Health Beliefs, Health Insurance Status, and the Uninsured: Revisiting the Findings From the Part-Time Worker Study and Barriers to Participation in Subsidized Health Insurance Programs, Exploring the Implications for Nursing Practice

Utilizing a qualitative case study inquiry approach, participants included part-time direct care employees who were eligible to participate in the PTWCVP, a subsidized health insurance program offered through the Dirigo Health Agency (DHA). Recruitment of participants included members of both the current and past parttime direct-care staff from September 2010 to September 2012 who were eligible to participate in the program. The direct care workforce includes individuals employed as nursing assistants, personal care aides and home health aides. Additional criteria require the employees to work between 20-34 hours per week (defined as parttime status) to be eligible to apply for participation in the program. DHA eligibility criteria require potential enrollees be without health insurance coverage for the last 90 days, earn an annual household income that falls below 300% of federal poverty level or less than $34,470 for a single individual, and assets must fall below established Abstract

educational efforts aimed at the uninsured population. These steps have already been identified as important initiatives to ensure the success of efforts under health care reform [6][7][8][9].

Methods
Utilizing a qualitative case study inquiry approach, participants included part-time direct care employees who were eligible to participate in the PTWCVP, a subsidized health insurance program offered through the Dirigo Health Agency (DHA). Recruitment of participants included members of both the current and past parttime direct-care staff from September 2010 to September 2012 who were eligible to participate in the program. The direct care workforce includes individuals employed as nursing assistants, personal care aides and home health aides. Additional criteria require the employees to work between 20-34 hours per week (defined as parttime status) to be eligible to apply for participation in the program. DHA eligibility criteria require potential enrollees be without health insurance coverage for the last 90 days, earn an annual household income that falls below 300% of federal poverty level or less than $34,470 for a single individual, and assets must fall below established

Introduction
As the ongoing debate surrounding the Affordable Care Act continues in the political arena and efforts to continue to support access to affordable health insurance remain paramount to health policy initiatives, the need to explore factors influencing health and health insurance status are critical in developing strategies to address barriers. As we consider the role of health beliefs in influencing health and health insurance status, revisiting the findings from participation in the subsidized health insurance program can lend important insight into nurse led strategies to improve health and increase participation in health insurance programs. The national uninsured population has gained significant attention over the last several years and studies examining the rates of uninsured have continued to identify costs as a significant barrier to obtaining health insurance coverage [1][2][3].
The purpose of the study was to identify and explore the nature of some of the barriers influencing non-participation in the PTWCVP, a voluntary subsidized health insurance program in Maine aimed at the uninsured part-time and seasonal workforce. Previous studies examining the Health Belief Model have found that perceived barriers are one of the most important influencing factors in whether or not individuals will engage in health promotion and prevention activities [4,5].
Based on the HBM, the findings from the study can be utilized to develop nurse led strategies to enhance the likelihood of taking action. Through the development and implementation of these strategies, cues to action can overcome barriers, address misconceptions associated with perceived benefits and risks, and promote greater awareness and understanding of threats to overall health. These strategies can include public awareness campaigns, outreach programs, and enrollment management plans that address perceived barriers through targeted guidelines based on household size [10]. Data collection procedures included self-report data and relied solely on focused interview techniques. The interviews occurred one-on-one with participants. The semi-structured approach asked open ended questions to provide participants the opportunity ample time to respond to the questions. The interview process took place over a prearranged 30-60 minute period of time with data collection occurring over the course of 1 month.

Results
The findings from the study identified a number of factors influencing non-participation in the PTWCVP. Financial reasons remained the primary impediment. The cost of health insurance coverage has been cited as one of the biggest barriers to obtaining health insurance coverage amongst the uninsured population [1,2,3,11]. A number of other important findings emerged that influenced non-participation in the program including perceptions of general health; perceptions regarding the role, purpose, and function of health insurance programs; program design and delivery; and lack of knowledge/effort to obtain health insurance coverage. These findings are consistent with other studies which suggested that subsidies alone are not enticing enough to encourage participation in subsidized programs [12,13]. Lack of knowledge regarding preventative care services can serve as a barrier in understanding the full role, function, and purpose of health insurance coverage. This is particularly important in light of health care reform efforts that emphasize preventative practices as a primary means of improving overall health. The findings from the study continued to underscore both financial and non-financial barriers as primary impediments to participation in the PTWCVP. Based on the HBM, the perceived financial barriers associated with participation are significant to participants and impede the likelihood of taking action.
Despite the presence of chronic disease, pre-existing conditions, abnormal findings from examinations, and infrequent health assessment and follow-up, participants' perceptions regarding susceptibility, severity, and threat of disease were not significant enough to generate action. While participants identified health-related risks and the presence of disease, they consistently rated their general health as good or better suggesting their perceptions surrounding susceptibility, severity, and threat of disease were low. Griffith, Lovett, Pyle, & Miller, [14] concluded that perceptions of self-rated health are not in congruence with their actual health status and behaviors. Based on the underlying assumptions of models such as the HBM, nurse led educational strategies and public health initiatives must increase the benefit to risk ratio in order to promote health seeking behaviors.
A number of influencing factors contributing to these perceptions were also identified. While participants felt health insurance was valuable and most felt a need for health insurance, they attributed both the need and value of health insurance for emergent/sick care needs. Based on these findings, participants may not understand the purpose, role, and function of health insurance coverage and therefore cannot perceive all of the potential benefits associated with obtaining health insurance coverage for preventative care. Lack of understanding or knowledge pertaining to the role of preventative care may minimize its role in mitigating health related risks and therefore result in a failure to recognize the full benefits of participation in activities such as these. These preventative care practices include annual physical exams, breast and pelvic health screenings, colorectal cancer screenings, cholesterol screenings, bone density testing, and others designed to promote prevention and early intervention. A number of recent studies evaluating the effectiveness of educational interventions to address knowledge gaps through use of the HBM found that educational interventions were successful in increasing perceived susceptibility, threat, and severity of disease while increasing perceived benefits and subsequently reducing perceived barriers resulting in increased participation in health promotion activities [15][16][17][18].

Conclusion
The findings from the study contribute to a growing body of knowledge related to barriers to non-participation in subsidized health insurance plans and collectively, offer some evidence that both financial and non-financial barriers influenced enrollment trends in subsidized health insurance programs. The findings from the study also provide some direction towards the development of nurse-led strategies to overcome perceived barriers. Based on the theoretical dimensions of the Health Belief Model and extensive evidence from the literature to support both the role of perceived barriers in influencing health seeking behaviors [19,[20][21][22], and the effectiveness of educational interventions to increase the likelihood of participation in health seeking behaviors and health promotion activities [15][16][17][18], the findings can be useful in the development of nurse led strategies. The Institute of Medicine's Future of Nursing Report underscores the role of the nursing profession in assuming lead roles in reforming the health care delivery system to broadly influence the policy arena including health care reform efforts [23]. Opportunities for the nursing profession to lead educational strategies aimed at addressing barriers can play a role in improving health status and participation in health insurance programs.