1. Are Low Income Women More Likely to Seek Primary Care if They Discuss Health Problems with Their Family Planning Providers? Janet M. Bronstein, Ph.D., Joshua Klapow, Ph.D., Holly C. Felix, Ph.D., Herman R. Foushee, Ph.D., M.Kate Stewart, M.D., M.P.H., Zoran Bursac, Ph.D. U Alabama Birmingham and U Arkansas for Medical Sciences

2. Thanks Supported by DHHS Office of Population Affairs, Family Planning Service Delivery Improvement Award 4 FPRPA 006018- 02

3. The Fragmented U.S. Safety Net Public subsidies are available for low income women to access family planning services (Title X and Medicaid Family Planning Waivers) These subsidies do not cover the costs of treatment of general medical problems or reproductive health problems.

4. The Mandate to Refer for Primary/Specialty Care Primary care is beyond the scope of practice for many public sector family planning providers (FPP). Title X and Medicaid expect FPP’s to refer clients when necessary to other providers. Challenges in referring: 1. Is the health problem identified? 2. Does the FPP have a relationship with an appropriate referral resource? 3. Will this referral resource accept patients without insurance? 4. Will the FP client actually go for care?

5. Study Methodology 1. Mail survey of Title X and Medicaid FP Waiver providers in Arkansas and Alabama on referral practices and awareness of referral resources for categories of non-fp health problems. Response rate 22% for MD offices, 59% for clinics, n=459. 2. Telephone survey of Medicaid FP clients of these responding providers on actions taken for a checklist of medical problems, with trust, self efficacy and enabling characteristics also measured. Response rate 78.5% n = 1991.

6. Research questions for telephone survey component 1. Do FP clients consult FP providers about health problems beyond the scope of family planning? 2. Do FP providers refer clients for care of these problems? 3. Does referral make a difference in whether clients seek and receive care?

7. 56.3% of respondents report one or more non-family planning health issue Factors associated with reporting a health issue (bivariate analysis): Age over 30 (p <.001) Less education (p <.05) Unemployed (p <.01) No car (p<.10) Usual source of care (p<.05) Worse subjective health rating (p<.001)

8. Did you discuss this problem with your family planning provider? 7.2% report 2.7% report 6.9% report 3.0% report 10.1% report 2.4% report 2.6% report 11.7% report

9. Did you discuss this problem with your family planning provider? 12.4% report 2.7% report 2.0% report 12.2% report 13.4% report 18.3% report 18.7% report

10. Respondents discussed 42.8% of health issues reported with FP provider Factors associated with discussing a health issue (multivariate analysis, n=2234 issues): Has usual source of care (O.R. 1.24 p <.05) Has health insurance (O.R. 1.19 p<.10) High trust in doctors (O.R. 1.29 p <.01) Believe problem is treatable ( O.R. 1.98 p <.001) Little concerned vs. concerned (O.R. 0.72 p <.05) Controlling for demographics, reported health status, self efficacy measures, all n.s.

11. Did your family planning provider give you some treatment or suggest a place you could go for care? (of issues discussed with FPP)

13. Respondents were referred to another source for care for 48.2% of issues discussed with FPP Factors associated with reporting a referral (multivariate analysis, n=1067 issues discussed): Age 26-29 vs 20-25 (O.R. 0.69 p <.05) High trust in doctors (O.R. 1.53 p <.01) Believe problem is treatable ( O.R. 1.89 p <.05) Very concerned vs concerned (O.R. 1.38 p <.05) Can tell when need med care (O.R. 0.69 p <.05) Can solve new health problems (O.R. 1.38 p <.05) Controlling for other demographics, reported health status, all n.s.

14. Action taken N (%)No FPP Care Given (34.7%) FPP Refer Only (26.0%) FPP Treat and Refer (21.0%) FPP Treat Only (18.3%) Did not seek care 534 (45.8) 43.1%32.7%**46.1%69.5%*** Sought but could not get care 153 (13.1) 16.1%20.1%5.7%***6.1% Sought and got care 478 (41.0) 40.8%47.2%48.2%***24.4% ** P <.01, *** p <.001 each compared to No Care Given Care Seeking Behavior and Family Planning Provider Activity (of issues discussed with FPP)

15. Respondents reported seeking care from another provider for 54.2% of health issues Factors associated with seeking care (multivariate analysis, n=2228 issues): Discussed with FPP (O.R. 1.36 p <.05) Treated by FPP (O.R. 0.42 p <.001) Referred by FPP ( O.R. 1.67 p <.001) African American vs Caucasian (O.R. 0.57 p <.001) Native American vs Caucasian (O.R. 0.45 p <.05) Other Ethnicity vs Caucasian (O.R. 0.44 p <.05) Some College vs High School Grad (O.R. 1.43 p <.001) Has usual source of care (O.R. 1.74 p <.001) Has health insurance (O.R. 1.85 p<.001) Worse reported health status (O.R. 1.20 p<.001) Believe problem is treatable (O.R. 1.57 p <.05) Very concerned vs. concerned (O.R. 1.35 p <.05) Controlling for other demographics, self efficacy, distance to health care resources, all n.s.

16. Respondents who sought care reported that they did see another doctor for 77.3% of health issues Factors associated with receiving care (multivariate analysis, n=1137 issues where care was sought): Treated by FPP (O.R. 3.30 p <.001) Age 40-45 vs 20-25 (O.R. 2.68 p <.05) Not High School Grad vs Grad (O.R. 0.55 p <.01) Has usual source of care (O.R. 1.71 p <.001) High trust in doctors (O.R. 1.40 p <.05) Can tell when need med care (O.R. 1.65 p<.01) Very concerned vs. concerned (O.R. 0.66 p <.05) Controlling for other demographics, distance to health care resources, all n.s.

17. Summary The most commonly reported non-FP issues include fatigue, emotional conditions and dental problems About half of non-FP issues are discussed with FPP, but reproductive and diagnosed conditions are discussed more frequently than the more common syndromes. FPP’s refer about half of discussed conditions – they also offer treatment for many non-FP conditions. Both discussion with and referral from FPP increase the likelihood that client will seek care for issue. Referral combined with FPP treatment increases likelihood that client will receive primary or specialty care.

18. Conclusions Family planning clients experience a broad range of other health problems. Family planning providers serve as both facilitators of care and providers of care for non-FP related conditions Policies that support family planning providers as “first responders” in health care for low income women can improve access to primary and specialty care.