Table 1.
Cluster Themes and Factors Affecting American Indian Elder Health Care
| Cluster name | Statements included in cluster |
|---|---|
| 1. Difficulties Obtaining and Using Insurance | Uncertainty about what health care services/medications are covered by insurance |
| Insurance or Indian Health Service won’t cover enough health care costs | |
| Difficulty communicating with insurance company (including rude or unhelpful insurance representatives, understanding insurance lingo) | |
| Having to deal with billing departments and debt collectors | |
| Not knowing how to report or appeal health care/insurance decisions | |
| Needing to change insurance companies | |
| Difficulties using insurance at Indian Health Service | |
| Too many forms to fill out to get insurance | |
| Difficulties using multiple types of insurance | |
| Difficulties paying for the cost of insurance | |
| Lack of education about insurance plan choices | |
| Doctors/health care professionals not accepting insurance plan | |
| Insurance or Indian Health Service refusing to cover certain health care services or prescriptions | |
| Not having insurance/prescription card to show for services | |
| Too many forms to fill out when getting health care services | |
| Not being aware of Purchased Referred Care or how to use it | |
| 2. Insecurity from Lack of Knowledge | Not knowing where to find health care information |
| Limited knowledge of computers or the Internet to obtain information about insurance | |
| Not having access to Native language interpreters/translators to help with insurance enrollment | |
| Difficulties paying for health care costs | |
| Getting inaccurate health care/insurance advice from Indian Health Service and/or Tribal services | |
| 3. Limited Availability of Services | Not having a health facility open on weekends or after hours in or near my community |
| Not knowing where to obtain good health care | |
| Health services/providers being shut down | |
| Not having access to Native language interpreters/translators when communicating with health care professionals | |
| 4. Scheduling Challenges | Needing to change to a new doctor and/or health care facility |
| Difficulty communicating with health care professionals (including rude or unhelpful providers, not understanding medical “lingo” or terminology) | |
| No same-day appointments available or walk-in access | |
| Long waits at health care facilities | |
| Doctors/health care professionals cancelling/rescheduling appointments | |
| Difficulty scheduling appointments (i.e., being told to call back at a later date when trying to schedule an appointment or having to schedule appointments more than a month in the future) | |
| Difficulties getting medication prescriptions filled/refilled | |
| 5. Provider Issues and Relationships | Not having a qualified/skilled doctor who can be trusted |
| Rushed appointments with the doctor (e.g., 5-min visit) | |
| Not being able to see the desired doctor or health care professional | |
| Not having all your doctors, nurses, pharmacists, and facilities know the right information about you | |
| Not having a “regular” doctor that knows your personal health history | |
| Concerns about doctors or health care professionals not maintaining privacy/confidentiality | |
| Not knowing how to choose the right doctor | |
| Being overprescribed too many drugs | |
| 6. Family and Emotional Challenges | Family being unwilling or unavailable to advocate on behalf of the elder |
| Difficulties dealing with emotions related to health care (e.g., feeling like a burden on family | |
| Living alone | |
| Not wanting to tell others about personal health issues | |
| Not being able to be honest with family about health care-related wants and needs | |
| Denying the need for care (“tough guy” mentality) | |
| 7. Health-Related Self-Efficacy | Not being comfortable/confident enough to ask questions |
| Not knowing how to advocate for own personal health care | |
| Reluctance to use services provided by Indian Health Service or Tribe | |
| Not being able to read or understand instructions for taking medicines correctly | |
| Not knowing when to go to the doctor (i.e., knowing the “warning signs”) | |
| 8. Accessibility and Transportation Barriers | Limited availability of elder-specific services (including home health caregivers) |
| High cost of transportation to obtain health care | |
| Needing to travel long distances to obtain care (e.g., doctors or emergency care) | |
| Not having reliable transportation to get to health care appointments | |
| Not having access to community health programs (e.g., senior center or clinics) that provide transportation | |
| 9. Tribal/National Policy | Health care is a low priority for Tribal leadership |
| Information not shared with the community or general meetings | |
| Tribal affiliations or blood quantum restrictions make it hard to get good health care | |
| Not knowing how to influence Tribal leadership | |
| Health care is a low priority for national politicians |