Student-led health education programmes in the waiting room of a free clinic for uninsured patients

Abstract

Objective:

Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged in the USA. Free clinic patients may have health education needs, but experience barriers to attending health education programmes. In an attempt to reach out to free clinic patients who might not otherwise attend health education classes, this project examined the efficacy of student-led health education classes conducted in the waiting room prior to a patient’s appointment with a provider.

Design:

The classes had two areas of focus: women’s health and health information. Health educators and Spanish interpreters were graduate and undergraduate students.

Setting:

This study was conducted in the waiting room of a free clinic in the Intermountain West region of the USA.

Method:

The health education classes were held 22 times in total from late August to early December 2014.

Results:

While the survey-based assessment of the programme did not show a difference in levels of health consciousness, health information seeking and health attitudes, the programme potentially increased interest in attending the health education classes.

Conclusion:

There were some challenges associated with the implementation of a health education class in the waiting room setting, particularly in regards to environments, evaluation and interpretation services. Future projects are needed to address challenges associated with conducting a health education class in a waiting room setting. In addition, a variety of health topics, evidence-based evaluation and interpreter services are key for future success.

Keywords

Free clinics health promotion patient education student-led programmes uninsured patients USA

Introduction

Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged in the USA (Nadkarni and Philbrick, 2003, 2005; Schiller et al., 2013). In 1967, the first free clinic opened with the goal of increasing healthcare access. Today, it is estimated that there are approximately 1,200 free clinics in operation throughout the USA (Schiller et al., 2013). Most free clinics rely on volunteer providers and staff, and operate under limited financial resources (Isaacs and Jellinek, 2007). Hence, there is a significant variation in the services each free clinic can offer which may limit opportunities for free clinics to provide health education interventions. Free clinic patients represent an economically disadvantaged population (Gertz et al., 2011) with lower levels of physical and mental health functioning compared to the US general population (Kamimura et al., 2013). Thus, providing care for uninsured patients with chronic diseases is one of the most important tasks for free clinics (Nadkarni and Philbrick, 2003).

However, it is well established that the treatment of chronic diseases is most effective when coupled with patient health education, to promote patient self-management (Bodenheimer et al., 2002). Previous studies suggest needs for increased patient education on diabetes (Gorrindo et al., 2014; Kamimura et al., 2014c, 2014d), mental health (Kamimura et al., 2014e), women’s health (Kamimura et al., 2014a, 2014b, 2014f), tobacco cessation (Foley et al., 2012; Pockey et al., 2012) and health literacy (Kamimura et al., 2013) among free clinic patients. A study on diabetic free clinic patients suggests that free clinic patients with diabetes have a low level of self-efficacy and need health education that includes empowerment as well as the knowledge of treatment and self-management (Kamimura et al., 2014c). Providing health education programmes is one of the factors that may improve patient satisfaction and engagement among free clinic patients (Kamimura et al., 2015b) and may also improve the health of free clinic patients because patients engaging with their own healthcare are more likely to report better health and engage in patient self-management (Bodenheimer et al., 2002; James, 2013).

Nevertheless, free clinic patients often have concerns about the costs required to comply with physician recommendations and transportation to visit a clinic (Kamimura et al., 2015b). One study reported a diabetes health education programme, which required medical students to volunteer at free clinics (Gorrindo et al., 2014). In this approach, a medical student was paired with a patient as a case manager and acted as a health educator. A low medical student to patient ratio is necessary for this approach to work, a prerequisite many free clinics are unable to meet. In addition, other programmes have found training high numbers of volunteers to be problematic from an administrative standpoint. Free clinics are likely to face programming challenges in general; for example, a tobacco cessation intervention programme faced challenges in training volunteers who were unable to attend on-site trainings (Foley et al., 2012).

Purpose

Given the limited financial and human resources of most free clinics, low-cost interventions such as health education classes in a clinic waiting room may be more feasible for reaching out to free clinic patients who may have health questions or concerns rather than using formal health education formats (Oermann, 2003). Because patients are already waiting for an appointment and would not need to visit a clinic for the sole purpose of attending a programme, health education programmes in a waiting room may be one of the solutions to connect free clinic patients to health education and other resources. However, few projects have addressed how to implement health education programmes in a waiting room for an underserved population. This study applied Oermann’s (2003) approach of waiting room health education interventions in Ophthalmology to the primary care free clinic setting.

The purpose of this project was to deliver waiting room health education interventions at a free clinic and assess the impact of the interventions on health consciousness, health information seeking behaviour, health attitude and interest in attending a women’s health class in the future. There were two hypotheses: (1) The attendance of a waiting room class will be associated with higher levels of health consciousness and health information seeking behaviour, and improved health attitude; (2) Patients who attend a waiting room class will be more likely to be interested in future health education programmes than those who do not.

Interventions

Setting and organisation

The free clinic provides free primary healthcare services to uninsured individuals who live below the 150% US federal poverty level and do not have access to employer-provided or government-funded health insurance. The clinic is not student-run, and is staffed by six full-time paid personnel and over 300 active volunteers including approximately 60 volunteer interpreters. Volunteers of the clinic have diverse backgrounds. They are undergraduate or graduate students, or non-students. The clinic, which has been in operation since 2005, has no affiliation with any religious organisations and is funded by non-governmental grants and donations. The clinic is open 5 days a week. The number of patient visits was 15,209 in 2012. The clinic serves US citizens, documented immigrants and undocumented immigrants. While clinic patients are from more than 50 countries, about half of the patients are Spanish speakers. Other than English and Spanish, languages spoken by patients included, for example, Tongan, Portuguese, Urdu, Chinese, Arabic, Farsi and Russian. Although the clinic has provided formal health education classes focusing on nutrition, physical activity and stress management twice a month for the past 5 years, the programme has struggled to recruit participants. The waiting room offers a good opportunity for a health education class because the physician–patient ratio often results in a long wait. While the clinic does not accept walk-ins and all patients have an appointment, patients are often in the waiting room for more than 1 hour. Additionally, family members who accompany the patient or people who are at the clinic for another reason (e.g. pharmacy, lab, talking to a receptionist) also occupy the waiting room. The University of Utah Institutional Review Board (IRB) approved this study.

Theory and focus areas

Based on the Health Belief Model (HBM) (Rosenstock et al., 1988), which explains health behaviours of individuals through their attitudes and beliefs, the intervention attempted to increase awareness of perceived susceptibility and severity of health problems, as well as the barriers and benefits to changing individual actions towards healthy behaviours. The HBM has been previously applied to women’s health education and management of chronic conditions (Hallgren et al., 2015; Peterson et al., 2012). The health classes of this study had two areas of focus: women’s health (information regarding mammograms, self-breast exams, Pap smear exams, cervical cancer, healthy eating habits, menopause, weight loss, sexually transmitted infections, birth control and pregnancy) and health information (information about resources such as formal health education classes, free exercise classes at the clinic and in the community).

The focus areas were determined based on the clinic’s interest and needs, and previous studies. Female free clinic patients reported fewer opportunities for breast health screening and lower levels of knowledge of breast health compared to the general population or breast cancer screening patients (Kamimura et al., 2014b). Moreover, female free clinic patients reported the need for gender-specific interventions for positive body image and exercise motivation (Kamimura et al., 2014a).

The programme

The programme examined the possibility and success of a student-led health education programme in a free clinic waiting room. The goal of such programmes is to increase patient health consciousness and access to formal resources by providing patients with free health education in a waiting room while they are waiting for an appointment with a provider. The intended outcomes include increasing patient awareness and access to formal resources, thus enhancing interest in health education.

As the average number of participants in each class was small, the classes were participant-driven. Participants typically prompted specific topics of each class and asked questions anytime during the class. Educators used a resource guide developed by the clinic and educational materials from government resources (e.g. the US National Institute of Health). Most materials were available in English and Spanish and used visual information to accommodate a wide range of the literacy levels. Based on the HBM, educators focused on increasing awareness of health problems, as well as the barriers and benefits to changing individual actions towards healthy behaviours. Health educators were graduate and undergraduate students with relevant experience and academic backgrounds. The graduate student who taught the women’s health class has taught women’s health at another community organisation for underserved populations. The undergraduate student who taught the health information class majored in health promotion and education and had received training on health education in the curriculum of her major. In addition, a Spanish language interpreter and one or two student assistants were present at each class because half of the clinic patients are Spanish speakers. It was not feasible to have an interpreter in other languages because it was difficult to arrange an interpreter for the diverse languages spoken by a small number of patients. Most undergraduate students assisted the programmes as a part of their internship or community-engaged learning experience. Graduate students supervised undergraduate students.

Intervention methods

The health education classes were held from late August to early December 2014, 22 times in total (13 women’s health and nine health information classes). The expected main outcomes of the interventions were improved health consciousness, health information seeking behaviour and health attitude; and increased interest in health education. The schedule of the classes was posted on a flyer in both English and Spanish inside the waiting room. Women’s health classes were taught at random time slots each week. Health information classes were held at the same time slot every week (Wednesday afternoon). When the student teachers were starting class, they made an announcement and gave a brief introduction to all patients in the waiting room in both English and Spanish. Following the announcement and introduction, the health information classes were held in the waiting room after creating a circle of chairs in a designated corner. Patients who expressed interest in the women’s health class were escorted to the reflection room, a room approximately 30 feet from the main waiting room. The reflection room has sofas, chairs and small tables for approximately 10 people. The class started by introducing the instructors and interpreters. Then, the instructor asked participants about topics of their interests and areas of inquiry. The class was interactive, rather than a lecture, and the class content was based on the participants’ interests and questions. Specific topics that were addressed include breast cancer, mammograms, self-breast examinations, prostate cancer, human papillomavirus (HPV), Pap smear tests, cervical cancer, menopause, healthy eating habits, physical activity, contraception and pregnancy. In line with the HBM, the topics and questions from participants were organised to fulfil two purposes: to increase awareness of health problems and to address the barriers and benefits to changing individual actions towards healthy behaviours. Participants received a small gift (e.g. tooth brush, water bottle, pen, memo pad) for their participation. After each class, one of the students who led or assisted the class submitted a report to the first author.

Intervention results

While the number of people in the waiting room varied from one or two to approximately 30, each health education class had one to eight participants with an average of 3.75 participants. Before the class started, the educators announced the class to all people in the waiting room. Unfortunately, we do not have an accurate number of participation rate. But based on the reports from the educators, when the number of patients waiting in the room was very small, the participation rate was approximately two-thirds. Based on the average number of participants per class, we assume the participation rate was much lower when the waiting room was busy. The majority of participants were Spanish-speaking women, especially for the women’s health classes. It was common for participants to attend the class with their child(ren). The length of the class depended upon the number of participants. The majority of the classes lasted one hour.

Based on the reports submitted after each class from the educators, two common lessons regarding recruitment and increasing patient health knowledge were identified: clear communication and maintenance of a professional yet relaxed environment. At first, it was not easy to get patients to be interested in a class held in the waiting room. But after making the following communication efforts, the classes consistently had participants. Face-to-face engagement with each patient both immediately before and during class was effective for recruiting participants. Posting class details on the reception desk before each session also helped increase patient awareness of a class. It was important to announce the class in both English and Spanish. A relaxed and professional environment gave participants ease of mind. It was helpful to inform the patients that the women’s health class was question directed and informal, participants could come and go as they pleased, bring their children and partners and that they would be given a small gift. Most importantly, the participants were told they would not miss their clinic appointment by attending the class and that the clinic staff would come find them in the reflection room for their appointment. The clinic staff indicated that some of the more engaged patients would ask for the date of the next class. Staff also indicated that participants in the women’s health class in particular expressed interest in receiving a mammogram, and even signed up to be notified when these services would be available.

Assessment survey

Methods

We conducted a self-administered survey that fit the context of the classes, women’s health and health consciousness, in the waiting room during the same 4-month period. The full procedures and results of the survey are described elsewhere (Kamimura et al., 2015a, 2015c). The survey was accompanied by an informed consent document for all participants, and were both IRB approved. Table 1 summarises the instruments which were used for the assessment. The instruments which were used to evaluate the intervention included the health consciousness scale (five items, estimation of duration – not specified, for example, ‘Living life in the best possible health is important to me’) (Dutta-Bergman, 2004), health information seeking (eight items, estimation of duration – not specified, for example, ‘When I take medicine, I try to get as much information as possible about its benefits and side effects’) (Dutta-Bergman, 2004), health attitudes (nine items, estimation of duration – not specified, for example, ‘I’m constantly examining my health’) (Gould, 1990), and the Women’s Health Questionnaire (WHQ) (30 items, estimation of duration – the last few days, for example, ‘My breasts feel tender or uncomfortable’) (Hunter, 1992). Only female participants answered women’s health-related questions. Multiple regression and a general linear model were used for statistical analysis.

Table 1.

Instruments used to evaluate the waiting room health intervention programme.

Name/type	Number of items used	Estimated duration	Example questions
Health consciousness (Dutta-Bergman, 2004)	5	Not specified	‘Living life in the best possible health is important to me’
Health information seeking (Dutta-Bergman, 2004)	8	Not specified	‘When I take medicine, I try to get as much information as possible about its benefits and side effects’
Health attitudes (Gould, 1990)	9	Not specified	‘I’m constantly examining my health’
Women’s health questionnaire (Hunter, 1992)	30	The last few days	‘My breasts feel tender or uncomfortable’

Results

Table 2 summarises the results of the assessment survey. The number of returned surveys was 769 (average age 45.2, female 66%, Hispanic/Latino/Latina 64%, some college or higher 41%, currently employed 52%, married 52%, US-born 29%). The percentages of participants who had attended health education classes were as follows: waiting room class 18%, healthy living education 22% and healthy living evening class 11%). The attendance of a waiting room class was not a significant predictor of levels of health consciousness, health information seeking behaviour and health attitude at the .05 significance level based on the results of multiple regression. More than 60% of the survey participants, who had attended or had not attended a women’s health class, expressed interest in attending a women’s health class in the future. Nearly 80% of the women who attended the class and participated in the survey indicated they would like to attend the class again. The percentage was significantly lower among the survey participants who had not attended the class.

Table 2.

Summary of assessment survey results (N = 769).

Participant characteristics	n	%	Mean	SD
Age			45.2	13.7
Female	508	66.1
Hispanic/Latino/Latina	494	64.2
Some college or higher	318	41.4
Currently employed	398	51.8
Married	401	52.1
US-born	223	29.0
Had attended a waiting room class	139	18.1
Had attended a healthy living education class	165	21.5
Had attended a healthy living evening class	83	10.8
Interested in women’s health class in the future (among 389 female participants who completed the women’s health questions)	250	64.3
Association among variables
Factors positively associated with health consciousness	Social cohesion (p < .01)
	Lower levels of available healthy food in the community (p < .01)
	Spanish speakers (p < .01)
Factors positively associated with information seeking	Social cohesion (p < .01)
Factors positively associated with information seeking	Spanish speakers (p < .01)
Factors positively associated with health attitudes	Social cohesion (p < .01)
Factors positively associated with attending waiting room classes	Spanish speakers (p < .01)
	Non-US-born English speakers (p < .01)
Factors positively associated with attending healthy living evening class	Spanish speakers (p < .05)
	Non-US-born English speakers (p < .05)

SD: standard deviation.

Other results from the multiple regression analysis or chi-square analysis of the survey are as follows: social cohesion is positively associated with health consciousness (p < .01), information seeking (p < .01) and attitudes (p < .01); lower levels of available healthy food in the community were associated with higher levels of health consciousness (p < .01); Spanish speakers were more likely to be health conscious and have higher levels of health information seeking compared to US-born or non-US-born English speakers (p < .01); Spanish speakers as well as non-US-born English speakers were more likely to attend health education classes compared with US-born English speakers (p < .01 for waiting room classes; p < .05 for evening classes). Compared to the general population, female free clinic patients reported lower health-related quality of life on all aspects of women’s health and were less likely to utilise preventive care including mammograms, Pap smear and HPV vaccination compared to the US general population (Kamimura et al., 2015c).

Discussion

The results of the survey-based assessment and the field notes from the waiting room interventions suggest important practice implications. Based on the results of the survey, Hypothesis 1 was not supported, while Hypothesis 2 was supported. In other words, while the survey-based assessment of the programme did not show a difference in levels of health consciousness, health information seeking and health attitudes, the programme potentially increased interest in attending health education class as more than 60% of female patients in the survey stated they would like to attend it in the future. Also, the research team was notified of interest in the health classes as patients inquired about the next class. In reality, it is unlikely that one 60-minute health education class would change health status or behaviour. Because recruiting free clinic patients to health education programmes is often challenging (Kamimura et al., 2015b), the most notable success of this programme is increasing interest in health education. Yet, increased interest in health education may not be strong enough to warrant the conclusion that the intervention was successful because successful interventions need to show the improvement of outcomes, such as increased knowledge (Whittingham et al., 2008). The next step is structuring the programme to actually enhance health knowledge and conducting systematic assessment of the outcomes of the programme.

Ensuring environments in which participants could focus on learning was challenging, and may potentially have limited participants’ ability to learn. For example, since participants were waiting for a provider appointment and the class did not immediately start after each patient arrived at the clinic, they were rarely able to sit through the duration of the class. In addition, some participants entered the class mid-way, causing disruption at times. The waiting room was sometimes too crowded or busy. When the reflection room was not available, teaching in the actual waiting room was unavoidable even if it was crowded because the clinic has limited space. It is important to pick a time slot that has a reasonable number of patients in the waiting room. It appeared beneficial to separate the women’s health class from the main waiting room area as much as possible. This facilitated a more comfortable environment for the participants to discuss issues that are potentially socially or culturally sensitive as well as provided an opportunity for those who are uncomfortable with such topics to avoid participation if they so desired (Kamimura et al., 2016a).

Language barriers are important to be dealt with for successful interventions (Kamimura et al., 2015b). Although none of the educators were able to speak Spanish fluently, the majority of the participants were Spanish speakers. Some of these Spanish speakers did speak English. But the levels of their English varied. When the participants switched between Spanish and English, it sometimes became complicated for the interpreters. It was essential to consistently interpret everything from English into Spanish and vice versa. While more than half of the clinic patients speak either English or Spanish, there are other languages spoken by patients such as Portuguese, Tongan, Vietnamese, Arabic, Urdu, Mandarin and Russian. The language or translation needs of patients in a waiting room are unpredictable. In addition, scheduling interpreters for these languages is often difficult due to limited availability of such interpreters. Patients who do not speak English or Spanish had fewer opportunities to participate in health education programmes. In fact, patients whose native language was neither English nor Spanish tended to decline the invitation to participate perhaps because of these language barriers. While using students as educators benefits the provision of educational opportunities to the students (Sevin et al., 2016) and the quality maintenance of classes (since student educators have already received training on teaching health education classes), using peer patients may help to make classes more culturally responsive and teach classes in a number of languages (Kim et al., 2006). In any case, it is very challenging to teach classes in more than two languages even if interpreters are available.

Finally, this project sought to provide more direct health information to free clinic patients. A previous study at a free clinic suggests that face-to-face communications would be the best way to deliver health-related information to free clinic patients (Kamimura et al., 2016a). Other studies on underserved populations also support in-person strategies. For example, less educated first generation Hispanic immigrants prefer in-person strategies to obtain health information (Cristancho et al., 2014). In fact, patients of the free clinic noted that they were often not aware of available resources at the clinic unless they were informed in-person (Kamimura et al., 2016a). It would be helpful to maintain the list of items which are needed to inform patients in-person. Interactive sessions and active engagement were found to be useful in delivering health information to the underserved community (Geana et al., 2011). In-person education courses held in the waiting room may be more effective in shaping the health knowledge and beliefs of free clinic patients. To promote interactive engaged health education classes, it would be helpful for the class size to be kept small and classes tailored towards specific sub-populations of clinic patients.

Conclusion

This study delivered and assessed waiting room health education interventions at a free clinic and suggested that the current waiting room health education classes potentially increased interest in health education among free clinic patients. This project provides unique practice-related insights by implementing health promotion interventions in a waiting room within a free clinic setting. Waiting room health education classes are worthwhile avenues to further investigate as a means of health education for underserved populations. There are some challenges associated with environments, evaluation and interpretation services, however. Future projects would be necessary to reduce such challenges. Evidence- and theory-based implementations of health education that include a cycle of needs assessments and practice evaluation should be established for quality assurance. The programme covered limited topics that may not be sufficient in meeting patients’ needs and interests. In the future, the programmes could include other topics, such as mental health and the Affordable Care Act (Kamimura et al., 2016b; Petrany and Christiansen, 2014). After this project was conducted, waiting room classes on the Affordable Care Act were held in Spring 2015 and were assessed in Summer 2015 (Kamimura et al., 2016b). In addition, follow-up assessments about health education programmes were conducted in Autumn 2015. Future research should gather more evidence to measure the effectiveness of the programmes. Finally, while this project did not evaluate performance of volunteer educators, free clinics can potentially provide educational value for medical students and other students through partnerships with education programmes (Schutte et al., 2015). Future research should evaluate such educational values that free clinics could offer to students.

Footnotes

Acknowledgements

The authors want to acknowledge the contribution of the staff and volunteers of the Maliheh Free Clinic. In addition, we thank Raylynn Campbell, Travis Dixon, Natalie Meadows, Kole Mickolio, Anthony Mills and Javiera Reyes for their help in interpretation or programme assistance.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the Public Service Professorship, Lowell Bennion Community Service Center, University of Utah.

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