 2020).
9

Organization of the Dissertation
This paper is organized into five chapters. The first chapter presents the problem of
practice, the theoretical framework, and key definitions relevant to patients seeking services from
free medical clinics. Chapter Two contains a literature review identifying factors that contribute
to poor health outcomes and the role of free clinics in addressing those needs. Chapter Three
contains the research questions, methodology of the study, and criteria for study participants.
Chapter Four reveals the study data and analyzes the results. Chapter Five presents possible
solutions for TMC and recommendations for further research.

10

Chapter Two: Review of the Literature
This literature review studies key factors contributing to poor health outcomes for low
socioeconomic status (SES) adults in the United States, and in particular the impact of Social
Determinants of Health (SDH) factors. Based on the literature, health disparity can be attributed
to multiple SDH factors, such as lack of adequate income, education, housing, transportation,
food security, and social networks. Research suggests that the ongoing stress associated with the
lack of SDH resources may also lower self-efficacy, which can then contribute to poor mental as
well as physical health. Free clinics play an important role in providing safety-net health services
for low SES adults who cannot afford the cost of basic health care. The conceptual framework
illustrating how the literature applies to the problem of practice is presented at the end of the
chapter.
Social Determinants of Health (SDH)
In the 1970s, McKinlay and McKinlay analyzed the impact of vaccines on death rates for
nine infectious diseases (1977). While they found that the decline in death rates were attributable
in large part to improved sanitation measures introduced in communities which took place prior
to the medical intervention, this study helped set in motion further research and strategic plans to
address the social causes of poor health globally (Ratcliff, 2017). Ratcliff (2017) categorizes
these ‘social determinants of health’ in two categories:
1. Conditions of life, like how we live, how we work, how we move from place to place,
and what we eat and drink.
2. Causes or triggers of those conditions of life, such as government policies, social
structure, and actions of powerful actors and organizations.
11

In 2005, the World Health Organization (WHO) formed the Commission on the Social
Determinants of Health. The purpose for this group was to create an evidence-based approach to
addressing social causes of poor health around the globe. The commission found that those in the
lowest socioeconomic status, around the globe, suffered the worst health (World Health
Organization, 2008). These non-medical factors such as income, education, and social networks
are often referred to as flexible resources, and studies show that these resources more readily
available to higher SES families are linked to better health (Phelan et al., 2010). This gap in SDH
resources is a significant problem for low SES adults. After adjusting for age, risk of health-
related death is greater by more than double for lower SES individuals (Phelan et al., 2010).
The WHO model considers several SDH factors experienced by low SES communities
globally. This literature review focuses on four common SDH factors facing patients of Texas
Mission Clinic (TMC): income, physical environment, food, and transportation. The literature
review also considers how SDH factors negatively impact mental health, which then compounds
health problems by impacting self-care efficacy.
SDH Factors Concerning Physical Health
Income inequality has been linked to poor health (Matthew & Broderson, 2018). Studies
show that those who are the poorest and the least educated tend to have the worst health
(Braveman et al., 2010). One’s educational level directly impacts earning potential (Price et al.,
2018). Those with low incomes suffer from obesity, heart disease, diabetes, and other chronic
health conditions more often than those with higher incomes (Matthew & Broderson, 2018).
For many low SES families, the condition and location of their home contributes to poor
physical and mental health (Thornton et al., 2016). Neighborhood environmental factors, such as
a lack of outdoor recreation space, reduce opportunity for exercise, impeding physical health.
12

Living in communities with high rates of crime results in ongoing fear and mental stress felt by
both parents and children (Fenelon et al., 2017). These physical and mental health conditions
improve when low SES families move to safer neighborhoods (Fenelon, et al. 2017).
Inadequate household income and lack of assets are linked to food insecurity for
households in the United States (Shobe et al., 2018). Individuals experience food insecurity when
they lack access to safe, nutritious, and culturally appropriate food in a socially acceptable way
(Bazerghi et al., 2016; Ramsey et al., 2012). Low income neighborhoods are also less likely to
have grocery stores, leaving local residents to rely more on convenience stores and fast-food
restaurants (Kaiser et al., 2019). Food banks and food pantries play an important role in meeting
needs for those who are food insecure, though they often lack important nutritional needs for
those who depend on them, due in part to affordability and availability in quantity (Bazerghi et
al., 2016). Studies show that those who are food insecure more often have high rates of obesity
and type II diabetes (Kaiser et al., 2019).
Struggles related to reliable transportation have been found to complicate medical
services and chronic health management for low SES patients (Syed et al., 2013). Transportation
barriers contribute to chronic health conditions because patients miss follow-up medical
appointments and lack the ability to pick up medication (Kamimura et al., 2018). One study
determined that 20% of free clinic patients missed an appointment due to lack of transportation
(Kamimura et al., 2018). This problem is important because, without transportation, basic
healthcare needs cannot be met and chronic conditions worsen, even when healthcare services
are available.

13

SDH Factors Concerning Mental Health
The lack of reliable housing, healthy food, and transportation creates emotional barriers
to a healthy lifestyle (Kamimura et al., 2018). The daily stress felt by low SES adults related to
lack of income negatively impacts mental and physical health (Santiago et al., 2011). Mental
stress reduces one’s ability to plan ahead and make good decisions, resulting in poor choices
regarding such things as financial decisions, food choices, and whether or not to exercise. Low
SES adults are more often diagnosed with chronic diseases with sensitivity to stress, such as
diabetes, heart disease and metabolic disorders, than higher SES adults (Santiago et al., 2011).
Diabetic patients often face increasing financial implications related to the cost of medications
and may also need to make significant lifestyle changes to manage their health. These financial
and lifestyle challenges may create additional mental stress which erode efficacy in a diabetic
patient’s ability to manage their chronic health condition (Santiago et al., 2011, Bandura, 2010).
Self-Efficacy in Managing Health
Self-efficacy, one aspect of the social cognitive theory, is a person’s belief that they are
capable of successfully accomplishing a goal (Bandura, 2010) and is specific to a particular
behavior (Clark & Dodge, 1999). Bandura (2012) describes four ways in which self-efficacy is
developed: through mastery experiences, from social modeling, through social persuasion, and
from controlling physical and emotional states. Self-efficacy is part of the self-regulatory process
which determines health behavior (Clark & Dodge, 1999). Self-efficacy theory reasons that
“choice of activities and environment” will determine the course of one’s life and what one
becomes (Bandura, 2012, p. 12). Self-efficacy is helpful to understand in this context in that it
can predict specific and important health behavior for chronic health management (Cavalhieri et
al., 2019; Clark & Dodge, 1999). The concern is that the barriers that many low SES individuals
14

encounter each day, such as housing instability, food insecurity, and racism can diminish self-
efficacy (Cavalhieri et al., 2019; Mansyur et al., 2011; Vijayaraghavan et al., 2011).
The concepts of self-efficacy, self-care, and self-management are often used
interchangeably in health research. Self-care self-efficacy is defined as a “domain-specific
psychological concept that is an indicator of one’s confidence in the performance of relevant
behaviors in the context of self-care” (Eller et al., 2016, p. 45). Self-efficacy is a predictor of
one’s ability to manage their health (Clark & Dodge, 1999; Mansyur et al., 2011). Self-care self-
efficacy is essential for managing chronic conditions, such as diabetes and heart disease, which
require ongoing medication adherence, dietary management, and regular exercise. Bandura’s
(2012) work argues that one sets their life’s course based on their choices and environment.
Efficacy and motivation can decrease when factors outside of one’s control affect goal
attainment (Cavalhieri et al., 2019).
Generational Effects of Low SES and Poor Health
Physical, mental, and behavioral health issues have been found to pass from one
generation to the next. Shared habits and living conditions, such as lack of access to nutritious
food or lack of exercise, affect the entire family (Glied & Oellerich, 2014). Like their parents,
children also suffer stress resulting from poverty. Stress impacts a child’s ability to concentrate,
affects mood and social behavior, and suppresses the immune system (Thompson, 2014). Anti-
social behavior and increased number of sick days negatively impact children’s academic
performance. The result is diminished advanced education and employment opportunities in
adulthood. Children growing up in poverty who experience poor health are more likely to have
poor health in adulthood, creating a cyclical effect (McLaughlin & Rank, 2018). According to
Shaefer et al. (2018), adults who grew up in low-income households were much more likely to
15

be obese than adults from high income families. The research shows that health issues of parents
are often mirrored in their children, and those health problems are carried into adulthood. The
daily experiences relevant to SDH, such as poor housing conditions, neighborhood needs, and
transportation barriers felt by low SES families negatively impacts the health of the entire
family.
The Role of Free Clinics
Free medical clinics offer important safety-net services for medically uninsured adults in
the United States. Healthcare visits combined with prescription enrollment programs create
opportunities for those who may not be able to manage their health otherwise. Most chronic
disease management is unaffordable for low SES adults without the services of free clinics
(Riddle & Herman, 2018). Healthcare services are critical, though it is also important for free
clinics to offer additional resources relevant to SDH to improve long-term health outcomes
(Shortell et al., 2010). Free clinics effective in addressing health outcomes also mitigate disparity
in access and quality of care for patients (Versey & Curtin, 2016).
Safety-Net Healthcare
The need for free clinics has increased dramatically since the 1970s, due to rising
numbers of uninsured and underinsured adults in the United States (Gertz et al., 2010). Free
primary care clinics play an important role in Texas. The Affordable Care Act (ACA) was
introduced in 2010 as a path to healthcare coverage for those not previously able to afford
coverage for themselves and their families. The ACA also expanded Medicaid in order for states
to leverage federal funds and expand coverage to those earning less than 138% of the federal
poverty guide (healthcare.gov). The Texas state government declined this expansion opportunity.
16

As a result, nearly 5 million Texans lack medical insurance, the most of any state in the United
States (Texas Medical Association, 2021).
Free and charitable clinics play an important role in the safety-net system for medically
uninsured adults who are unable to afford primary care (Darnell, 2010). According to Gertz et al.
(2010), free and charitable clinics tend to have similar services and serve similar patients; the
services offered by these clinics are as follows:
1. Help medically uninsured adults, the working poor, immigrants, and the homeless.
2. Offer primary medical care.
3. Provide prescription drugs or help with drug program enrollment.
4. Offer additional health services, such as dental and women’s wellness.
5. Partner with other community organizations for additional helpful services and
programs.
Demand and Costs for Diabetic Care Increasing
The prevalence of diabetes is a significant contributing factor to the rising costs of health
care in the United States. In 2018, nearly 27 million people (about 8% of the population) had
been diagnosed with diabetes (Centers for Disease Control and Prevention, 2020). Diabetes
accounts for 25% of all health care dollars spent in the United States (Riddle & Herman, 2018).
Increased costs for insulin are a factor, as is diabetes-related hospitalization, particularly for at-
risk populations. Alarmingly, 34% of the U.S. population is pre-diabetic, meaning they are at
risk of needing diabetes healthcare resources in the future (Riddle & Herman, 2018).
Without healthcare insurance, the average cost in 2017 for one person to manage their
diabetes in the United States was $16,752 annually (Riddle & Herman, 2018). A diagnosis of
diabetes makes taking care of one’s health unaffordable for many. In 2019, the average per
17

capita income in Texas, according to the U.S. Census Bureau, was $31,277
(www.census.gov/quickfacts/TX). An average income earner who is medically uninsured in
Texas would have to spend more than half their income managing diabetes.
Chronic care management for conditions such as diabetes requires multiple elements to
be effective. Chronic Care Model takes coordination between a healthcare team and the patient
(Tillman, 2020). The six elements described by Tillman (2020) in the model are “self-
management, delivery system design, decision support, clinical information systems, health care
organization and community resources” (p.117). In free clinic settings, aspects of the model can
be more challenging for both the patient and the organization. For patients, lack of transportation
or conflicting work hours can be problematic for health workshop attendance and doctor’s visit
consistency. For nonprofit safety-net services, dependence on volunteers and other community
partners can create gaps in services based on availability and capacity.
Health and Social Services Integration
In 1964, during the Johnson administration, the Office of Economic Opportunity was
formed to address poverty alleviation in the United States (Bailey & Duquette, 2014). During
this time, important social service programs addressing physical and financial wellbeing were
developed, including Medicare, Medicaid, food stamps, subsidized housing, and welfare
benefits, among others (Bailey & Duquette, 2014). These programs sought to address equitable
access to health care, education, and social programs in some of the poorest districts in the
United States. Since then, studies show that adults with barriers in one wellbeing domain often
experience barriers in several others. Studies of healthcare delivery in the United States have
concluded that cross-sector collaborations between public, private, and government agencies
18

should be considered in order to integrate social services within medical practices (Shortell et al.,
2010).
Improving Patient Self-Efficacy
Improving self-efficacy can be one aspect of a health improvement plan. Several studies
have shown that self-efficacy for low SES adults can be improved with social support (King et
al., 2010; Williams & Bond, 2002). Self-care self-efficacy strategies including counseling,
education, and cognitive therapy have been successful in improving self-care behavior, leading
to improved health (Eller et al., 2016). Promising practices include family support to improve
diet and exercise (Williams & Bond, 2002). Lay-led group education has also improved self-
efficacy self-care and can be cost effective (Eller, et al., 2016). Culturally matching patients to
providers should also be considered in order to mitigate discrimination and improve self-efficacy
of communication between patients and providers (Cavalhieri et al., 2019). Developing strategies
to improve patient self-efficacy is essential to ensuring health resources are accessed and
implemented consistently long-term.
When it comes to patient motivation, Anderson’s Behavioral Model of Healthcare
Utilization outlines a framework for both individual and societal determinants of healthcare
access (Anderson & Newman, 2005). Recent iterations of this framework assume that
“individual access is dependent on the predisposition of the individual to use services, his ability
to secure services, [and] his illness level” (Anderson & Newman, 2005, p. 12). What an
individual believes about their own health, health care options, their family’s beliefs, and
socioeconomic status all influence healthcare utilization (Anderson & Newman, 2005).

19

Systemic Racism in the Health Care System
African Americans are more likely than other racial groups to live in low SES conditions
and experience chronic health problems, such as hypertension and heart disease (Centers for
Disease Control and Prevention, 2010). African Americans also experience racial discrimination
in the health care system, which has been linked to poor health outcomes (Cavalhieri et al.,
2019). Individual, systemic, and internalized discrimination all contribute to disparities in health
for Black and Hispanic women (Sacks, 2013; Williams et al., 2016). Racial discrimination has
proven to diminish mental health and self-confidence (Centers for Disease Control and
Prevention, 2010). Addressing needs that are upstream relevant to SDH are important strategies,
but effective solutions must also address systematic racism in the health care sector (Williams &
Purdie-Vaughns, 2016). A physician’s perception of a patient based on race and gender, and lack
of trust on the patient’s part, are factors which negatively impact health (Clay et al., 2018; Sacks,
2013; Williams & Purdie-Vaughns, 2016). This disparity results in poor physical health and
takes a toll on mental health (Santiago et al., 2011; Versey & Curtin, 2016). Physicians who are
not overtly racist may still have racist beliefs. Physician perceptions based on race and gender
can result in less time spent with the patient, negatively impacting the level of medical care they
receive (Loggins et al., 2018; Sacks, 2013; Williams & Purdie-Vaughns, 2016). Individual
racism can result in patients not trusting their healthcare provider (Santiago et al., 2011; Versey
& Curtin, 2016). Lack of trust also makes it less likely that a patient will follow their doctor’s or
nurse’s advice.
20

Clark and Estes’ (2008) Knowledge, Motivation, and Organizational Influences
Framework
Clark and Estes (2008) introduced a framework to help organizations improve
performance by assessing gaps within three areas: knowledge, motivation, and organizational
causes (KMO). The KMO framework emphasizes a need to assess results against predetermined
goals and to wait until a complete organizational analysis has been conducted in order to design
and implement a fully integrated plan. One of the reasons for the suggested comprehensive
approach is the common need for an integrated solution which could include interconnected
aspects such as new training, resources, processes, and motivational tools (Clark and Estes,
2008).
Stakeholder Knowledge, Motivation, and Organizational Influences
Volunteers play a critical role in free healthcare clinics. Salaries for nurses, physicians
and specialists are often cost prohibitive to free clinics. The services these organizations offer
local communities are often possible because healthcare professionals provide their expertise pro
bono. Volunteer healthcare providers are recruited based on their skill set and, in many cases,
complete a credentialing process and background check for the nonprofit organization which is
similar to a paid employer’s process. Healthcare volunteers may treat patients in free clinic
settings who have income levels, living conditions, and other social factors that differ from
patients they see in their paid practice. SES patients accessing the free medical help may face
multiple SDH challenges uncommon to the medical volunteers’ typical patient demographic.
Knowledge Influences
Volunteers require adequate knowledge and skills to achieve performance goals (Clark &
Estes, 2008). Physician education includes teaching on what the SDH are so doctors have
21

familiarity, though teaching often does not cover strategies on how to address these issues for
patients (Sharma & Kumagai, 2018). In contrast, the nursing profession more often emphasizes
the importance of understanding, as well as addressing, SDH for patients during a medical visit
(Thornton & Persaud, 2018). In traditional nursing undergraduate programs, community health
and public health courses include SDH within the curriculum (Thornton & Persaud, 2018).
Increasingly more nursing programs are including SDH training as a thread in their curricula
rather than content within a few courses (Thornton & Persaud, 2018). Table 3 presents key
knowledge influences, knowledge types, and the assessment strategy for knowledge influences
relevant to the healthcare volunteer role.

22

Table 3
Knowledge Influences, Types, and Assessments for Analysis
Knowledge influence Knowledge type
Knowledge influence
assessment
Volunteers need to understand
the philosophy of SDH and
how these factors affect health
for low SES patients.
Declarative
(conceptual and
procedural)
Volunteers were asked in
interviews to describe what
aspects of SDH are discussed
in a typical healthcare visit.
Volunteers need to know how to
implement TMC SDH
resources and referrals.
Declarative
(procedural)
Volunteers were asked what
SDH referrals have been
made internally or externally.
Volunteers need to reflect on
their role in helping patients
address SDH during a
healthcare visit.
Value Volunteers were asked how
important they believe their
role is in helping patients
address issues related to SDH.

Volunteers were asked what
additional information or
resources relevant to SDH
would be helpful to patients.

Note. The volunteer’s knowledge of SDH resources and their understanding of their role in
helping patients access resources is important to know what additional knowledge may be
required to support these efforts.

Motivation Influences
Healthcare professionals volunteer due to intrinsic and extrinsic motivation factors
(McGeehan et al., 2017). Volunteers are motivated to continue donating their time when the
work they perform aligns to their skill set (Rimes et al., 2017). Understanding what motivates
23

people is important when designing appropriate performance improvement plans (Clark & Estes,
2008).
Factors Motivating Healthcare Professionals to Volunteer
Healthcare volunteers may be motivated by intrinsic or extrinsic factors. Most often,
healthcare volunteers in free clinics express that they are motivated by intrinsic reasons because
giving back to the community aligns with their values (McGeehan et al., 2017). To a lesser
extent, volunteers may also donate time out of guilt or to make themselves feel better (Dwyer et
al., 2013). In some instances, healthcare volunteers donate their time for extrinsic reasons, such
as boosting their professional development and to socialize with likeminded professionals
(Dwyer et al., 2013).
Volunteer Self-Efficacy
Self-efficacy, one aspect of the social cognitive theory, is a person’s belief that they are
capable of successfully accomplishing a goal (Bandura, 2010) and is specific to a particular
behavior (Clark & Dodge, 1999). Bandura (2012) describes four ways in which self-efficacy is
developed: through mastery experiences, from social modeling, through social persuasion, and
partly from controlling physical and emotional states. Self-efficacy felt by volunteers in their role
is important to volunteer retention. Volunteers who perform a skills-based activity based on their
profession are more likely to continue volunteering (Rimes et al., 2017). Table 4 presents the
motivation influence described in the previous section accompanied by sample assessment
approaches and interview prompts.

24

Table 4
Motivation Influences and Assessments for Analysis
Assumed motivation influences Motivation influence assessment
Healthcare volunteers need to provide
services which align with their values.
What motivated you to begin serving at the
clinic?
Healthcare volunteers need to be given tasks
which align to their professional
experience.
How important, if at all, do you think your
role is in influencing a patient’s SDH?

Note. Volunteer motivation, whether intrinsic or extrinsic, is important to learn in order to know
how best to support volunteers with volunteer-centered strategies to increase SDH resource
access for patients.

Organizational Influences
Improving organizational performance requires analyzing internal resources and
processes needed by those who are tasked with delivering a service (Clark & Estes, 2008). Lack
of appropriate resources can create barriers to performance. Organizational culture is also a
factor when considering the implementation of a change process (Clark & Estes, 2008).
Clinic Operations
Free clinics often operate with structures consisting of paid staff and volunteers.
Maintaining healthy volunteer and staff relationships is important to retaining volunteers. Some
ways that nonprofit volunteers report not feeling supported by an organization’s staff include
communication issues, emotional discord, or lack of interpersonal compatibility (Rimes et al.,
2017). Factors which may negatively impact volunteerism in free clinics include lack of
appropriate medical supplies, overall disorganization, lack of patient compliance, concerns
25

regarding malpractice insurance, and inadequate social services for patients (McGeehan et al.,
2017).
Patient Access to Free Care
Accessibility of care is an important aspect of health equity. Free clinics vary with
respect to operating hours and frequency of appointments, often based on the availability of
volunteers. There are several barriers that low SES adults have reported when attempting to get
help from free clinics. Some barriers that patients face when attempting to access free healthcare
include not being able to take time off from work during clinic hours, having to wait in line too
long, and not being able to reach anyone when calling the clinic for information or to make
appointments (Kamimura et al., 2018).
Integrating Social Services With Healthcare Practice
Warren et al. (2017) provide a literature review with evidence for the importance of
social services integration with free health care in order to improve health outcomes for low
income families. To implement this well, organizations must be intentional about creating new
integrated goals and ensure that processes are aligned to achieve the expected outcomes leading
to improved SDH. In nonprofits, this often requires changing patterns and mind-sets of staff and
volunteers. Applying new models in order to frame aspects of an organization in new ways can
improve clarity and create new possibilities (Bolman & Deal, 2017).
Diversity, Equity, and Inclusion in Healthcare
Addressing needs upstream relevant to SDH are important strategies, but effective
solutions must also address systematic racism in the health care sector (Williams & Purdie-
Vaughns, 2016). Based on the literature, effective strategies for health equity must address
racism within the healthcare system and eliminate colorblindness from programs addressing
26

SDH. Two promising approaches implemented by community health organizations are joint
service delivery with social service providers and staff training to recognize and address cultural
bias (Braveman et al., 2019; Price et al., 2018). Table 5 presents assumed organizational
influences impacting volunteer capability for achieving organizational goals and the assessment
process to identify gaps.

Table 5
Organizational Influences and Assessments for Analysis
Assumed organizational influences Organizational influence assessment
TMC needs to provide appropriate
resources and tools to support
volunteers in their work.
What do you perceive are the best resources TMC
offers patients, and why?

From your experience, what additional resources do
you believe would be helpful to patients that are
not currently offered by TMC?

TMC needs to equip volunteers with
appropriate training to help patients
access SDH resources.

What additional training or tools could TMC offer
you that would be helpful in your role?

What other community agencies should TMC
partner with to create greater access to resources
relevant to improving SDH?

What other suggestions do you have for TMC which
could improve SDH for patients?

What other suggestions do you have for TMC,
broadly, which could help TMC provide more
care to more adults in our community?

Note. Volunteers are well positioned to provide SDH resources to low SES patients, though only
if the organizational tools and processes are in place to support them.

27

Components of Conceptual Framework
This study seeks to determine what knowledge and motivation is needed by health care
volunteers and what organizational resources are helpful to support improved medical and SDH
outcomes for low SES patients. By applying both the Gap Analysis Framework (Clark and Estes,
2018) and key findings in the research relevant to this problem of practice, the conceptual
framework creates a tool for developing a comprehensive organizational strategy to improve
whole person health for low SES adults.
Based on the research, there are key components which influence volunteer knowledge,
motivation, and organizational processes. Key components of volunteer knowledge and
motivation include ensuring their volunteer assignments align with their values and they are
performing tasks aligned to their experience. Key components of organizational resources and
systems helpful to volunteers include healthy communication and trust.
Figure 1 illustrates the relationship between the knowledge and motivation of healthcare
volunteers influenced by organizational practice and culture at TMC.

28

Figure 1
Conceptual Framework

Summary
The links between low SES, SDH, and self-efficacy are complex. Health outcomes are
improved when individuals have confidence in their ability to manage their own health, yet they
also need the resources to do so. Free health care clinics offer important services which address
SDH and aim to increase health equity. This integration of SDH resources and healthcare creates
greater opportunity for improved health. Most nonprofits are able to offer their services because

Healthcare
Volunteer
Knowledge

Understand patient SDH
needs and the resources
available to improve health
equity for low SES adults

Healthcare
Volunteer
Motivation

Clinic organization’s mission
aligns with the volunteer’s
values

Volunteer duties align with
their professional experience
and expertise

Nonprofit
Organization
Resources &
Support

Clinic provides services that
align with patient health and
SDH needs

Organizational systems enable
volunteers to achieve their goals
29

of the generous amount of time given by volunteer healthcare providers. Assessing volunteer
knowledge and motivation, along with appropriate organizational resources and support, may
lead to improved SDH outcomes for patients. The next chapter outlines the methodology of the
study to perform a gap analysis of the volunteer knowledge, motivation, and organizational
resources by applying the Clarke and Estes (2008) framework.

30

Chapter Three: Methodology
The purpose of this study was to identify the knowledge and motivation of volunteers and
TMC’s organizational resources and systems which create access to SDH resources for low SES
adults. The study participants were TMC volunteers with medical credentials to serve patients.
The purpose of this research was to reveal how volunteer knowledge and motivation, as well as
organizational resources and processes, contribute toward patient access to SDH resources. The
three guiding questions for this study included:
1. To what extent do healthcare volunteers have the knowledge needed to provide SDH
resources to patients?
2. What motivates healthcare volunteers to provide patients with SDH resources?
3. What organizational resources and systems improve or diminish a volunteer’s ability
to provide SDH resources to patients?
This chapter presents the methodology applied to the participant selection, the data
collection process, and analysis of the research findings. This chapter also explores the research
context and the worldview and positionality of the researcher, as well as how validity and
reliability were ensured. This chapter concludes with limitations and delimitations of the study,
as well as ethical considerations within the context of TMC.
Overview of Design
The design of this study is qualitative. Applying a qualitative approach allows the
researcher to learn directly from participants of their own experience of a particular situation
(Creswell & Creswell, 2018). This approach was chosen in order to assess the knowledge and
motivation of the volunteers of TMC regarding the inclusion of SDH resources for low SES
patients during a clinic visit. This approach also gave the volunteers opportunity to share what
31

gaps exist in organizational resources and processes to support them in these efforts. Using an
inductive strategy by gathering data through participant interviews allows the researcher to
gather specific information from multiple sources and then organize information according to
themes (Merriam & Tisdell, 2016). Volunteer interview results were synthesized into categories
within knowledge, motivation, and organizational themes applying the Clark & Estes (2008) gap
analysis framework. Themes can then be used to build theories which address the problem of
practice (Merriam & Tisdell, 2016).
Research Setting and Participants
The stakeholder group of focus for this study was TMC volunteers with various medical
credentials, including doctors, opticians, physician assistants, nurse practitioners, nurses,
certified nursing assistants, and students. These volunteers donate their time to provide free
healthcare services to TMC’s patients. TMC’s volunteers differ in age, education, experience,
race, ethnicity, religion, and length of experience working with low SES patients. The objective
of this research is to understand the knowledge volunteers have regarding SDH resources, their
motivation in providing the resources, and the organizational systems available in order for
patients to gain access to SDH resources during each medical visit.
Participant Selection Criteria
Each participant met the following criteria:
 TMC volunteer credentialed and approved by the clinic oversight committee and
board of directors to serve patients in a healthcare capacity
 TMC volunteer who has served in at least two clinic rotations in the six months prior
to the study. Clinic rotations are four-hour intervals or longer
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These criteria are important in order to ensure the volunteer has gained adequate
exposure to the clinic goals and processes and has developed an understanding of TMC patient
needs.
Participants
TMC volunteers complete a rigorous application process which includes credentialing,
background screening, and orientation to TMC’s history, culture and practices. TMC has 42
healthcare volunteers who have successfully completed the application process and are approved
to work directly with patients; however, not all of them volunteer on a consistent basis. A
purposeful sampling method was applied to ensure the most helpful data would be gathered. The
process of purposeful sampling ensures the participant selection criteria are met (Merriam &
Tisdell, 2016). Of the 42 volunteers, 30 volunteers met both selection criteria and were invited to
participate in this study. Of the 30 invited, 12 volunteers were available for interviews during the
research period. Table 6 provides an itemization of the volunteer participants selected for the
study according to their credentials.

33

Table 6
Participant Breakdown According to Credentials
Role Number
Physician 3
Optometrist 1
Nurse practitioner 2
Nurse 5
Emergency medical technician 1

Note. Volunteers who participated in the study held five different kinds of healthcare credentials,
providing various perspectives regarding SES resources.

The Researcher
In a qualitative study, the researcher’s background and biases have the potential to
influence the research process and data analysis (Creswell & Creswell, 2018). Self-reflection and
articulation of positionality based on these influences may help to mitigate bias in the research
process (Gibbs, 2018). This process, referred to as reflexivity, is also important in becoming
aware of power relations within the research process between the researcher and participants
(Merriam & Tisdell, 2016). In this section, I provide context for my worldview, my positionality,
and my relationship to the participants.
My pragmatic worldview has been shaped by my personal experience and vocation. A
pragmatic approach to research seeks to identify strategies to practically solve problems (Hinga,
2019). I chose a pragmatic approach to this research because I have lived experience in a family
that needed SDH resources and I now lead an organization which provides SDH resources in a
similar community context. My goal with this project is to help create strategies that will
34

improve access to SDH resources for TMC’s patients, much like the needs felt within my
community growing up.
I grew up in rural East Texas in a low SES community that experienced a shortage of
SDH resources such as lack of living wage employment, no public transportation, food
insecurity, lack of childcare options, and no free or subsidized healthcare for the medically
uninsured. My parents were resourceful, and my family had a strong social support network to
overcome these barriers; however, this was not the case for many of my classmates. Having now
spent nearly 20 years in the nonprofit sector designing services for low SES families, I
understand the opportunities organizations have to support those who need these SDH resources
the most.
Given the importance of ensuring the trustworthiness of the findings, I applied strategies
to address my personal perspective and biases during the interviews. Making the researchers’
positionality clear and practicing ongoing reflexivity are strategies which improve research
integrity (Maxwell, 2013). The strategies I implemented included providing transparency
regarding my role and ensuring that volunteers were aware their participation was voluntary. I
am the researcher and also the senior leader of the organization. Rather than invite the selected
volunteers to an interview directly, the Clinic Director emailed each volunteer individually on
my behalf. The volunteers are not accountable to either the Clinic Director or to me; they are
accountable to the Medical Director, who was aware of the research project goals and
methodology. The invitation to participate clearly indicated that research participation had no
bearing on the volunteer’s role or on their ability to continue serving at TMC, and that all
interview content would be held confidential and reported anonymously.
35

Data Source
Qualitative research often uses interviews with participants (Creswell & Creswell, 2018).
This study’s data collection method was a purposeful sampling of TMC volunteers for
interviews. The rationale for this method was to learn specific examples of their experience and
their recommendations for the organization. Interviews are useful when it is not possible to
observe participants in their context (Creswell & Creswell, 2018).
Interviews
Advantages to conducting interviews in research include gathering deeper insights into
the participant experience and having some control over the questioning (Creswell & Creswell,
2018). 30 TMC volunteers who met the sample criteria were invited to participate in the study
and 16 responded. Of the 16 who expressed interest, I was able interview 12 volunteers who
were available during the research period. The interview process was semi-structured with 13
open-ended questions.
Instrumentation
My data collection tool for the interviews was adapted from a Kaiser Permanente study
conducted in a for-profit healthcare setting (Schickedanz et al., 2019). The Kaiser Permanente
research questions and findings were published in “Clinician Experiences and Attitudes
Regarding Screening for Social Determinants of Health in a Large Integrated Health System”
(Schickedanz et.al, 2019). The tool asked questions of healthcare workers about their experience
applying SDH knowledge during a medical appointment (Schickedanz et al., 2019). I adapted the
survey tool questions and created an interview tool to attain similar findings from TMC
volunteers concerning their knowledge and motivation regarding their practice of addressing
36

SDH needs for patients, as well as the organizational processes which support them in these
efforts.
The interview protocol (Appendix A) includes the open-ended interview questions to
dive deeper into the volunteer knowledge and motivation and the organizational resources and
systems that are applied to help meet patient needs regarding SDH. The protocol also includes
additional prompts and specific elements of the gap analytic framework addressed. The questions
were tested in mock-interviews with two TMC staff members who provided feedback for
revisions and further suggestions for the interview setting. Additional prompts were then added
to the questions to improve the process. Paid staff were not eligible to participate in the research
project. Table 7 lists the interview questions, the research question being addressed, and the type
of question according to Patton’s description (2002).

Table 7
Interview Protocol
Interview question RQ addressed Q type (Patton)

What motivated you to begin serving at the clinic?

RQ2

Background
How long have you served in this capacity?

RQ2 Background
Prior to volunteering with the clinic, have you
volunteered to provide free medical services in
other settings, such as at other free medical clinics
or on mission trips?

RQ2 Background
To what extent, if any, do you discuss various
aspects of the patient’s life, such as SDH, during
the patient’s appointment?

RQ1 Knowledge
What lifestyle changes, if any, do you often counsel
your patients on to improve their health?
RQ1 Knowledge
37

Interview question RQ addressed Q type (Patton)

How important, if at all, do you think your role is in
influencing a patient’s SDH?

RQ2 Motivation
In your opinion, what is the most common obstacle
that patients of the clinic face in improving their
health?

RQ1 Knowledge
What do you perceive are the best resources, if any,
this clinic offers patients, and why?

RQ3 Organizational
From your experience, what additional resources, if
any, do you believe would be helpful to patients
that are not currently offered by the clinic?

RQ3 Organizational/
Knowledge
What additional training or tools, if any, could this
clinic offer you that would be helpful in your
role?

RQ1/3 Organizational
What other community agencies, if any, should the
clinic partner with to create greater access to
resources relevant to improving SDH?

RQ3 Organizational
What other suggestions, if any, do you have for the
clinic that could improve SDH for patients?

RQ3 Organizational
What other suggestions do you have for the clinic,
broadly, if any, that could help TMC provide
more care to more adults in our community?
RQ3 Organizational

Note. The research questions have been designed to gain first-hand insights from volunteers
regarding the knowledge, motivation, and organizational gaps which may need to be addressed
to support them in their efforts to connect patients with SDH resources.

Data Collection Procedures
Volunteers were made aware of the research project one month in advance through an
article in the monthly TMC volunteer newsletter. TMC’s Clinic Director then emailed each of
38

the 30 eligible volunteers individually, inviting them to be part of the research project. The email
introduction was explicit in identifying that as the researcher, I am in a dual role as both a
doctoral student and the head of the organization. The email invitation emphasized that
volunteers were being offered the opportunity to participate completely of their own volition and
that their participation would have no bearing on their eligibility to volunteer at TMC or the
work they would be assigned to going forward. Interested volunteers were asked to reply by
email to the Clinic Director, and those responses were then forwarded to me as the researcher in
order to schedule appointments directly with participants.
Interview participants were asked to determine the meeting time and location most
convenient to them. Six participants opted to be interviewed in person in a meeting room at
TMC, six opted to be interviewed virtually with Zoom, and one participant invited me to their
home. All 13 interviews were completed in September 2021. The practice of audio recording
interviews is the most common way to ensure comprehensive data collection for analysis
(Merriam & Tisdell, 2016). Each interview was recorded and transcribed using Otter.ai. The
interview recordings were then uploaded to Atlas.ai to prepare for coding. In addition to the
audio recordings, I kept memos during each interview to refer to key themes and notes of novel
responses during the analysis phase.
Data Analysis
In qualitative data research, the collection and analysis happen simultaneously (Merriam
& Tisdell, 2016). I applied inductive and comparative coding after each interview as themes
emerged. Coding involves organizing the data into segments and designating a word to represent
the category (Creswell & Creswell, 2018). I then identified axial codes to further arrange the
data. Axial codes help connect specific themes in analysis (Merriam & Tisdell, 2016).
39

Descriptive Analysis
Descriptive analysis is a process that summarizes key themes which emerge during the
research process (Merriam and Tisdell, 2016). In this study, the research findings have been
categorized according to themes within the Clarke and Estes (2018) gap analytic framework. The
results presented in Chapter Four organize the data according to themes which emerged
pertaining to volunteer knowledge, motivation, and organizational factors related to SDH
resource accessibility for TMC patients.
Validity and Reliability
Validity and reliability are critical concepts which determine the merit of research
(Merriam & Tisdell, 2013). Validity is determined by whether the research results measured
what was proposed (Merriam & Tisdell, 2013). Internal validity, or credibility, ensures that what
is actually happening is what the research findings ultimately report (Merriam & Tisdell, 2009).
By maintaining flexibility with interview schedules and location, I removed barriers to
participation, which helped ensure adequate representation for the key stakeholders and thus,
validity.
Reliability considers the likelihood of whether the study could be replicated and produce
comparable results (Merriam & Tisdell, 2009). This study adopted a questionnaire used in a
different setting, but it seeks the same insights relevant to how healthcare providers use patient
SDH information in their treatment plans. Research instrument reliability can be maintained if it
is not modified or combined with another (Creswell & Creswell, 2018). However, organizations
and human behavior change over time. Getting the same research results twice, even in the same
setting, is difficult to predict (Merriam & Tisdell, 2009).
40

Credibility and Trustworthiness
Credibility and trustworthiness in qualitative research can be ensured through several
helpful strategies in the research process (Merriam & Tisdell, 2016). In this study, I applied
reflexivity and member checks to increase credibility and trustworthiness. Reflexivity and
member checks help mitigate bias and ensure accuracy in the data collection and analysis
process.
Reflexivity
It is important for the researcher to demonstrate reflexivity by articulating personal
positions and how these may influence the interpretation of study results (Merriam & Tisdell,
2016). The researcher’s transparency allows the reader to understand how conclusions may be
influenced by the researcher’s perspective. Reflexivity in this study has been demonstrated by
clearly describing my worldview stemming from childhood and my leadership role of the
organization of study.
Member Checks
Applying the member check strategy is helpful to ensure participant data is accurate
(Maxwell, 2013). As part of this research process, I sought clarity from participants during each
interview to validate their responses and to minimize the possibility of misinterpreting
participant answers due to any potential bias. This was done by repeating back to the participant
key content they had articulated, and in some cases, asking follow-up questions for clarity sake.
After the interview portion of the research was completed, each transcript was reviewed multiple
times in order to discern themes and to look for additional comments which may have been
missed during the first phase.
41

Ethics
Ethical considerations are important to the trustworthiness of qualitative research
(Merriam & Tisdell, 2016). Relational ethics are important to consider, particularly as they relate
to the relationship between the researcher and the participants. In this case, the researcher is in a
senior leadership role and the volunteers are indirectly accountable to the researcher for their
work. The goal of this research is to improve health outcomes of TMC patients by increasing the
knowledge and skills of healthcare providers, as well as improving organizational tools and
processes. However, the healthcare volunteers may perceive the research process (and results) as
being critical of their work. To mitigate this, one strategy applied was transparency about my
dual role as both the researcher and the organizational leader. Communication about the research
project emphasized the helpfulness of the volunteers’ honest perspective regarding their
experience volunteering with TMC. Another strategy applied was to ensure that those invited to
participate were made aware their participation is completely voluntary and that participants
understood their rights should they chose not to participate. Interview participants were assured
that their comments will remain confidential and that all data will be destroyed upon final
acceptance of this study from the USC doctoral program.
Summary
Chapter Three provides a summary of the methodology chosen for this study.
Information pertaining to sampling, data collection, and analysis have been included. The
researcher’s perspectives and ethical considerations have been outlined, as well as limitations
and delimitations. Research results will be documented in Chapter Four.

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Chapter Four: Findings
The purpose of this study was to understand the role healthcare volunteers play in helping
low SES patients access SDH resources during a healthcare visit. Non-medical factors, such as a
lack of access to nutritious food, inadequate income, and unsafe neighborhoods can exacerbate
the health challenges felt by low SES patients. The interview questions were designed to
understand the volunteers’ knowledge, motivation, and organizational resources in order to
connect patients with the SDH resources most helpful for them. The research comprised of 12
interviews with TMC’s volunteers. Interviews were conducted in person and on Zoom over a
two-week period in September 2021. There were three research questions that framed the study:
1. What knowledge is required for healthcare volunteers to provide SDH resources to a
patient?
2. What motivates healthcare volunteers to provide patients with SDH
resources?
3. What organizational resources and systems improve or diminish a volunteer’s ability
to provide SDH resources to patients?
This chapter organizes the interview findings into themes which are aligned to the
research questions. The interviews were recorded using Otter.ai and transcribed for analysis. The
research findings in this chapter are from a qualitative analysis of the interview transcripts. As
the interview transcripts were analyzed, key themes emerged. The findings have been organized
along these themes and are presented with specific quotes from participants.
Participants
Interview participants met purposeful sample criteria. Each participant had fully
completed TMC’s credentialing and onboarding process and served in at least two clinic
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rotations in the six months prior to the study. Participants were given the flexibility to be
interviewed in person or via Zoom at the time most convenient for them. The interview results
have been aggregated and quotations are only associated with each participant’s assigned
number. Since there is only one optometrist who volunteers at TMC, this participant and all other
medical doctors who were interviewed have been categorized as ‘doctor’ to ensure anonymity
when quoted. Table 8 provides an overview of the length of time each volunteer has served with
TMC and whether they have volunteered in a similar capacity serving low SES adults with any
other agency.
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Table 8
Participant’s Length of Experience Volunteering Services to Low SES Adults
Participant Credential
Years of volunteer
service at TMC
Prior volunteer
experience
1 Nurse practitioner 2 No
2 Nurse 5 No
3 Doctor 2 Yes
4 Doctor 2 No
5 Doctor 10 Yes
6 Nurse 2 Yes
7 Nurse 1 No
8 Doctor 2 Yes
9 Nurse practitioner 1 Yes
10 Nurse 5 No
11 Nurse 1 Yes
12 EMT 2 Yes

Note. The information presented in Table 8 is helpful in understanding the length of experience
each volunteer has in providing free healthcare to low SES patients.

Findings
The following section presents the interview findings and categorizes them according to
key themes. Themes were determined based on words or concepts expressed by four or more
45

interview participants. These findings have been grouped with the corresponding research
questions framing this study.
Research Question 1: What Knowledge Is Required for Healthcare Volunteers to Provide
SDH Resources to a Patient?
The interview questions in this category were designed to learn from volunteers about
knowledge influences regarding their understanding of patient SDH needs, the implementation of
resources and referrals, and their understanding of their role in helping patients access SDH
resources. The following themes emerged from the volunteer interviews. Volunteer discussion
indicates that all 12 volunteers are knowledgeable of patient SDH needs and that these
discoveries are made primarily when creating patient treatment plans for diabetic patients.
Theme 1: Volunteers Have Knowledge of SDH Factors Impeding Patient Health
Each of the healthcare volunteers who were interviewed indicated that they assume
patients have needs related to SDH because all of TMC’s patients lack medical insurance and
their household income is low enough to meet the TMC intake guidelines. Three of the
participants shared that they intentionally attempt to create a welcoming environment so that
patients feel comfortable talking with them about their needs:
I try to make them feel comfortable. Because they’re coming to a free clinic, they might
think we’re looking at them a certain way. I want to try to alleviate all that and help them
be comfortable to talk about whatever they need. (Participant 2)
Interview participants shared that they ask questions relevant to SDH factors that pertain to the
patient’s presenting health condition. Specifically, six of the participants said they ask questions
to understand the likelihood that a patient will have the ability to follow their medical advice and
implement the recommendations to improve the health issue they are managing. Participants
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shared that these factors often include learning from the patient if they are able to afford certain
prescriptions, if they can work safely at their job, and if they can follow recommendations to
modify their diet and exercise habits. Volunteers learn from their patients about concerns
connected to SDH which may impede health progress, specifically when managing diabetes.
These concerns include the patient’s housing situation, access to nutritious food, access to
transportation, and employment conditions.
Prevalence of Diabetes
Every interview participant discussed the need to ensure that SDH resources are available
to diabetic patients. Health issues they discussed that result from diabetes included deteriorating
vision, kidney failure, and wounds on the feet. Each participant expressed concerns that patients
either lack awareness or lack a sense of urgency in managing their diabetes. Table 9 includes
quotes from volunteers indicating the prevalence of diabetes in the TMC patient population.
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Table 9
Concern for Diabetic Patients
Barrier type Example quote
Diabetic patients are not
managing their health
I see so many patients who have diabetes. I’d say diabetes
education and resources are essential for almost all of
our patients. There are many health risks people aren’t
aware of, like blindness and kidney failure. If it isn’t
managed it’s terrible, and many of the people we treat
don’t know how bad it can get. I think there must be a
lot more we can do to help them. (Participant 5)

The populations we serve are likely at greater risk of
having, or developing, diabetes. A lot of them can’t or
won’t do much to take care of themselves, so by the
time we see them they can be pretty sick or maybe
they’ve been in the hospital and the hospital sent them
to us for follow-up care. (Participant 4)

Diabetes is an expensive disease to manage. I’m glad we
started the A1c testing clinics so we can get a baseline
reading for blood sugar levels. We can make sure we’re
talking with the patients who need information and give
them feedback each time they come. We need them to
be consistent, but many aren’t. (Participant 7)

Note. TMC’s patients are routinely diagnosed with diabetes. This is a serious chronic health
condition that can lead to significant long-term health issues if patients do not manage it
consistently.

Nutritional Needs
Ten of the 12 interview participants indicated that during an appointment, they will
discuss the patient’s diet and any barriers the patient might face to improving their nutrition.
These participants recommend specific dietary instructions to help lower a diabetic patient’s
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blood glucose levels. The volunteers have learned that patients have several barriers related to
time and food access. Some examples the volunteers gave include limited time due to taking care
of several family members, trying to cook for many family members on a limited budget, family
food preferences outside of the patients’ recommended diet, and not knowing how to plan ahead.
Table 10 includes specific participant quotes relevant to barriers patients encounter in
implementing changes to their diet.

Table 10
Patient Nutrition Barriers
Barrier type Example quote
Limited time This one patient… she has so many hats she wears. She’s
driving her kids to and from places and also has her
parents who need her for things. She’s so busy taking
care of everyone else I don’t think she has time for
herself. (Participant 3)

A lot of the people I see are moms who are single and
working and taking care of their kids. They don’t have
the help or the time to plan and prepare what would be
good. She just has to do whatever is cheap, easy, and
quick. (Participant 7)

Cultural preferences These wives, they cook what their family expects and is
used to, not always what is best for their health. It’s hard
because they don’t have time to make different things,
especially if their family won’t eat it. (Participant 2)

We were talking about what to eat during the day to
manage his blood glucose and I just asked, what do most
of their meals look like. He talked a lot about rice. I
don’t know what a good swap would be. He needs to do
something else for lunch or to get balance because his
blood glucose levels are too high, but rice is a big part of
his culture. (Participant 1)

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Barrier type Example quote
Basic nutritional knowledge I was trying to explain to a patient about eating healthy
and what that means, and he told me he eats healthy
snacks during the day. I don’t believe him … I think
they just tell me what they think I want to hear.
(Participant 1)

I don’t know how much they know about what to eat.
Like, if they can read labels and understand what they
mean, what’s good for them or not or what to limit. I
talk with them and recommend eating a Mediterranean
diet. I give basics and ask if they have questions.
(Participant 4)

Budget constraints

It’s expensive to buy fresh. I try to talk about it, but I don’t
know if they can afford it. The food TMC gives out in
the pantry might be fresh, but I’m not sure. They
probably get food benefits of some kind. (Participant 3)

I think some of our patients go to the food pantry and
sometimes they can get fresh food, but the pantries
usually have canned and packaged. It’s hard to eat well
if you can’t afford it. I don’t know if they can get food
stamps or some other kind of food programs.
(Participant 5)

Note. Volunteers routinely discuss nutritional needs with patients but find there are several
factors patients must address in order to improve their diet such as time, education, and financial
means.

Neighborhood Conditions
Five of the 12 participants shared that they discuss neighborhood conditions with
patients, specifically whether or not their neighborhood is walkable. These volunteers indicated
that they often recommend that their diabetic patients consider walking in order to get more
exercise as part of their diabetes management plan. Of the five volunteers who recommend a
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walking regimen to patients, all shared that some patients are unable to walk in their
neighborhood due to lack of time or safety concerns. Table 11 includes example quotes
concerning barriers patients encounter when attempting to increase their daily exercise.

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Table 11
Barriers TMC Patients Encounter Concerning Exercise
Barrier type Example quote
Neighborhood safety I was talking with a patient about just starting with a ten-
minute walk down her street when she has time, nothing
major. That’s usually what I say to start, a little at a
time. But she said there’s no sidewalks and it just isn’t
safe with all the cars and trucks. (Participant 6)

This area hardly has sidewalks. I mean, if you live in the
neighborhoods around the country club it’s easy to walk,
these nicer neighborhoods, but where our patients live,
it’s just not. (Participant 11)

Some of these patients don’t live in town. Where they live,
it isn’t easy to just get out and walk. A few told me there
are loose dogs out, especially out in the country, these
dogs run around and bark at people. They’re scared of
dogs and won’t walk around there. (Participant 1)

Lack of time I ask patients if they can walk a little, it doesn’t have to be
too much, just get up and move a little bit every day.
They usually say they don’t have time. Some of them
are on their feet at work, but I think sometimes we have
some that don’t do much during the day. (Participant 9)

We have a program where we can give people a
membership for exercise to a local fitness facility. I
think it’s a great opportunity, but I don’t know who
actually goes. When I talk about it, they usually say they
will try to find the time to do it, but they don’t commit.
(Participant 3)

Note. Patient feedback indicates a willingness to get more exercise; however, the time and
location are routinely discussed as limitations.

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Working Conditions
In nine of the 12 interviews, the volunteer said they ask patients specifically about
employment because it is often relevant to the patient being able to manage the health issue that
brought them to the clinic. Volunteers named a variety of medical conditions where the type of
work performed could impede recovery, such as chronic back problems, repetitive motion
strains, wounds or lacerations, and chronic disease management. Each of the nine specifically
mentioned diabetic patients and how their employment conditions can impact their health
management. Table 12 includes participant quotes detailing the volunteer knowledge of patient
working conditions and the impact they have on health.

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Table 12
Working Conditions Relevant to Health Management
Barrier type Example quote
Working conditions Ability to monitor blood sugar levels for diabetics is a
problem. I don’t think they have test strips with them at
work usually, and sometimes they don’t have time or
there’s no place to go to test. (Participant 1)

One of the guys I’ve treated for diabetes said they don’t
ever have time to take breaks. With his job they just
keep working right through. He doesn’t test his blood
sugar during the day. (Participant 6)

Some of these guys do really hard work, which for a
diabetes patient, the work is sometimes putting them at
risk even more. Sometimes they get dehydrated because
they don’t take time to drink water… I worry about
those who work outside all day. (Participant 10)

Employed or unemployed I have to ask patients about what they do for work,
because treatment could be related to what they do every
day. I usually hear if they have a job or not. (Participant
4)

I always ask patients about their work and job status and a
lot of them say they’re in between jobs. (Participant 8)

I’ve treated patients with issues related to the kind of work
they do. It’s hard for me to tell them what to do to get
better because they have to go to work. If they don’t
work, they don’t have money, so taking any time off
really isn’t an option. (Participant 2)

Note. TMC volunteers often learn whether a patient is employed or not. Employment discussions
with patients focus on how the patient is able to work safely given their health condition. Three
participants did not mention that they discuss employment conditions with patients.
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Transportation
Four of the 12 volunteers shared that patients have issues with transportation. There is no
public transportation in the community where TMC is located. Each of the four volunteers
expressed that because some patients do not have a car, they have to depend on a family member
or friend for a ride to the clinic. Transportation issues were exacerbated during the COVID-19
pandemic. However, TMC also implemented a telehealth program to continue serving the
community. Prior to COVID-19, patients could wait inside the TMC lobby for their appointment.
This gave the patient a safe space inside before and after their appointment. When the pandemic
started, TMC suspended walk-in appointments due to a lack of waiting room space to safely
social distance. Since there is no waiting room, patients must now find transportation for a much
narrower time slot, which does not always work for those they are depending on for a ride to the
clinic. Telehealth appointments have been a helpful option to patients with transportation
barriers. TMC’s telehealth format involves a phone call between the patient and a provider using
a specific portal. A cell phone is the only tool that a patient needs and all of TMC’s patients have
their own or have access to a cell phone. Since technology has not been a barrier, telehealth has
been very helpful for patients with easily diagnosable conditions and prescription refills.
However, telehealth does not provide the same level of care patients would experience during an
in-person appointment. Table 13 includes quotes from participants detailing how transportation
impacts patient access to healthcare and how telehealth helps and hinders access to resources.

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Table 13
Transportation Challenges and Health
Barrier type Example quote
Lack of public or private
transportation

I had a patient who missed their appointment a few times.
His daughter was bringing him, but she works, and she
has to ask for time off to bring him, which isn’t easy.
(Participant 10)

I think there is a problem for patients who need rides to
get to the clinic. They need something reliable, but if the
person who’s supposed to take them can’t make it, they
usually cancel and have to reschedule. When there’s
only one car in the family, it’s hard to juggle everything
the family needs to get done. (Participant 12)

Since COVID, I’ve seen a lot of people waiting outside or
in cars because they can’t wait in the lobby. If they’re
getting a ride, then the driver has to stay too, which
doesn’t always work out well for them, and it’s too hot
for people to sit outside that long. (Participant 2)

Telehealth versus in-person
visits

I do a lot of telehealth appointments because people can’t
come to the clinic for a variety of reasons, and this is a
good option for them to get basic help and prescription
refills. We obviously can’t run tests, but it’s a good
option otherwise. I don’t think I know that much about
their overall life situation. We just talk about the issue
they need to discuss and that’s it. (Participant 4)

I’ve done some telehealth appointments, and it’s a good
service we offer, but I don’t spend as much time on the
phone with people as I would in person. It just isn’t the
same environment, the same experience. It’s pretty fast
and I don’t hear too much about their life. (Participant 3)

Note. Participants indicate that telehealth appointments are helpful when patients are not able to
be seen in person, though in-person visits are more ideal for learning more about the patient’s
social conditions.

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Summary
Volunteers routinely identify the SDH needs of TMC’s patients. These needs are
discovered during conversations with the patients about their ability to follow the doctor’s health
recommendations. Patient needs regarding nutrition, exercise, employment, and transportation
featured prominently in the volunteer feedback. Volunteers feel telehealth appointments are
helpful for people unable to come to the clinic, though they spend more time with patients
discussing their SDH needs when visits are in person.
Theme 2: Volunteers Lack Knowledge of TMC’s SDH Resources
Each of the 12 volunteers indicated they are aware that TMC offers a variety of services
to help community members, but they are unclear of the full scope of SDH resources. Each of
the 12 healthcare volunteers shared that they are aware TMC has social workers on site, but each
indicated that they are not completely aware of how these TMC staff members provide patients
with SDH resources. Four participants said they tell the clinic staff when one of their patients is
in need of food or financial help. All 12 interview participants shared that they would find it
helpful to learn more about TMC’s services and how they can work together with the staff to
provide more robust care for patients. Two volunteers recommended specific resources that
TMC should offer, unaware that TMC offers these services already. Table 14 includes
participant quotes regarding the volunteers’ knowledge of TMC’s SDH resources.

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Table 14
Volunteer Knowledge of SDH resources offered by TMC
Barrier type Example quote
Volunteers unclear about staff
roles
I think there is a social worker that helps people from the
community who need financial help or maybe looking
for a job, but I don’t know exactly how that part of the
organization works. (Participant 3)

I see the staff are sometimes meeting with the patients. I
think it’s to help them get enrolled in programs or
maybe help pay their bills. It would be good to know
what all they can do to help the patients too. I just never
thought about it until now. (Participant 5)

I often hear the front office staff on the phone talking
about the services and answering questions for people.
Sometimes she’s making appointments for someone
who needs help with paying a bill or looking for a job. I
overhear what she is saying but I only get part of the
conversation. I would like to know more. (Participant
12)

Volunteers unaware of scope of
TMC services
I know TMC gives out food and helps with other financial
things. I should probably know more about that part of
the organization and get the information. (Participant 8)

Because all our patients are struggling financially, I think
it would be good to do more to help with employment or
other things that maybe could help them with budgeting.
We might want to help with financial literacy and taxes,
because I bet all of our patients would benefit from that.
(Participant 4)

I think the staff are really good at helping patients with a
lot of things. I know the prescription enrollment
programs are some of the most important because
patients can’t afford the medication they need. They
probably help them with a lot of things outside of
medical, like paying rent. (Participant 7)

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Based on the interview findings, TMC volunteers understand the SDH concepts and the
impact that SDH factors have on low SES patient health. However, there are gaps in the
volunteers’ knowledge of what resources exist within the TMC organization and how best to
connect their patients to these services. Based on the interview findings, the volunteer lack of
knowledge of SDH resources is one barrier to creating access for low SES patients.
Theme 3: Volunteers Lack Knowledge of Some Patients’ Culture and Language to Provide
Care Equitably
Seven of the 12 volunteers expressed concern that they often do not have adequate
interpretation help during patient visits. Two volunteers who provide diabetic education shared
their lack of knowledge concerning culturally appropriate dietary suggestions because they lack
understanding of appropriate food swaps based on the patient’s culture. Table 15 includes
volunteer quotes regarding gaps in language and culturally appropriate resources for patients.

Table 15
Volunteer Performance Barriers Due to Language and Culture Differences
Barrier type Example quote
Language proficiency We have a lot of patients whose first language is Spanish.
Sometimes one of the bilingual staff will help translate,
or sometimes the patient will have a family member
with them. I don’t know if sometimes what I’m saying is
translated the right way, so I try to keep it as simple as
possible. We sometimes have patients who speak other
languages, but mostly Spanish. (Participant 9)
There’s bilingual staff who help translate in Spanish
sometimes. It’s helpful, but they’re not medically
trained, so I probably don’t go into depth like I would
otherwise. I wish I could have a more in-depth
conversation sometimes, but at least they’re getting
access to care, because without us I don’t know where
they’d go. This is probably their best option. (Participant
11)
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Barrier type Example quote
The staff is usually pretty good at making sure I have
someone who can help translate in Spanish if they’ve
booked patients for me that they think I will need help
with. I come to the clinic a few times a month and I
know I’m trying to share this person between all the
other visits happening that day; it can feel a little rushed.
So, I think there could probably be more translation help
and that would be good all around. (Participant 5)
During COVID, we tried to minimize the number of
people interacting with patients, as well as reduce the
amount of people in the building overall. We made
exceptions for patients who needed a family member to
come with them to translate, but not everyone has
someone who can take time off to come help them.
(Participant 3)
Culturally relevant resources

I see so many patients with diabetes and they only speak
Spanish. I don’t know what to offer them regarding
some things that would help. Like their diet. We don’t
have a lot of resources. I don’t know what they would
eat or things their family would like. We have the take-
home glucometers to test blood sugar, which are really
important. But the lifestyle things, I just don’t know. It
would be great to have some more information for them.
(Participant 10)
I’m from a different country and I know what people eat if
they’re from where I’m from; I know my own culture.
There’s a lot of sodium in our diet, and I know that’s a
problem before they even mention it. I can help people
from there better because I understand what they eat and
what they believe about food. It’s a little harder to help
someone if they’re from a different country. I don’t
know what to tell them, so I usually don’t talk about
these kinds of changes as often. (Participant 9)

Note. Seven of the interview participants shared that they would benefit from additional
interpretation services when treating patients who do not speak English. When volunteers treat
TMC patients who speak a different language, they have limited resources for translation and
also lack literature in different languages.
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In summary, volunteers believe SDH resources are important to low SES patients but
lack awareness of the full scope of SDH resources offered by TMC and how to coordinate with
staff to create access for patients. Unanticipated knowledge influences emerged from the
interviews concerning the lack of language and cultural understanding between the volunteer and
the patient.
Research Question 2: What Motivates Healthcare Volunteers to Provide Patients With
SDH Resources?
Interview questions were designed to understand what motivates healthcare professionals
in the community to serve low SES patients and to provide SDH resources during a medical
visit. The participants most often shared that they are compelled by their faith to volunteer in
service to others. Volunteers also said that they are motivated to discuss SDH needs with patients
when it is directly applicable to the health issue which resulted in the doctor’s appointment.
Theme 4: Volunteers Are Intrinsically and Extrinsically Motivated to Serve Low SES
Patients
Volunteers gave several examples of intrinsic and extrinsic motivation factors for
donating their time to serve patients at TMC. Intrinsic motivation stems from an individual’s
own satisfaction in the work they perform and extrinsic motivation concerns things which
incentivize a person to perform an activity (Elliot et al. 2017). Volunteers shared frequently that
their personal faith was the primary reasons they began volunteering at TMC, while others gave
reasons regarding professional advancement.
Faith Perspective
Eight of the 12 volunteers indicated that they volunteer at TMC because their faith
convictions compel them to serve the local community. They shared that they genuinely desire to
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help people live better lives. Five participants learned about the volunteer opportunity at TMC
through their church.
Employer Incentive
Two of the 12 volunteers described their employer incentive program. Employees are
awarded merit points based on the number of hours they serve in the community. Their employer
uses this point system to determine, in part, promotions and annual salary increases. These
volunteers give of their time because they are rewarded by their employer. One participant
shared their hopes of going to medical school and that their volunteerism could improve their
application. Table 16 includes quotes from volunteers regarding what motivates them to
volunteer in caring for low SES patients at TMC.

Table 16
Volunteer Motivation to Care for Low SES Patients
Motivation type Example quote
Intrinsic motivation factors I heard about this opportunity for the first time at church.
One of our pastors was starting a local mission group
project and I felt like this was something God was really
calling me to be part of. It feels really good to use my
expertise to help others. (Participant 2)

I’ve been volunteering here a long time as well as different
mission trips all over. I love it. As a Christian, I believe
this is what we’re supposed to do, to take care of people
who can’t take care of themselves. I feel I get more out
of it than I give. (Participant 5)

In my work, I treat patients who have similar barriers to
TMC’s patients. I’ve always felt called to help people.
When I was young, I knew I wanted to work in some
way to help others, and healthcare was the pathway.
(Participant 10)

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Motivation type Example quote
I first heard about TMC from the mission’s pastor at my
church. They were wanting to get a group together from
our church that could start volunteering once a month to
see patients. I knew immediately this was something I
wanted to get involved in so I could serve. (Participant
11)

Extrinsic motivation factors

I have volunteered here and at another local clinic many
times. I first started because at my work we get points
for the number of hours we spend volunteering. My
employer gives special recognition each year for the one
with the most hours, and that’s how we get
consideration for raises or promotions. I prefer this
clinic to the other, so I only volunteer here now.
(Participant 6)

I really like volunteering here. I started because I wanted
the experience and to be able to put it on my application
to help my chances to get into medical school. If I end
up living in this area though, I would continue
volunteering here; it’s a good place for the community,
and I really like the people who work here. (Participant
12)

Note. TMC volunteers began donating their time at the clinic due to intrinsic and extrinsic
motivation factors. Each volunteer described the satisfaction of treating patients in need and the
overall positive work environment at the clinic as the reasons why they return on a regular basis.

Summary
Volunteers are both intrinsically and extrinsically motivated to donate their time serving
low SES patients through TMC. Some began volunteering because the opportunity resonated
with them from a faith perspective. Those who were extrinsically motivated did so for
professional purposes. However, those who started volunteering because of extrinsic factors have
continued to volunteer because they now feel intrinsically motivated.
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Theme 5: Volunteer Motivation to Provide Patients With SDH Resources Is Based on
Volunteer Perception of Whether Patient Will Implement Advice
Four of the 12 volunteers shared that while they understand the patient SDH needs, they
do not engage every patient in a conversation about next steps. These factors were connected to
the volunteer’s perception of the patient’s willingness to act on the advice. Volunteers indicated
that these perceptions were based on the patient’s attitude and behavior.
Four volunteers shared that they did not have strong motivation to address SDH needs
with patients because they believe that patients would not follow through with recommendations.
Three shared the belief that some of TMC’s patients lack commitment to improve their health.
One shared that they lack credibility with patients because of their young age. Expectancy value
theory posits that one’s motivation is influenced by an expected outcome of their effort
(Ambrose, 2010). These volunteers perceive that most of their patients would not implement
their advice, so they do not engage the patient in these topics during the appointment. Table 17
includes quotes from volunteers describing factors which influence their motivation to provide
SDH resources to patients.

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Table 17
Motivation Factors Which Influence Whether Volunteers Provide SDH Resources
Motivation factors Example quote
Perception that patients will not
follow through with SDH
resource recommendations
Patients just want to get their prescription filled and get
out. I don’t think they care much about anything else
when they come. I just mostly help with the immediate
need that brought them to the clinic in the first place.
(Participant 1)

For patients who’ve been coming to the clinic for years
and their health doesn’t seem to be getting better or
they’re not being consistent with what we tell them, then
it seems like a waste of time to talk about other ways to
improve health. (Participant 2)

I can usually tell which patients need our help and if they
might be trying to play the system. Some of them don’t
look like they really need free help, but we treat them
anyway. I’m sure the TMC employees do the best they
can to make sure we’re only seeing people that truly
need it, but some of them, I don’t know. (Participant 5)

Volunteer self-perception People tell me how young I look. I think when I meet with
the patients, they probably don’t perceive me as
someone with enough experience to help them. A lot of
our patients are older. So, sometimes I have things I
could tell them, but I don’t think they will probably
listen. So, no, I don’t talk often with them about
recommendations for things they could do differently.
(Participant 12)

Four study participants indicated that they do not always engage the patients in
conversation regarding SDH needs if they believe the patient may have received referrals in the
past and did not act on them. One participant indicated they lack confidence sharing
recommendations with patients because they believe they lack credibility with patients. Interview
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findings did not indicate that the volunteer’s motivation was influenced by their self-efficacy to
provide appropriate SDH resources to the patient.
Research Question 3: What Organizational Resources and Systems Improve or Diminish a
Volunteer’s Ability to Provide SDH Resources to Patients?
Interview questions were designed to learn from volunteers what organizational resources
TMC offers and how systems support them in providing their patients with SDH resources.
Participant responses indicated several gaps in having appropriate tools which would enable
volunteers to connect patients with SDH resources more equitably. Lack of assessment and
monitoring tools were discussed, as well as processes to work more seamlessly with TMC’s
social workers.
Theme 6: TMC Lacks Clear Organizational Policies and Procedures to Assist Volunteers in
Connecting Patients With SDH Resources
Participants indicated a lack of understanding of the organization’s expectations
regarding how much time should be spent with patients and how best to refer patients to other
services. Specific issues regarding the documentation and follow-up notes in patient charts was
mentioned. The organizational barriers discussed by participants are related to policies,
procedures and resources.
Lack of Standard Appointment Length
Four volunteers indicated that a barrier to attaining adequate knowledge of patient SDH
needs is the lack of time with any given patient. Most volunteers serve monthly at TMC during a
specific clinic rotation, and these four shared that they lack clarity regarding what is the
appropriate amount of time to spend with a patient. These participants shared that they often feel
they need to move quickly from one patient to the next in order to see as many patients as
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possible. They shared that this was largely in part to honor the patient’s time so they can get back
to work, not because they themselves need to rush or feel compelled by TMC to hurry to the next
appointment.
Lack of SDH Documentation in Patient Charts
Three volunteers commented that patient medical charts lack space to document
discussions specific to SDH needs. Two volunteers indicated that lack of continuity with a
patient is a challenge because they are unaware what needs may have been discussed with the
patient in the past. Providers and nurses may never see the same patient twice based on volunteer
schedules and appointment times. Patient appointments are booked on a first come, first serve
basis and are not assigned to a specific provider.
Internal Referral Process
All 12 volunteers interviewed were not aware of how to appropriately transfer knowledge
they gleaned from a patient to a TMC social worker who can follow-up with the patient
concerning their SDH needs. Volunteers are somewhat aware that the TMC staff can help
navigate SDH resources, but they lack understanding in how to connect the patient to the
available resources. Table 18 includes quotes from volunteers describing organizational barriers
relevant to connecting patients with SDH resources.

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Table 18
Organizational Processes Barriers for Connecting Patients with SDH Resources
Barrier type Example quote
Lack of standard appointment
length
I don’t always know what the issue is, why the patient is
coming to the clinic. If a patient has something a little
more complicated happening, I might need to take more
time with them. So, when I’m talking with a patient who
has a fairly straightforward condition we’re trying to
solve, I’ll take care of them quickly in case I need to
spend more time with the next patient. When I’m there,
I don’t have a lot of time, so I want to make sure I can
get to everyone. (Participant 3)

Some of my patients are taking time off work for their
appointment, and if they don’t work, they’re not getting
paid. I just want to get them what they need as quickly
as possible and let them get back. (Participant 4)

Sometimes when I come to volunteer there are only a few
patients scheduled, but other times we have a lot. When
I see the number of appointments, I want to make sure
no one is waiting very long, so I will make sure we work
quickly so no one is turned away at the end. (Participant
8)

Lack of documentation space in
patient charts
We have very basic patient charts. The notes we make
aren’t extensive. We’re really just trying to capture the
essential medical information and if we talk about the
SDH resources, like if they need to know where to get
food, I don’t spend a lot of time writing that down. It’s
just a conversation. (Participant 1)

It would be great to know if a patient is already in some of
the other programs TMC offers. I would think a lot of
them end up coming to see the doctor because they
came to TMC for something else, like to get help with
paying a bill, and then find out they can see a doctor for
free. It’s like we need some sort of internal system to
figure out what all the patients are getting or doing with
TMC. It seems like all the different programs are in silos
right now and we don’t know how we can work
together. (Participant 5)

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Barrier type Example quote
I don’t think I’ve ever seen the same patient twice. It’s
hard not having a relationship with them like I would
with the patients in the practice where I work. The
patient notes aren’t extensive, so it’s like starting over
with a brand-new patient with everyone I see.
(Participant 7)

The charts are not the easiest to deal with. I’m trying to
read a previous note from a nurse or provider and
sometimes from the last visit or two. If the patient file is
thick, I won’t go through the whole thing. It isn’t like
having an electronic system where all the notes are clear
and easy to get to. (Participant 11)

Unclear internal referral process I think it would be really helpful to know if there’s a way
we can send one of our patients to meet with one of the
TMC social workers. We’re in the same building, but
when I move from patient to patient, I don’t go out and
see what happens next after they leave their doctor
appointment. (Participant 8)

If there was a way we could tell a patient who they should
see next, what to do, that would be great. I’m usually
focused on their specific prescription instructions or
other health issues, so my main priorities are those
things. I think we could do better in helping our patients
just navigate what all we can do for them internally.
(Participant 5)

Since I started volunteering here, it seems like there have
been a lot of staff changes. I remember there was
someone who helped people with rent and utility bills,
and I think someone else who offered counseling, but I
think those people don’t work at TMC anymore. I
haven’t seen them for a while. (Participant 2)

Note. The volunteers interviewed in this study expressed that they want to be respectful of
patient wait time at the clinic. The volunteers also want to maximize their time spent providing
direct healthcare services.
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Theme 7: TMC’s Practice Not Reflective of TMC’s Mission
The interview findings indicate that TMC’s mission statement “Motivated by Christ’s
love for all, we promote comprehensive wellbeing so that all who live in our community can
thrive” is not always reflected in organizational practice. The gap in volunteer knowledge of
patient language and the motivational gap expressed by volunteers in providing resources based
on their perception of the patients results in a different healthcare experience for some patients.
These patients have shorter conversations with the healthcare volunteer and may not receive
additional information or access to SDH resources which could improve their health. One
volunteer spoke negatively about treating immigrants specifically. This is important because it
indicates that not only is TMC not fulfilling its mission, but also that organizational practices are
unintentionally perpetuating healthcare inequity for some low SES patients. Table 19 includes
quotes from volunteers which indicate a gap between TMC’s mission statement and volunteer
practices in providing healthcare and access to SDH resources equitably.

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Table 19
TMC Volunteer Efforts Do Not Always Align With the Organization’s Mission
Barrier type Example quote
Quality of patient care is
different for patients who do
not speak English
If a patient doesn’t speak English and I don’t have
someone in the building to help translate, I just do the
best I can. (Participant 3)
When I’m seeing a patient who speaks Spanish, I use the
Google translator on my phone. It works well enough
for me to figure it out, usually between that and the little
Spanish I know I can figure out what the issue is.
(Participant 6)
We have quite a few patients who don’t speak English
very well. Sometimes the patient brings someone from
their family to help translate or we might have another
person who can volunteer that day. Part of the issue is
they don’t typically know any medical terminology, so
I’m basically relying on them to understand the basics of
what the patient is saying so they can tell me what the
problem is and then I depend on them to understand the
basics of my instructions back to them. (Participant 5)

Negative attitudes towards low
SES patients
We have patients who just want whatever free things we
can give them. (Participant 7)
I talk with patients about different things they can do to
improve their health issues, like making better food
options and going for walks or just getting more
exercise in general, but you know that’s not something
all our patients care about. They’re just going to do
whatever they want anyway. (Participant 4)
Whatever we give them is better than anything else they
can get. I think people are just happy with what we can
do. Most of them are probably illegal and can’t go
anywhere else, so it’s good we can do what we can.
(Participant 11)

Note. Six participants interviewed for this study gave responses which indicate a discrepancy in
the quality of care between patients who do and who do not speak English. In addition to the
standard of care based on language, three interviewees expressed a lack of trust or respect based
on their personal perception of the patient.
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Summary
Each of the volunteers interviewed in the study acknowledged the importance of
connecting low SES patients to SDH resources. The interview findings generated data relevant to
TMC volunteer knowledge, motivation, and organizational factors which support the volunteers
in their role of connecting patients with SDH resources. The results show that TMC volunteers
routinely discuss potential SDH needs with patients during their medical appointment regardless
of the volunteer’s role or how many years of experience they have. However, lack of knowledge
of TMC’s SDH resources combined with lack of referral tools and processes create barriers for
volunteers to connect patients with the help they need. More complex themes also emerged in
this study regarding the language and cultural gaps between volunteers and patients which
ultimately impact health care equity. The gaps in volunteer knowledge, motivation, and
organizational processes is preventing TMC from fulfilling its mission to ensure all community
members receive the necessary care in order to thrive. Table 20 summarizes the research findings
and key themes which emerged during the data analysis.

Table 20
Summary of Knowledge, Motivation, and Organizational Themes and Findings
Themes Findings
Volunteers have knowledge of
SDH factors impeding patient
health
Discovery of SDH needs happens routinely during patient
visits

Diabetes is a prevalent health condition which often
requires access to SDH resources

Volunteers lack knowledge of
TMC’s SDH resources
Volunteers unaware of social workers’ purpose

Volunteers named resources they would like to see TMC
offer, unaware they exist internally already

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Themes Findings
Volunteers lack knowledge of
some patients’ culture and
language to provide care
equitably

Volunteers treat high percentage of Spanish speaking
diabetic patients, yet do not speak the language, other
languages also spoken but not named

Volunteers spend less time discussing patient needs when
English is not their first language

Volunteers desire more culturally relevant resources to
assist their patients

Volunteers are intrinsically and
extrinsically motivated to
serve low SES patients

Most volunteers learned of the service opportunity with
TMC through their church or employer

Volunteers continue to give their time regularly because
they gain satisfaction from it and like the organizational
environment

Volunteer motivation to provide
patients with SDH resources is
based on volunteer perception
of whether patient will
implement advice
Volunteers discuss SDH resources most often with patients
they believe are likely to follow through on
recommendations

Volunteer perception of patient follow-through is
diminished due to lack of understanding of whether
patients have been provided information in prior
appointments

TMC lacks organizational tools
and processes for volunteers to
connect patients with SDH
resources
Volunteers want patient visits to be short so patients can go
back to work, and so they can treat as many patients as
quickly as possible

Patient medical charts lack space to document discussions
with patients regarding SDH needs

TMC lacks processes to connect patients with social
workers to attain SDH resources

TMC practice not reflective of
its mission
Findings indicate inequity in patient care

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The findings from this study indicate that most TMC volunteers are motivated to provide
valuable healthcare for low SES patients. During patient visits, volunteers often attain
information regarding specific needs related to SDH which could improve the patients’ health
and overall quality of life. There are gaps which should be addressed to help improve volunteer
performance in order to provide the same standard of care for all TMC patients. These research
findings are discussed in Chapter Five with recommendations to improve volunteer knowledge,
motivation, and TMC’s organizational gaps.

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Chapter Five: Discussion and Recommendations
This chapter provides discussion regarding the research findings followed by
recommendations aligned to the conceptual framework presented in Chapter Two. The study
limitations and delimitations are also discussed. This chapter concludes with recommendations
for future research relevant to SDH resource access for low SES patients.
Discussion of Findings
Research findings from this study are organized within the six key themes articulated in
Chapter Four. Applying the Clarke and Estes (2008) gap analysis framework, the findings reveal
strengths as well as gaps within volunteer knowledge, motivation, and TMC’s organizational
processes for volunteers to connect low SES patients with SDH resources. The organizational
recommendations for TMC are based on these findings and are supported by the literature.
Theme 1: Volunteers Have Knowledge of SDH Factors Impeding Patient Health
The study found that TMC’s healthcare volunteers routinely discover SDH factors
relevant to low SES patient health. Each of the 12 volunteers interviewed discussed patient SDH
barriers and their relevance in providing realistic health recommendations. Research indicates
that medical and nursing school programs include education on SDH concepts, though nursing
schools tend to incorporate SDH knowledge as a theme throughout the entirety of their program
(Thornton & Persaud, 2018). Based on the participant interviews, TMC’s volunteers identify
patient needs relevant to SDH resources to the same extent regardless of the volunteer’s
professional healthcare credentials or years of experience volunteering. Interviews also revealed
that patient needs related to SDH are most often gleaned during visits related to diabetes
management.

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Theme 2: Volunteers Lack Knowledge of TMC’s SDH Resources
Each of the volunteers acknowledged that they were aware of TMC resources for low
SES patients. They also indicated a lack of understanding of the full scope of these services.
Before volunteers arrive for their first clinic rotation, they receive general information about
TMC’s programs and classes. Research indicates that the integration of SDH resources within
the context of free clinics can improve health outcomes for low SES patients (Shortell et al.,
2010). TMC has attempted to achieve this integration by hiring social workers who assist
patients with access to internal SDH resources such as employment programs, education,
financial assistance, housing assistance, transportation services, and free food. However, there
has been a challenge in providing SDH resources to patients due to the volunteers’ lack of
knowledge about what resources are available. Information alone can address a gap in
knowledge if that is all that is needed to accomplish a goal (Clark & Estes, 2018).
Theme 3: Volunteers Lack Knowledge of Some Patients’ Culture and Language to Provide
Care Equitably
Seven of the 12 volunteers spoke about the difficulties they experience in providing
quality care to patients who speak different languages and have different cultural backgrounds.
They do not spend as much time talking with these patients because of the language differences.
These volunteers indicated the disparity in patient care is due to language and culture barriers.
These gaps in knowledge are due to lack of specific language training and cross-cultural
education in areas of food and household management (Clark & Estes, 2018).
These findings also reveal an organizational gap of diversity, equity, and inclusion (DEI)
strategy within TMC’s organizational practice. Volunteers shared that there are attempts to
provide a Spanish language interpreter, but this is not always possible. Volunteers also described
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a challenge in addressing cultural backgrounds regarding dietary preferences. A lack of resources
available in the patient language and culture indicates a lack of intentionality concerning DEI
within TMC. TMC’s volunteers are primarily English speaking only, and any resources or
literature provided to patients is primarily in English. Lack of cultural understanding and
perceptions of racism may diminish trust with patients and make them less likely to follow
through with important health recommendations (Sacks, 2013).
Theme 4: Volunteers Are Motivated Intrinsically and Extrinsically to Serve Low SES
Patients
Volunteers described intrinsic and extrinsic factors which motivate them to volunteer at
TMC. The primary intrinsic motivation factor was an alignment between the faith values of the
volunteers and the organization’s values. Volunteers described feeling motivated to use their
expertise to help those who are less fortunate because their faith compels them to help the less
fortunate. Intrinsic motivation as the primary driver for healthcare volunteerism is supported in
the literature. When tasks align to volunteers’ values and skill sets, they are motivated to serve in
a long-term capacity (McGeehan et al., 2017).
The extrinsic motivation described by two volunteers stemmed from the rewards system
at their workplace for serving in the community. These volunteers shared that their eligibility for
work promotions and pay increases is tied to the number of hours they volunteer in the
community. One volunteer described an extrinsic motivation factor connected to improving their
application to medical school.

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Theme 5: Volunteer Motivation to Provide Patients With SDH Resources Is Based on
Volunteer Perception of Whether Patient Will Implement Advice
Four volunteers indicated that their conversations with patients concerning SDH
resources largely depends on their perception of whether patients will implement their
recommendations. Three of the volunteers shared that they perceive some patients are likely
unwilling to take steps to improve their health, and only wish to have their immediate health
needs met. One factor which impacted motivation was whether a patient seemed to have
demonstrated progress based on past recommendations. Another volunteer said they are less
motivated to engage the patient in a discussion concerning SDH resources if they perceive the
patient does not actually meet the low-income guidelines set by TMC and are taking advantage
of the charity. When a volunteer actively chooses to not have a conversation about SDH
resources because they do not believe their efforts will be effective, this indicates that they lack
motivation (Clarke & Estes, 2018). These interviews reveal that while volunteers are motivated
to serve low SES patients, they are not motivated to serve all patients equally. In addition, there
is no clear expectation or accountability for volunteers to make SDH recommendations. In this
case, the behavior of those responsible for providing services is influenced by their own values
and decision making (Hentschke & Wohlstetter, 2004).
Theme 6: TMC Lacks Organizational Tools and Processes for Volunteers to Connect
Patients With SDH Resources
Volunteers identified difficulties stemming from the length of time they had with
patients. Volunteers also shared frustration about the lack of documentation regarding SDH
needs in the patient medical charts. This lack of information made it difficult to know if the
patient had been referred to SDH resources in the past. Volunteers discussed the need to have
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better referral tools and processes to help their patients access SDH resources. Clearly articulated
processes would allow the volunteers and staff to work smoothly and accomplish organizational
goals (Clark & Estes, 2018).
Recommendations for Practice
This study with TMC’s volunteers and a similar study conducted with healthcare
professionals within a large integrated health system yielded similar results (Schickadanz et al.,
2019). In both contexts, participants cited the importance of providing patients with SDH
resources yet expressed difficulty due to gaps in knowledge, motivation, and organizational
barriers. The common barriers named by both sets of research participants include lack of time,
gaps in knowledge of what resources are available, and lack of appropriate training and tools to
respond to those needs (Schickadanz et al., 2019).
Six recommendations have been identified that may increase TMC’s volunteer
performance in connecting patients with SDH resources. Each of these recommendations address
the research findings and are supported by the literature review:
1. Develop SDH information resources for healthcare volunteers
2. Create organizational processes to help volunteers connect patients with TMC’s SDH
resources
3. Create tools to monitor patient SDH progress
4. Implement a process effectiveness evaluation plan
5. Monitor volunteer satisfaction
6. Develop a DEI strategy for volunteer recruitment and training

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Recommendation 1: Develop SDH Information Resources for Volunteers
All 12 interview participants in this study shared that they believe SDH resources are
helpful to improve health outcomes for low SES patients, particularly for diabetic patients. Each
participant indicated that they were not aware of the full range of resources TMC has available
for patients. Clark & Estes’ (2008) work identified that this type of knowledge gap can be
improved by simply providing the information needed. One strategy to ensure volunteers have
access to SDH information would be to include keeping a list of resources handy in each exam
room. This list can be kept on the counter next to other information, such as the list of available
prescription samples on site. Another strategy is to create a wall poster for each exam room
which markets TMC’s SDH resources for patients to see while they wait in the exam room.
These two efforts will ensure that both the volunteer and patients are aware of TMC’s scope of
services.
Recommendation 2: Staff to Collaborate With Volunteers to Create Organizational
Processes That Help Volunteers Connect Patients With SDH Resources
Creating a clear referral process will address one of the organizational barriers to
providing SDH resources to patients. Literature shows that there is a risk of volunteers quitting if
additional responsibilities beyond patient care are expected (McGeehan et al., 2017). There is a
risk that in creating a new process to address this gap in volunteer performance, a new problem
concerning volunteer retention could occur (Clark & Estes, 2008). Stakeholder engagement in
designing the process is one way to mitigate this risk (Lewis, 2011). TMC can prepare volunteers
for the change by including them in the change process. A collaborative effort between staff and
volunteers interested in designing the solution may also have a secondary effect of improving
relationships and increasing volunteer retention (Rimes et al., 2017). Creating a team structure
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with representatives from the various health and SDH resource teams to collaborate on an
ongoing basis may help overall organizational effectiveness (Bolman & Deal, 2017).
One strategy the volunteers and staff should consider is a modified referral process for
SDH resources. Utilizing a referral form with the list of SDH resources paired with check boxes
could help volunteers quickly indicate which resources the patient should consider. The
volunteer could present the patient with the SDH referral form to present to the clinic coordinator
at check-out. The additional administrative work would then be managed by the clinic employees
responsible for making appointments with the social workers. This process could ensure the
healthcare volunteer is able to initiate the process in connecting patients with SDH resources and
minimizes additional administrative tasks.
A strategy to support the referral process could be to frame the SDH referral process as a
‘prescription’ for SDH resources. TMC has a program called Rx for Ex in which a provider can
write a prescription for a free family membership to a local fitness center. One doctor
interviewed in the study mentioned the program but did not indicate if they had personally made
a referral for exercise. Communicating a new SDH resources referral process as another form of
prescription writing may reinforce TMC’s expectations of the volunteer role to help patients.
Recommendation 3: Create Tools to Assess and Monitor Patient SDH Needs
There should be a way to measure patient progress regarding access to SDH resources
within the patient chart. Including a simple discussion tool with space for notes, similar to the
referral form, can solve this. Based on the participant interviews, the space for notes is one way
to address volunteer motivation to discuss SDH resources with their patients by allowing them to
see what has been discussed with patient in previous visits. Volunteer motivation to provide
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SDH resources may increase if they know their recommendations are being followed-up on with
the patient during the patient’s next visit (Clark & Estes, 2008).
Creating a standardized patient SDH assessment tool in the languages most helpful to
patients could minimize the possibility of subjective patient care. The document text could be
accompanied by infographics to further address language gaps. This tool could be completed by
patients as a self-assessment upon check-in. The patient can identify their own SDH needs and if
they would like to discuss them with someone during their appointment. This removes the
burden of decision making from the volunteer. This helpful resource could be placed in the
patient file for the healthcare volunteers to see at the time of the patient visit. The tool can
include space for volunteers to make notes during their conversation with the patient. This SDH
assessment document can remain in the patient chart for future volunteers to reference should the
patient return for a subsequent visit. These recommendations may provide clarity regarding
previous recommendations and act as a baseline to discuss patient progress towards accessing
SDH resources (Billioux et al. 2017).
Recommendation 4: Implement Orientation and Training to Equip Volunteers With New
Tools and Process
To address the volunteer lack of knowledge regarding how to provide patients with SDH
resources, an orientation and on-the-job training program should be developed. Since volunteers
complete rotations once per month, the clinic coordinator can provide an overview of the new
tools and process accordingly. As patients check out from their appointment, the clinic
coordinator can quickly troubleshoot any gaps between the volunteer’s understanding of the
SDH referral tool process and next steps for patients. The Kirkpatrick framework outlines four
levels of evaluation which identify the relationship between learning and outcomes. Level 1
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questions assess the degree to which participants find training relevant and enjoyable. Level 2
helps identify the extent to which participants gain knowledge anticipated from the training.
Level 3 assesses how the participant applied the learning. Level 4 measures the outcomes
achieved as a result of the training and resources provided (Kirkpatrick & Kirkpatrick, 2016).
The Kirkpatrick framework (Kirkpatrick & Kirkpatrick, 2016) could be valuable to TMC
in its efforts to address the problem of practice by applying it to volunteer performance.
Applying the Kirkpatrick Framework to volunteer performance may help clarify additional
training, tools, and performance outcomes. Helpful questions within each level could be as
follows:
1. How helpful are the training and resources you have received thus far?
2. What additional training would be helpful to you?
3. How have you applied what you were presented in training with your patients?
4. Do you believe your patients are achieving their desired health outcomes through
better access to SDH resources?
Ongoing volunteer self-assessment and feedback could help ensure the organizational change
process is sustained while creating a learning culture (Clark & Estes, 2008).
Recommendation 5: Monitor Volunteer Satisfaction
The participant findings indicate that volunteers donate their time with TMC because the
opportunity to serve the community aligns with their values. The healthcare services that TMC
offers the community are made possible by the professional healthcare workers who volunteer.
As the organization adapts new processes and volunteers begin to work in new ways, TMC may
consider a process to regularly evaluate the level of satisfaction volunteers experience in their
roles. Investing in volunteers should help with continued engagement and motivation (Bolman &
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Deal, 2017; Clark & Estes, 2008). One way that volunteer satisfaction can be measured is
through survey feedback (Bolman & Deal, 2017). Based on feedback, TMC’s staff can gauge
volunteer perspectives, needs, and elicit suggestions for rewarding volunteer performance,
further increasing engagement and motivation.
Recommendation 6: Develop DEI Strategy for Volunteer Recruitment and Training
Six of the 12 volunteers interviewed indicated that at times they have difficulty treating
patients and providing SDH recommendations when the patient’s first language is not English.
Most named Spanish language resources as a gap. Approximately 20% of residents in TMC’s
county are Spanish speaking (https://datausa.io/). The third and fourth most common languages
spoken in the region after English and Spanish are Vietnamese and Arabic. Based on this study’s
research, TMC’s volunteers indicate a gap in cultural competency to provide appropriate health
recommendations for patients of a different cultural background. This may diminish the
confidence of volunteers to perform consistently, and lack of confidence can diminish motivation
(Pajares, 2006).
A first step in a diversity, equity, and inclusion strategy (DEI) could be to address the
language gap between volunteers and their patients. Implementing a new interpretation resource
such as Boostlingo (www.boostlingo.com), may help volunteers with immediate needs when
treating a patient whose first language is not the same as their own. Boostlingo is an on-demand,
HIIPA compliant interpretation service that can be used with a phone, tablet or computer in the
exam room or on the phone in conjunction with a telehealth appointment. Boostlingo interpreters
are required to be proficient in medical terminology and can provide services in 300+ languages.
In addition to patient appointment interpretation, SDH referral information and resources should
be translated as needed.
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TMC should also consider creating a comprehensive DEI strategy for the organization.
The Global Diversity, Equity & Inclusion Benchmarks (GDEIB) tool could be a helpful resource
to TMC’s staff and board of directors in this process (Molefi et al., 2021). This tool provides DEI
assessment, design, and performance indicators. The organization’s ability to implement the
GDEIB tool is dependent upon the readiness of TMC’s board of directors and leadership team.
One technique to appeal to the leadership team and board should be to address the disparity of
care between patients and this inconsistency with TMC’s mission, vision and values.
Based on the research, two key activities the strategy should include are goals to
broaden the diversity of its volunteer base and training for volunteers to understand implicit bias.
Culturally matching patients and providers can mitigate bias and improve communication
between patients and providers (Cavalhieri, et al, 2019). Volunteers indicated that they spend
less time with patients who do not speak English well and they do not discuss additional SDH
resources if they perceive a patient is unlikely to follow through with recommendations. The
differences in the standard of care provided could be attributed to implicit bias. Understanding
implicit bias may help volunteers avoid subconsciously deciding to treat patients differently
based on any specific patient characteristics (FitzGerald & Hurst, 2017). Ensuring a consistent
standard of care for all patients will help TMC align its practice to its mission of helping all
community members thrive.
Integrated Recommendations
The intended outcome of these six recommendations is to increase the likelihood that
TMC’s volunteers will successfully connect low SES patients to SDH resources. These
recommendations require changes in multiple aspects of the organizational operations and
culture. Developed by two business consultants in the early ‘80s, McKinsey’s 7S framework
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(Singh, 2013), if applied to the recommendations, may help TMC ensure the change strategy is
comprehensive enough to be successful. McKinsey’s 7S framework approaches change through
the assessment of seven organizational elements: strategy, structure, systems, skills, staff, style,
and shared goals. Table 21 applies McKinsey’s 7S model to the recommendations which are
supported by the literature.

Table 21
Applying the McKinsey 7S Framework to Successfully Implement Recommendations
McKinsey’s 7S Recommendations Research
1. Strategy: How will we
accomplish our goals?
Invite volunteers to be part
of SDH referral strategy
formation.
Inclusive planning approach with
staff and volunteers may improve
overall organizational
effectiveness (Bolman & Deal,
2017).

2. Structure: How will
we organize
departments to
accomplish our goals?

Distinguish between
volunteer and staff roles
to mitigate unnecessarily
burdening volunteers with
tasks outside their scope
of expertise.

Volunteer retention is influenced by
the kinds of tasks they are asked
to perform outside their area
expertise (Rimes et al., 2017).
3. Systems: What
systems do we need?

Create organizational
processes to help
volunteers connect
patients with SDH
resources.

Develop SDH resources
such as brochure and
promotional poster in
exam room.

Adopt interpretation
technology to bridge
language barriers between
the volunteer and patient.
Patient documentation processes to
know if volunteer efforts are
effective may improve volunteer
motivation (Clark & Estes, 2018)

Information shared with volunteers
will improve their knowledge of
SDH resources (Clark & Estes,
2018).

Volunteer confidence to treat
patients of different language and
cultural backgrounds may
improve motivation (Clarke &
Estes, 2018)
86

McKinsey’s 7S Recommendations Research
4. Skills: What skills do
we need?
Provide volunteers with
training on new tools and
processes to connect
patients with SDH
resources.

Effective training leads to behavior
change which can be measured
(Kirkpatrick & Kirkpatrick,
2017)

5. Staff: Who are the
right people?

Monitor volunteer
satisfaction through an
annual engagement
survey process.

Recruit culturally diverse
volunteers.
Feedback to gauge volunteer
motivation after the changes
occur can help TMC leaders
assess whether or not the same
volunteers should be retained
(Bolman & Deal, 2017)

Matching patients and providers of
the same language and culture
can improve communication
(Cavalhieri, et al, 2019)

6. Style: What
organizational culture
do we need?

Provide implicit bias
training to volunteers.
Mitigate implicit bias, which
impedes improved health
outcomes (FitzGerald & Hurst,
2017).

7. Shared goals: What is
our purpose?

Create a comprehensive
DEI strategy for the
organization.
TMC’s mission statement:
Motivated by Christ’s love for
all, we promote comprehensive
wellbeing so that all who live in
our community can thrive.

Note. McKinsey’s 7S model creates a framework for assessing strategic elements of a change
process, as well as more granular tasks and resources required. This model may serve as a
helpful tool to ensure changes are articulated well and have allocated the necessary resources for
successful implementation.

87

Limitations and Delimitations
Limitations in the research process, as well as delimitations, help the reader better
understand the context of the study. Limitations are outside of the researcher’s control.
Delimitations are choices the researcher makes that create confines to the scope of study
(Creswell & Creswell, 2014).
Limitations
There were data limitations which could have been helpful in the analysis of the
interview findings. TMC lacks an electronic system for capturing patient demographics. It would
have been helpful to know the percentage of patients who are English speaking versus Spanish
speaking, as well as additional existing patient languages. The recommendations made assume
that TMC’s patient population is reflective of the community demographics. Another limitation
related to this research was the volunteer’s availability for an interview. There were 18 additional
eligible volunteers who were traveling or working extensively during the research period and not
available to meet, some of whom have longer tenure serving TMC’s patients. Unfortunately,
during this period our region experienced a significant spike in COVID-19 cases. Several of the
physicians and nurses were working additional hours in their own clinic setting and unable to
participate. Those with a longer history of service with TMC may have shared more in-depth
knowledge and organizational resources which have been helpful in providing SDH resources to
patients in the past.
Delimitations
I chose not to review the patient documents as part of this research process. It would have
extended the length of time needed to devise the study in a way which would allow for patient
confidentiality and to meet HIPAA compliance. In addition, staff were not included in the
88

interviews to provide insights into TMC’s processes and SDH resources, so the
recommendations made are solely based on what was learned from volunteers.
Recommendations for Future Research
There is extensive literature which discuss the SDH resources needed by low SES
patients to improve long-term health outcomes. Based on the interview findings, there does seem
to be a prevalence of diabetes in the low SES patient population. Future research could include
an assessment of strategies which best improve access to SDH resources specifically for diabetic
patients. Additional research may also consider what strategies have been successful in
improving DEI in free and charitable clinics. Given the dependence on volunteers in the free
clinic sector, this aspect of the research should include what strategies can be deployed to
increase diversity of healthcare volunteers. In TMC’s context as a Christian organization, the
alignment between the volunteer’s values and motivation to serve came through in the findings,
but there was a gap in volunteer motivation to serve all patients equally. I would recommend
additional research to better understand the practice of volunteer on-boarding techniques to
ensure alignment with the organization’s mission and goals.
Implications for Equity
Unequal access to affordable health care explains health disparity for low SES adults.
Bias within the healthcare system perpetuates health inequality, and this inequality is felt for
generations (Clay et al., 2018; Sacks, 2013; Williams & Purdie-Vaughns, 2016). Addressing
needs relevant to social determinants of health are important strategies, but effective solutions
must also address systemic racial and ethnic disparities in the health care sector in order to effect
long term health outcomes for underrepresented communities (Williams & Purdie-Vaughns,
2016).
89

Conclusion
TMC is a community-based organization providing access to healthcare for patients who
would not have access otherwise. Volunteers play an important role by donating their time and
expertise to improve health for low SES patients. An important way volunteers improve their
patients’ health is by connecting patients with SDH resources. The research indicates that TMC
volunteers are knowledgeable and motivated to connect low SES patients with SDH resources;
however, there are gaps which need to be closed to ensure equity. In addition, TMC as an
organization strives to care for as many low SES community members as possible yet lacks a
strategy to ensure all patients receive the same standard of care. By implementing the
recommendations rooted in this research, TMC’s patients will experience greater access to SDH
resources, which in turn will improve patient health outcomes and ultimately create greater
equity in healthcare for low SES patients. Once implemented, TMC will improve its ability to
fulfill its mission in the community by creating the possibility that everyone can have the
opportunity to thrive.

90

References
Alderwick, H. & Gottlieb, L. (2019). Meanings and misunderstandings: A social determinants of
health lexicon for health care systems. The Milbank Quarterly, 97(2), 407–419.
https://doi.org/10.1111/1468-0009.12390
American Academy of Family Physicians (n.d.) Social needs screening tool.
https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/patient-short-
print.pdf
American Health Lawyers Association. (2016). The free medical clinic: A practical handbook
for health care providers. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-
browser/public/ama-foundation/free-medical-clinic-handbook.pdf
American Psychological Association. (2020). Socioeconomic status.
https://www.apa.org/topics/socioeconomic-status
Anderson, R., & Newman, J. F. (2005). Societal and individual determinants of medical care
utilization in the United States. Milbank Quarterly, 83(4).
https://doi.org/10.1111/j.1468-0009.2005.00428.x
Babitsch, B., Gohl, D., & von Lengerke, T. (2012). Re-revisiting Andersen’s behavioral model
of health services use: A systematic review of studies from 1998–2011. GMS Psycho-
Social-Medicine, 9, 1–15. https://doi.org/10.3205/psm000089
Bandura, A. (2010). Self‐Efficacy. In I.B. Weiner and W.E. Craighead (Eds.), The Corsini
Encyclopedia of Psychology. https://doi.org/10.1002/9780470479216.corpsy0836
Bandura, A. (2012). On the functional properties of perceived self-efficacy revisited. Journal of
Management, 38(1), 9–44. https://doi.org/10.1177/0149206311410606
91

Bailey, M. J., & Duquette, N. J. (2014). How Johnson fought the war on poverty: The economics
and politics of funding at the office of economic opportunity. The Journal of Economic
History, 74(2), 351–388. https://doi.org/10.1017/S0022050714000291
Bazerghi, C., McKay, F., & Dunn, M. (2016). The role of food banks in addressing food
insecurity: A systematic review. Journal of Community Health, 41(4), 732–740.
https://doi.org/10.1007/s10900-015-0147-5
Bolman, L., & Deal, T. (2017). Reframing organizations: Artistry, choice and leadership (6th
ed.). Jossey-Bass.
Bradford, L.D., Newkirk, C., & Holden K.B. (2009). Stigma and mental health in African
Americans. In R.L. Braithwaite, S.E. Taylor, & H.M. Treadwell (Eds.), Health issues in
the black community (pp. 119–133). Jossey-Bass.
Braveman, P. A., Cubbin, C., Egerter, S., Williams, D. R., & Pamuk, E. (2010). Socioeconomic
disparities in health in the United States: What the patterns tell us. American Journal of
Public Health, 100(S1), S196. https://doi.org/doi:10.2105/AJPH.2009.166082
Braveman, P., Gottlieb, L., Francis, D., Arkin, E., & Acker, J. (2019, November 12). What can
the health care sector do to advance health equity? Robert Wood Johnson Foundation.
https://www.rwjf.org/en/library/research/2019/11/what-can-the-health-care-sector-do-to-
advance-health-equity.html
Callaghan, D. (2006). Basic conditioning factors' influences on adolescents' healthy behaviors,
self-efficacy, and self-care. Issues in Comprehensive Pediatric Nursing, 29(4), 191–204.
https://doi.org/10.1080/01460860601087156
Cavalhieri, K., Chwalisz, K., & Greer, T. (2019). The role of self-efficacy in the relationship
between discrimination and health care utilization among college students in the United
92

States. Journal of Health and Social Sciences, 4(3), 373–388.
https://doi.org/10.19204/2019/thrl6
Center for Disease Control. (2020). Aging disparities index.
https://www.cdc.gov/aging/disparties/index
Center for Disease Control and Prevention. (2010). A closer look at African American men and
high blood pressure control. U.S. Department of Health and Human Services.
https://purl.fdlp.gov/GPO/gpo38620
Clark, N., & Dodge, J. (1999). Exploring self-efficacy as a predictor of disease management.
Health Education & Behavior, 26(1), 72–89.
https://doi.org/10.1177/109019819902600107
Clark, R. E. and Estes, F. (2008). Turning research into results: A guide to selecting the right
performance solutions. IAP-Information Age Publishing.
Claydon, E., Austin, A., & Smith, M. V. (2016). Linking obesity prevention and mental health
promotion to address health disparities. Community Mental Health Journal, 52(4), 395–
398. https://doi.org/10.1007/s10597-015-9915-z
Cresswell, J. W. & Cresswell, J. D. (2018). Research design: Qualitative, quantitative, and
mixed methods approaches. (5
th
ed.). SAGE Publishing.
Darnell, J. S. (2010). Free clinics in the United States: A nationwide survey. Archives of Internal
Medicine, 170(11), 946–953. https://doi.org/10.1001/archinternmed.2010.107
Data USA (2021). Tarrant county, TX. https://datausa.io/profile/geo/tarrant-county-tx
Di Angelo, R. (2011). White fragility. The International Journal of Critical Pedagogy, 3(3), 54–
70. http://libjournal.uncg.edu/ijcp/article/view/249/116
93

Dominquez, K., Penman-Aguilar, A., Chang, M., Moonesinghe, R., Castellanos, T., Rodriguez-
Lainz, A., & Schieber, R. (2015). Vital signs: Leading causes of death, prevalence of
diseases and risk factors, and use of health services among Hispanics in the United States
2009-2013. Morbidity and Mortality Weekly Report 64(17), 469–478.
Dwyer, P. C., Bono, J. E., Snyder, M., Nov, O., & Berson, Y. (2013). Sources of volunteer
motivation: Transformational leadership and personal motives influence volunteer
outcomes. Nonprofit Management and Leadership, 24(2), 181–
205. https://doi.org/10.1002/nml.21084
Eller, L. S., Lev, E. L., Yuan, C., & Watkins, A. V. (2018). Describing self‐care self‐efficacy:
Definition, measurement, outcomes, and implications. International Journal of Nursing
Knowledge, 29(1), 38–48. https://doi.org/10.1111/2047-3095.12143
Fenelon, A., Mayne, P., Simon, A. E., Rossen, L. M., Helms, V., Lloyd, P., Sperling, J. &
Steffen, B. L. (2017). Housing assistance programs and adult health in the United
States. American Journal of Public Health, 107(4), 571–578.
https://doi.org/10.2105/AJPH.2016.303649
Fisher, M. & Elnitsky, C. (2012). Health and social services integration: A review of concepts
and models. Social Work in Public Health, 27(5), 441–468.
https://doi.org/10.1080/19371918.2010.525149
FitzGerald, C. & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic
review. BMC Med Ethics. https://doi.org/10.1186/s12910-017-0179-8
Ford, C., & Airhihenbuwa, C., (2010). Critical race theory, race equity, and public health:
Toward antiracism praxis. American Journal of Public Health, 100(Suppl 1).
https://doi.org/ 10.2105/AJPH.2009.171058
94

Gertz, A., Frank, S., Blixen, C., (2011). A survey of patients and providers at free clinics across
the United States. Journal of Community Health, 36(1), 83–93.
https://doi.org/10.1007/s10900-010-9286-x
Glied,S. & Oellerich, D. (2014). Two-generation programs and health. The Future of
Children, 24(1), 79–97. https://doi.org/10.1353/foc.2014.0006
Health Care.gov. (n.d.). Centers for medicare & medicaid services.
https://www.healthcare.gov/glossary/centers-for-medicare-and-medicaid-services/
Health Care.gov (n.d.). Federal poverty level. https://www.healthcare.gov/glossary/federal-
poverty-level-fpl/
Healthy People 2030. (n.d.). Social determinants of health.
https://health.gov/healthypeople/objectives-and-data/social-determinants-health
Hentschke, G.C., & Wohllstetter, P. (2004). Cracking the code of accountability. University of
Southern California Urban Education, Spring/Summer, 17–19.
http://hillkm.com/yahoo_site_admin/assets/docs/unit_1_hentschke_wohlsetter.pdf
Kaiser, M. L., Dionne, J., & Carr, J. K. (2019). Predictors of diet-related health outcomes in
food-secure and food-insecure communities. Social Work in Public Health, 34(3), 214–
229. https://doi.org/10.1080/19371918.2019.1575313
Kamimura, A., Panahi, S., Ahmmad, Z., Pye, M., & Ashby, J. (2018). Transportation and other
nonfinancial barriers among uninsured primary care patients. Health Services Research
and Managerial Epidemiology, 5, 1–6. https://doi.org/10.1177/2333392817749681
Kamimura, A., Christensen, N., Myers, K., Nourian, M.M., Ashby, J., Greenwood, J.L.J, & Reel,
J.J. (2014). Health and diabetes self-efficacy: A study of diabetic and non-diabetic free
95

clinic patients and family members. Journal of Community Health, 39(4), 783–791.
https://doi.org/10.1007/s10900-014-9831-0
King, D. K., Glasgow, R. E., Toobert, D. J., Strycker, L. A., Estabrooks, P. A., Osuna, D., &
Faber, A. J. (2010). Self-efficacy, problem solving, and social-environmental support are
associated with diabetes self-management behaviors. Diabetes Care, 33(4), 751–753.
https://doi.org/10.2337/dc09-1746
Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick's four levels of training evaluation.
Association for Talent Development.
Ladson-Billings, G. (2013). Critical race theory—What it is not! In M. Lynn & A.D. Dixson
(Eds.), Handbook of critical race theory in education.
https://www.routledgehandbooks.com/doi/10.4324/9780203155721.ch3
Leverack, G. (2004). Contemporary health approaches to health promotion. In Health promotion
practice: Power and empowerment. SAGE Publications.
https://dx.doi.org/10.4135/9781446215258.n2
Loggins Clay, S., Griffin, M., Averhart, W. (2018). Black/White disparities in pregnant women
in the United States: An examination of risk factors associated with Black/White racial
identity. Health Soc Care Community. 26:654–663. https://doi.org/10.1111/hsc.12565
Mansyur, C., Pavlik,V., Hyman, D., Goodrick, G. (2013). Self-efficacy and barriers to multiple
behavior change in low-income African Americans with hypertension. Journal of
Behavioral Medicine, 36(1), 75–85. https://doi.org/10.1007/s10865-012-9403-7
Matthew, P., & Brodersen, D. M. (2018). Income inequality and health outcomes in the United
States: An empirical analysis. The Social Science Journal, 55(4), 432–442.
https://doi.org/10.1016/j.soscij.2018.05.001
96

McGeehan L, Takehara MA & Daroszewski E. (2017). Physicians’ perceptions of volunteer
service at safety-net clinics. The Permanente Journal, 21(1), 64–82.
https://doi.org/10.7812/16-003.
McLaughlin, M., & Rank, M. R. (2018). Estimating the economic cost of childhood poverty in
the United States. Social Work Research, 42(2), 73–83.
https://doi.org/10.1093/swr/svy007
McNichol, E., Hall, D., Cooper, D., & Palacios, V. (2012, November 15). A state-by-state
analysis of income trends. Center on Budget and Policy Priorities.
https://www.cbpp.org/sites/default/files/atoms/files/11-15-12sfp.pdf
Merriam, S. B. & Tisdell, E. J. (2016). Qualitative research: A guide to design and
implementation. (4th ed.). Jossey-Bass.
Price, J. H., Khubchandani, J., & Webb, F. J. (2018). Poverty and health disparities: What can
public health professionals do? Health Promotion Practice, 19(2), 170–174.
https://doi.org/10.1177/1524839918755143
Phelan, J.C., Link, B.G., & Tehranifar, P. (2010). Social conditions as fundamental causes of
health inequalities: Theory, evidence, and policy implications. Journal of Health and
Social Behavior, 51(Suppl 1), 28–40. https://doi.org/10.1177/0022146510383498
Ramsey, R., Giskes, K., Turrell, G., & Gallegos, D. (2012). Food insecurity among adults
residing in disadvantaged urban areas: potential health and dietary consequences. Public
Health Nutrition, 15(2), 227–237. https://doi.org/10.1017/S1368980011001996
Ratcliffe, C. (2015, September 9). Child poverty and adult success. Urban Institute.
https://search.proquest.com/docview/1820809884
97

Ray, R., Sewell, A., Gilbert, K., & Roberts, J. (2017). How health policies affect health equity
missed opportunity? Leveraging mobile technology to reduce racial health disparities.
Journal of Health Politics, Policy and Law, 42(5) https://doi.org/10.1215/03616878-
3940477
Riddle, M. C., & Herman, W. H. (2018). The cost of diabetes care–An elephant in the
room. Diabetes Care, 41(5), 929–932. https://doi.org/10.2337/dci18-0012
Rimes, H., Nesbit, R., Christensen, R. K., & Brudney, J. L. (2017). Exploring the dynamics of
volunteer and staff interactions. Nonprofit Management & Leadership, 28(2), 195–213.
https://doi.org/10.1002/nml.21277
Rodriguez, J. M. (2018). Health disparities, politics, and the maintenance of the status quo: A
new theory of inequality. Social Science & Medicine, 200, 36–43.
https://doi.org/10.1016/j.socscimed.2018.01.010
Sacks, T.K. (2013). Race and gender concordance: Strategy to reduce healthcare
disparities or red herring? Evidence from a qualitative study. Race and Social
Problems, 5(2), 88–99. https://doi.org/10.1007/s12552-013-9093-y
Santiago, C. D., Wadsworth, M. E., & Stump, J. (2011). Socioeconomic status, neighborhood
disadvantage, and poverty-related stress: Prospective effects on psychological syndromes
among diverse low-income families. Journal of Economic Psychology, 32(2), 218–230.
https://doi.org/10.1016/j.joep.2009.10.008
Schickedanz, A., Hamity, C., Rogers, A., Sharp, A. L., & Jackson, A. (2019). Clinician
experiences and attitudes regarding screening for social determinants of health in a large
integrated health system. Medical Care, 57(6), 197–201.
https://doi.org/10.1097/MLR.0000000000001051
98

Shaefer, H. L., Lapidos, A., Wilson, R., & Danziger, S. (2018). Association of income and
adversity in childhood with adult health and well-being. The Social Service Review,
92(1), 69–92. https://doi.org/10.1086/696891
Sharma, M., Pinto, A., & Kumagai, A. (2018). Teaching the social determinants of health: A
path to equity or a road to nowhere? Academic Medicine, 93(1), 25–30.
https://doi.org/10.1097/ACM.0000000000001689
Shobe, M. A., Narcisse, M., & Christy, K. (2018). Household financial capital and food
security. Journal of Poverty, 22(1), 1–22.
https://doi.org/10.1080/10875549.2017.1348426
Shortell, S. M., Gillies, R., & Wu, F. (2010). United States innovations in healthcare
delivery. Public Health Reviews, 32(1), 190–212. https://doi.org/10.1007/BF03391598
St. John’s Well Child & Family Center. (2019). Home page. https://www.wellchild.org/
Syed, S., Gerber, B., & Sharp, L. (2013). Traveling towards disease: Transportation barriers to
health care access. Journal of Community Health, 38(5), 976–993.
https://doi.org/10.1007/s10900-013-9681-1
Texas Health and Human Services (2021). https://www.hhs.texas.gov/services/food/snap-food-
benefits
Texas Medical Association. (2021). The uninsured in Texas.
https://www.texmed.org/uninsured_in_texas/
Thompson, R. A. (2014). Stress and child development. Center for the Future of Children, (24)1,
41–59. https://search.proquest.com/docview/1820779005
99

Thornton, M. & Persaud,S. (2018). Preparing today’s nurses: Social determinants of health and
nursing education. OJIN: The Online Journal of Issues in Nursing 23(3).
https://doi.org/10.3912/OJIN.Vol23No03Man05
Thornton, R. L., Glover, C. M., Cené, C. W., Glik, D. C., Henderson, J. A., & Williams, D. R.
(2016). Evaluating strategies for reducing health disparities by addressing the social
determinants of health. Health Affairs (Project Hope), 35(8), 1416–1423.
https://doi.org/10.1377/hlthaff.2015.1357
U.S. Bureau of Labor Statistics. (2020). Making volunteer work visible: Supplementary measures
of work in labor force statistics. www.bls.gov
U.S Census Bureau. (2018). Uninsured rate by state: 2008 to 2018.
https://www.census.gov/library/visualizations/interactive/uninsured-rate-2008-
2018.html
Versey, H. S., & Curtin, N. (2016). The differential impact of discrimination on health among
black and white women. Social Science Research, 57, 99–115.
https://doi.org/10.1016/j.ssresearch.2015.12.012
Vijayaraghavan, M., Jacobs, E. A., Seligman, H. K., & Fernandez, A. (2011). The association
between housing instability, food insecurity, and diabetes self-efficacy in low-income
adults. Journal of Health Care for the Poor and Underserved, 22(4), 1279–1291.
https://doi.org/10.1353/hpu.2011.0131
Warren, S., Puryear, E., Chapman, M., Barnett, T. M., & White, L. S. (2017). The role of social
work in free healthcare clinics and student-run clinics. Social Work in Health
Care, 56(10), 884–896. https://doi.org/10.1080/00981389.2017.1371097
100

Williams, D. R., Priest, N., & Anderson, N. B. (2016). Understanding associations among race,
socioeconomic status, and health: Patterns and prospects. Health Psychology: Official
Journal of the Division of Health Psychology, American Psychological
Association, 35(4), 407–411. https://doi.org/10.1037/hea0000242
Williams, D.R. & Purdie-Vaughns, V. (2016). Needed interventions to reduce racial/ethnic
disparities in health. Journal of Health Politics, Policy and Law, 41(4), 627–651.
https://doi.org/10.1215/03616878-3620857
Williams, K. E., & Bond, M. J. (2002). The roles of self-efficacy, outcome expectancies and
social support in the self-care behaviours of diabetics. Psychology, Health &
Medicine, 7(2), 127–141. https://doi.org/10.1080/13548500120116076
Woolf, S. H., & Braveman, P. (2011). Where health disparities begin: The role of social and
economic determinants—And why current policies may make matters worse. Health
Affairs (Project Hope), 30(10), 1852–1859. https://doi.org/10.1377/hlthaff.2011.0685
World Health Organization. (2008, August 27). Closing the gap in a generation: health equity
through action on the social determinants of health - Final report of the commission on
social determinants of health. https://www.who.int/publications/i/item/WHO-IER-
CSDH-08.1

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Appendix: Interview Protocol
Interview Script
Thank you for taking time out of your busy day to be part of this study! Your insights are
helpful in my understanding about the role of the clinic’s volunteers. As I mentioned when we
set up our appointment, I am wearing two hats today: I am both the Executive Director of the
clinic as well as a doctoral student at the University of Southern California. This interview
pertains to my doctoral research and in no way will impact your role as a clinic volunteer. Your
participation is completely voluntary. The interview is being recorded so that the transcript is
available for analysis, but the recording and all notes from the interview will be destroyed once
the final paper is approved.
None of the data in the paper will be associated with you. It will be aggregated with
responses from other volunteers. There will be no information shared which could associate your
responses with your name and no names will appear in the report.
Several of the questions pertain to social determinants of health. These are factors such as
income, education, housing, transportation, and social networks. There are no right or wrong
answers. Please ask for clarity at any time. And you may choose to not answer any question or
opt out of the interview at any time. Before we begin, do I have your permission to record our
session?

102

Table A1
Interview Questions for TMC Volunteers
Interview questions Potential probes RQ
addressed
Key concept
addressed
Q Type
(Patton)
What motivated you to
begin serving at the
clinic?
How did you learn
of the opportunity?
RQ2 KMO framework Background
How long have you
served in this
capacity?
RQ2 KMO framework Background
Prior to volunteering
with the clinic, have
you volunteered to
provide free medical
services in other
settings, such as
other free medical
clinics or on mission
trips?
RQ2 KMO Background
To what extent, if any,
do you discuss
various aspects of
the patient’s life,
such as SDOH,
during the patient’s
appointment?
Do you learn about
the patient social
needs potentially
relevant to their
physical health?
RQ1 SDOH Knowledge
What lifestyle changes,
if any, do you often
counsel your patients
on to improve their
health?
Perhaps lifestyle
recommendations
to help with
chronic health
management such
as diabetes?
RQ1 KMO Knowledge
How important, if at
all, do you think
your role is in
influencing a
patient’s SDOH?
RQ2 KMO Motivation
103

Interview questions Potential probes RQ
addressed
Key concept
addressed
Q Type
(Patton)
In your opinion, what
is the most common
obstacle that patients
of the clinic face in
improving their
health?
What barriers
might be relevant
to SDOH?
RQ1 SDOH Knowledge
What do you perceive
are the best
resources, if any,
this clinic offers
patients, and why?
RQ3 KMO Organizationa
l
From your experience,
what additional
resources, if any, do
you believe would
be helpful to patients
that are not currently
offered by the
clinic?
RQ3 KMO Organizationa
l/
Knowledge
What additional
training or tools, if
any, could this clinic
offer you that would
be helpful in your
role?
RQ1/3 KMO Organizationa
l
What other community
agencies, if any,
should the clinic
partner with in order
to create greater
access to resources
relevant to
improving SDOH?
RQ3 KMO Organizationa
l
104

Interview questions Potential probes RQ
addressed
Key concept
addressed
Q Type
(Patton)
What other
suggestions, if any,
do you have for the
clinic that could
improve SDOH
patients?
RQ3 KMO Organizationa
l
What other suggestions
do you have for the
clinic, broadly, if
any, that could help
TMC provide more
care to more adults
in our community?
RQ3 KMO Organizationa
l

Abstract (if available)

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Asset Metadata

Creator MacMillan, Carmin (author)

Core Title The role of healthcare volunteers in addressing social determinants of health

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2021-12

Publication Date 12/07/2021

Defense Date 11/15/2021

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

Tag healthcare,low socioeconomic status,OAI-PMH Harvest,social determinants of health,Volunteers

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Ferrario, Kimberly (committee chair), Filback, Robert (committee member), Phillips, Jennifer (committee member)

Creator Email carminmacmillan@gmail.com,macmilla@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC18010011

Unique identifier UC18010011

Legacy Identifier etd-MacMillanC-10284

Document Type Dissertation

Format application/pdf (imt)

Rights MacMillan, Carmin

Type texts

Source 20211210-wayne-usctheses-batch-903-nissen (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu