A lot has been written about barriers to accessing health. There are many journal articles and research papers on this topic, and on ideas of how to overcome them. I’m not trying to reinvent the wheel, so this is simply an attempt to write about some of the things I have seen in the past months. While working at HIPS, doing direct services with different sub-populations in Washington DC, I’ve learned about barriers to health and simple (and complex at the same time) ideas to start addressing these barriers.
I recently went to a talk on Hepatitis C (HCV) and how it is disproportionately affecting African Americans in the United States. According to the CDC, more than “75% of adults with Hepatitis C are baby boomers, i.e., born from 1945 through 1965” and within “the African American community, chronic liver disease, often Hepatitis C-related, is a leading cause of death among persons aged 45-64 years”. Many of the clients that HIPS serves fit into this category. One of the health services HIPS provides is HCV testing and counseling, and although we are reaching a lot of people, there is still a lot to do in the city. As I was listening to the different speakers, I just kept on thinking about our clients, and how we could talk about HCV and encourage more people to access testing. But testing for HCV is not the hardest part. It’s what happens next: whether the results are negative or positive. How can people remain HCV negative, what can they do to reduce the health risks, how can they access treatment and accompaniment if they are positive, and how can we reach out to that percentage of the population who doesn’t even know they could have HCV?
A few days after the HCV talk, while doing night time outreach with HIPS around DC, I encountered several Latino clients, who were happy and even relieved that there was someone who could give them information and answer a bunch of questions they had about safer sex practices in Spanish. One man, originally from Mexico, was very shy at the beginning, but after being surprised I was a native Spanish speaker, started asking me questions about different condoms, HIV testing, and risky behaviors. He shared some concerns regarding his health, and that of his partner, so I shared some information, specifically about organizations that were closer to where they live in the city and that have Spanish-speaking staff. He told me, “Oh, I know about that clinic, but I lost my health insurance, and they won’t cover us for that. Plus it’s really hard to go to some places, with our work schedules.” After giving him other referrals and answering his follow-up questions, we left to keep on with our night route. I couldn’t stop thinking about him and his wife, and how they were so frustrated, confused and fearful for several weeks, because they had not been able to get information or health services according to their needs.
These brief examples illustrate many of the barriers that people face to accessing health. And although they seem very clear, they are complex in so many ways. Outlining them is important, so that we can start thinking about possible alternatives to addressing them. Some of the most important and interconnected barriers I could identify (and I’m sure there’s more I have overlooked) are the following:
- Limited access to education, and specifically health education and information.
- Limited access to prevention, treatment and post-treatment care (this includes hindered access to health insurance).
- Generational gaps and differences between age groups.
- Ethnicity and race, and the social constraints that are embedded in these.
- Citizenship and immigration status.
And so, we could start addressing these complex barriers to accessing health by taking some simple and complicated issues into consideration.
Talking to people in their language. By this I don’t only mean to talk to people in a language that they can understand because that’s their first or native language, I also mean talking to people using intelligible vocabulary. If you are trying to reach out to an African American man in his late 60’s, veteran, currently using intravenous drugs . . . talk to him in his language. If you are trying to reach out to an undocumented working Latina in her forties who thinks she is HIV positive . . . talk to her in her language. Meet them there, at this point of their life’s journey, acknowledging that they have knowledge and power. Knowing that you have the privilege to be sharing health information with them, meet them at their education level, generational understanding of well-being and health, and socioeconomic status. Start there.
Promoting spaces for people to ask questions. People know what they want and need. Ask them. Listen. Meet them there. Provide as many safe spaces as possible for dialogue, health education and information sharing. Design education materials and strategies taking into consideration important characteristics of the populations you are trying to reach (and ask people what characteristics are important for them in the first place). How can we convey the important message of HCV testing within the 45 to 65-year-old generation among African Americans in DC? Start by asking them. We must pay attention to the social and cultural contexts of populations, so that the educational strategies are more effective and efficient. And provide information so that people can make better informed decisions, without forgetting that people can decide whatever they want.
If I was trying to access a health service or ask questions about my health to a service provider, I would like her or him to meet me where I am at. I would want that service provider to not patronize me, to understand that I am an empowered individual in some areas of my life, and that there are some barriers (that I might be able to point out on my own) for accessing health. I would want that health service provider to talk to me as a person. If you wanted to access health services, you would want to be treated in a similar way. So let’s do that for others. Meet clients, patients, and community members where they’re at in terms of their health, their needs and their context. Let’s start there.