{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T23:53:28Z","timestamp":1781654008447,"version":"3.54.5"},"reference-count":63,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,2,4]],"date-time":"2026-02-04T00:00:00Z","timestamp":1770163200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T00:00:00Z","timestamp":1772755200000},"content-version":"vor","delay-in-days":30,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The 2010 Affordable Care Act (ACA) led to Medicaid expansion, which expanded eligibility to low-income individuals below 138% of the federal poverty level in 41 states and Washington, DC. In California, over one-third of state residents are covered by Medicaid (Medi-Cal) insurance. Despite the 2014 Medicaid expansion in California, many individuals remain uninsured. Low-income women, in particular, face significant primary care access challenges due to socioeconomic status, education, and minority\/disability status. This qualitative study aimed to explore the experiences of low-income women seeking and accessing primary care services following the ACA\u2019s Medicaid expansion in California in an urban setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In-depth, semi-structured interviews were conducted with 18 women in Northern California (2021\u20132022). Data analysis employed Braun and Clarke\u2019s reflexive thematic analysis using a deductive approach. Levesque\u2019s conceptual framework of access to healthcare guided the coding and interpretation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The experiences of low-income women with primary care access post Medicaid expansion in an urban California setting were shaped by the complex interplay of individual demand-side factors and health system supply-side factors, and structural determinants. Levesque\u2019s framework highlights how individual factors (self-efficacy, health literacy, social support, and affordable insurance) interact with health system factors (geographic accessibility, availability and accommodation of services, and provider-patient relationships) to shape low-income women\u2019s experiences. However, Levesque\u2019s framework could be strengthened by incorporating macro-level structural factors (socioeconomic, political factors, and health policies) as these profoundly influence healthcare access.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>These findings provide a strong foundation for policymakers and practitioners to develop multi-level policies and interventions to address the ongoing barriers that urban low-income women encounter when accessing primary care following the ACA\u2019s Medicaid expansion. These findings are also relevant for other U.S. states and international settings that face similar challenges stemming from healthcare inequalities, including a lack of universal healthcare.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12913-025-13853-9","type":"journal-article","created":{"date-parts":[[2026,2,4]],"date-time":"2026-02-04T19:33:39Z","timestamp":1770233619000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Accessing primary care following the Affordable Care Act: a qualitative study of low-income women\u2019s experiences in urban California"],"prefix":"10.1186","volume":"26","author":[{"given":"Allison","family":"Gilchrist","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paula","family":"Holland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Faraz","family":"Ahmed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,4]]},"reference":[{"issue":"3","key":"13853_CR1","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1111\/j.1468-0009.2005.00409.x","volume":"83","author":"B Starfield","year":"2005","unstructured":"Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457\u2013502. https:\/\/doi.org\/10.1111\/j.1468-0009.2005.00409.x","journal-title":"Milbank Q"},{"key":"13853_CR2","doi-asserted-by":"publisher","unstructured":"Gumas E, Lewis C, Horstman C, Gunja M. The state of primary health care systems in ten high-income countries. Eur J Public Health. 2024;34. https:\/\/doi.org\/10.1093\/eurpub\/ckae144.298","DOI":"10.1093\/eurpub\/ckae144.298"},{"issue":"1","key":"13853_CR3","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1186\/s12939-018-0740-1","volume":"17","author":"L Corscadden","year":"2018","unstructured":"Corscadden L, Levesque JF, Lewis V, Strumpf E, Breton M, Russell G. Factors associated with multiple barriers to access to primary care: an international analysis. Int J Equity Health. 2018;17(1):28. https:\/\/doi.org\/10.1186\/s12939-018-0740-1","journal-title":"Int J Equity Health"},{"key":"13853_CR4","unstructured":"Wager E, Cox C. International comparison of health systems. In: Altman D, editor. KFF\u2019s Health Policy 101. Kaiser Family Foundation; 2025. Available from: https:\/\/www.kff.org\/global-health-policy\/health-policy-101-international-comparison-of-health-systems\/"},{"issue":"1","key":"13853_CR5","first-page":"57","volume":"1989","author":"K Crenshaw","year":"1989","unstructured":"Crenshaw K. Demarginalizing the intersection of race and sex: a Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Legal Forum. 1989;1989(1):57\u201380. Available from: http:\/\/chicagounbound.uchicago.edu\/uclf\/vol1989\/iss1\/8","journal-title":"Univ Of Chic Legal Forum"},{"key":"13853_CR6","volume-title":"Women\u2019s health insurance coverage","author":"KF Foundation","year":"2023","unstructured":"Kaiser Family Foundation. Women\u2019s health insurance coverage. Kaiser Family Foundation; 2023."},{"key":"13853_CR7","volume-title":"And coverage: findings from the 2022 KFF Women\u2019s health survey","author":"M Long","year":"2022","unstructured":"Long M, Frederiksen B, Ranji U, Salganicoff A, Diep K. Experiences with health care access, cost, and coverage: findings from the 2022 KFF Women\u2019s health survey. Kaiser Family Foundation; 2022. Available from: https:\/\/www.kff.org\/womens-health-policy\/experiences-with-health-care-access-cost-and-coverage-findings-from-the-2022-kff-womens-health-survey\/"},{"key":"13853_CR8","unstructured":"Sugar S, Ruhter J, Gordon S, Whitman A, Peters C, De Lew N, et al. Health coverage for women under the Affordable Care Act. Issue Brief No. HP-2022-09. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; 2022. Available from: https:\/\/aspe.hhs.gov\/reports\/health-coverage-women-under-aca"},{"key":"13853_CR9","volume-title":"10 things to know about the unwinding of the medicaid continuous enrollment provision","author":"J Tolbert","year":"2023","unstructured":"Tolbert J, Ammula M. 10 things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation; 2023. Available from: https:\/\/www.kff.org\/medicaid\/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision\/"},{"key":"13853_CR10","unstructured":"Cervantes S, Bell C, Tolbert J, Damico A. How many uninsured are in the coverage gap and how many could be eligible if all states adopted the Medicaid expansion? Kaiser Family Foundation; 2025 Feb 25. Available from: https:\/\/www.kff.org\/medicaid\/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion\/"},{"key":"13853_CR11","volume-title":"Women\u2019s health insurance coverage","author":"KF Foundation","year":"2024","unstructured":"Kaiser Family Foundation. Women\u2019s health insurance coverage. Kaiser Family Foundation; 2024. Available from: https:\/\/www.kff.org\/womens-health-policy\/womens-health-insurance-coverage\/"},{"key":"13853_CR12","unstructured":"Kaiser Family Foundation. Women who report having no personal doctor\/health care provider by race\/ethnicity. Kaiser Family Foundation; 2024."},{"issue":"1","key":"13853_CR13","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1186\/s12939-020-1133-9","volume":"19","author":"M Hailemariam","year":"2020","unstructured":"Hailemariam M, Felton JW, Key K, Greer D, Jefferson BL, Muhammad J, et al. Intersectionality, special populations, needs and suggestions: the Flint Women\u2019s study. Int J Equity Health. 2020;19(1):18. https:\/\/doi.org\/10.1186\/s12939-020-1133-9","journal-title":"Int J Equity Health"},{"issue":"1","key":"13853_CR14","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1080\/07370016.2014.868733","volume":"31","author":"DJ Biederman","year":"2014","unstructured":"Biederman DJ, Nichols TR. Homeless women\u2019s experiences of service provider encounters. J Community Health Nurs. 2014;31(1):34\u201348. https:\/\/doi.org\/10.1080\/07370016.2014.868733","journal-title":"J Community Health Nurs"},{"issue":"9","key":"13853_CR15","doi-asserted-by":"publisher","first-page":"979","DOI":"10.1080\/07399332.2016.1174244","volume":"37","author":"L Mann","year":"2016","unstructured":"Mann L, Tanner AE, Sun CJ, Erausquin JT, Sim\u00e1n FM, Downs M, et al. Listening to the voices of Latina women: sexual and reproductive health intervention needs and priorities in a new settlement state in the United States. Health Care Women Int. 2016;37(9):979\u201394. https:\/\/doi.org\/10.1080\/07399332.2016.1174244","journal-title":"Health Care Women Int"},{"issue":"2","key":"13853_CR16","doi-asserted-by":"publisher","first-page":"242","DOI":"10.1016\/j.outlook.2019.08.002","volume":"68","author":"O Olukotun","year":"2020","unstructured":"Olukotun O, Kako P, Dressel A, Mkandawire-Valhmu L. A qualitative exploration of the experiences of undocumented African immigrant women in the health care delivery system. Nurs Outlook. 2020;68(2):242\u201351. https:\/\/doi.org\/10.1016\/j.outlook.2019.08.002","journal-title":"Nurs Outlook"},{"issue":"9","key":"13853_CR17","doi-asserted-by":"publisher","first-page":"1334","DOI":"10.1177\/1049732318816676","volume":"29","author":"K Greder","year":"2019","unstructured":"Greder K, Reina AS. Procuring health: experiences of Mexican immigrant women in rural midwestern communities. Qual Health Res. 2019;29(9):1334\u201344. https:\/\/doi.org\/10.1177\/1049732318816676","journal-title":"Qual Health Res"},{"issue":"1","key":"13853_CR18","doi-asserted-by":"publisher","first-page":"310","DOI":"10.1186\/s12913-018-3138-2","volume":"18","author":"JS Luque","year":"2018","unstructured":"Luque JS, Soulen G, Davila CB, Cartmell K. Access to health care for uninsured Latina immigrants in South Carolina. BMC Health Serv Res. 2018;18(1):310. https:\/\/doi.org\/10.1186\/s12913-018-3138-2","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"13853_CR19","doi-asserted-by":"publisher","first-page":"233","DOI":"10.1353\/hpu.2013.0029","volume":"24","author":"KE Murray","year":"2013","unstructured":"Murray KE, Mohamed AS, Ndunduyenge G. Health and prevention among East African women in the U.S. J Health Care Poor Underserved. 2013;24(1):233\u201346. https:\/\/doi.org\/10.1353\/hpu.2013.0029","journal-title":"J Health Care Poor Underserved"},{"issue":"6","key":"13853_CR20","doi-asserted-by":"publisher","first-page":"1430","DOI":"10.1111\/hsc.12810","volume":"27","author":"A Ross Perfetti","year":"2019","unstructured":"Ross Perfetti A, Abboud S, Behme M, Barg FK. Understanding wellness and barriers to care among Iraqi refugee women in the United States. Health Soc Care Community. 2019;27(6):1430\u201337. https:\/\/doi.org\/10.1111\/hsc.12810","journal-title":"Health Soc Care Community"},{"issue":"5","key":"13853_CR21","doi-asserted-by":"publisher","first-page":"387","DOI":"10.1016\/j.whi.2018.03.009","volume":"28","author":"J Chor","year":"2018","unstructured":"Chor J, Garcia-Ricketts S, Young D, Hebert LE, Hasselbacher LA, Gilliam ML. Well-woman care barriers and facilitators of low-income women obtaining induced abortion after the Affordable Care Act. Womens Health Issues. 2018;28(5):387\u201392. https:\/\/doi.org\/10.1016\/j.whi.2018.03.009","journal-title":"Womens Health Issues"},{"issue":"2","key":"13853_CR22","doi-asserted-by":"publisher","first-page":"160","DOI":"10.1016\/j.wombi.2015.09.007","volume":"29","author":"JC Phillippi","year":"2016","unstructured":"Phillippi JC, Holley SL, Payne K, Schorn MN, Karp SM. Facilitators of prenatal care in an exemplar urban clinic. Women Birth. 2016;29(2):160\u201367. https:\/\/doi.org\/10.1016\/j.wombi.2015.09.007","journal-title":"Women Birth"},{"issue":"Suppl 1","key":"13853_CR23","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1007\/s10995-017-2372-2","volume":"21","author":"LA Roman","year":"2017","unstructured":"Roman LA, Raffo JE, Dertz K, Agee B, Evans D, Penninga K, et al. Understanding perspectives of African American Medicaid-insured women on the process of perinatal care: an opportunity for systems improvement. Matern Child Health J. 2017;21(Suppl 1):81\u201392. https:\/\/doi.org\/10.1007\/s10995-017-2372-2","journal-title":"Matern Child Health J"},{"key":"13853_CR24","unstructured":"Braun V, Clarke V. Successful qualitative research: a practical guide for beginners. London (UK): SAGE publications; 2013."},{"key":"13853_CR25","volume-title":"Social research methods","author":"A Bryman","year":"2016","unstructured":"Bryman A. Social research methods. 5th ed. Oxford: Oxford University Press; 2016.","edition":"Fifth"},{"issue":"2","key":"13853_CR26","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1002\/nur.4770180211","volume":"18","author":"M Sandelowski","year":"1995","unstructured":"Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995;18(2):179\u201383. https:\/\/doi.org\/10.1002\/nur.4770180211","journal-title":"Res In Nurs Health"},{"key":"13853_CR27","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1186\/1475-9276-12-18","volume":"12","author":"JF Levesque","year":"2013","unstructured":"Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. https:\/\/doi.org\/10.1186\/1475-9276-12-18","journal-title":"Int J Equity Health"},{"issue":"1","key":"13853_CR28","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1186\/s12939-021-01416-3","volume":"20","author":"A Cu","year":"2021","unstructured":"Cu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque\u2019s conceptual framework - a scoping review. Int J Equity Health. 2021;20(1):116. https:\/\/doi.org\/10.1186\/s12939-021-01416-3","journal-title":"Int J Equity Health"},{"key":"13853_CR29","doi-asserted-by":"crossref","unstructured":"Braun V, Clarke V, Terry G, Hayfield N. Thematic analysis. In: Liamputtong P, editor. Handbook of research methods in health social sciences. 1st ed. Singapore: Springer Singapore; 2019.","DOI":"10.1007\/978-981-10-2779-6_103-1"},{"key":"13853_CR30","doi-asserted-by":"publisher","unstructured":"Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589\u201397. https:\/\/doi.org\/10.1080\/2159676X.2019.1628806","DOI":"10.1080\/2159676X.2019.1628806"},{"key":"13853_CR31","doi-asserted-by":"publisher","unstructured":"Gilchrist A. A qualitative exploration of low-income women\u2019s access to primary care services and health-seeking behaviours in an urban setting in California in the Affordable Care Act era. [Ph.D. thesis]. Lancaster (UK): Lancaster University; 2024. https:\/\/doi.org\/10.17635\/lancaster\/thesis\/2271","DOI":"10.17635\/lancaster\/thesis\/2271"},{"key":"13853_CR32","doi-asserted-by":"publisher","unstructured":"Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3): 328 \u2013 52. https:\/\/doi.org\/10.1080\/14780887.2020.1769238","DOI":"10.1080\/14780887.2020.1769238"},{"key":"13853_CR33","doi-asserted-by":"crossref","unstructured":"Braun V, Clarke V. Thematic analysis: a practical guide. 1st ed. Thousand Oaks (CA): SAGE Publications; 2022.","DOI":"10.53841\/bpsqmip.2022.1.33.46"},{"key":"13853_CR34","doi-asserted-by":"publisher","unstructured":"Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u2013101. https:\/\/doi.org\/10.1191\/1478088706qp063oa","DOI":"10.1191\/1478088706qp063oa"},{"key":"13853_CR35","unstructured":"U.S. Preventive Services Task Force. Final recommendation statement: colorectal cancer: screening. 2021 [updated 2021 May 18]. Available from: https:\/\/www.uspreventiveservicestaskforce.org\/uspstf\/recommendation\/colorectal-cancer-screening"},{"issue":"2","key":"13853_CR36","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1300\/J013v40n02_06","volume":"40","author":"L Gelberg","year":"2004","unstructured":"Gelberg L, Browner CH, Lejano E, Arangua L. Access to women\u2019s health care: a qualitative study of barriers perceived by homeless women. Women Health. 2004;40(2):87\u2013100. https:\/\/doi.org\/10.1300\/J013v40n02_06","journal-title":"Women Health"},{"issue":"6","key":"13853_CR37","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1007\/BF01324513","volume":"16","author":"E Schlossstein","year":"1991","unstructured":"Schlossstein E, St Clair P, Connell F. Referral keeping in homeless women. J Community Health. 1991;16(6):279\u201385. https:\/\/doi.org\/10.1007\/BF01324513","journal-title":"J Community Health"},{"issue":"2","key":"13853_CR38","doi-asserted-by":"publisher","first-page":"217","DOI":"10.2105\/ajph.87.2.217","volume":"87","author":"L Gelberg","year":"1997","unstructured":"Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87(2):217\u201320. https:\/\/doi.org\/10.2105\/ajph.87.2.217","journal-title":"Am J Public Health"},{"key":"13853_CR39","unstructured":"Centers for Disease Control and Prevention. What is health literacy? 2024. Available from: https:\/\/www.cdc.gov\/health-literacy\/php\/about\/?CDC_AAref_Val=https:\/\/www.cdc.gov\/healthliteracy\/learn\/index.html"},{"issue":"4","key":"13853_CR40","doi-asserted-by":"publisher","first-page":"419","DOI":"10.1080\/13825580902741336","volume":"16","author":"BJ Ayotte","year":"2009","unstructured":"Ayotte BJ, Allaire JC, Bosworth H. The associations of patient demographic characteristics and health information recall: the mediating role of health literacy. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2009;16(4):419\u201332. https:\/\/doi.org\/10.1080\/13825580902741336","journal-title":"Neuropsychol Dev Cogn B Aging Neuropsychol Cogn"},{"issue":"3","key":"13853_CR41","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1093\/heapro\/16.3.289","volume":"16","author":"IS Kickbusch","year":"2001","unstructured":"Kickbusch IS. Health literacy: addressing the health and education divide. Health Promot Int. 2001;16(3):289\u201397. https:\/\/doi.org\/10.1093\/heapro\/16.3.289","journal-title":"Health Promot Int"},{"issue":"1","key":"13853_CR42","doi-asserted-by":"publisher","first-page":"975","DOI":"10.1186\/s12889-016-3621-9","volume":"16","author":"RV Rikard","year":"2016","unstructured":"Rikard RV, Thompson MS, McKinney J, Beauchamp A. Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL). BMC Public Health. 2016;16(1):975. https:\/\/doi.org\/10.1186\/s12889-016-3621-9","journal-title":"BMC Public Health"},{"key":"13853_CR43","doi-asserted-by":"publisher","first-page":"102396","DOI":"10.1016\/j.healthplace.2020.102396","volume":"64","author":"M Statz","year":"2020","unstructured":"Statz M, Evers K. Spatial barriers as moral failings: what rural distance can teach us about women\u2019s health and medical mistrust. Health Place. 2020;64:102396. https:\/\/doi.org\/10.1016\/j.healthplace.2020.102396","journal-title":"Health Place"},{"issue":"2","key":"13853_CR44","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1080\/01488376.2022.2035300","volume":"48","author":"GM Tefera","year":"2022","unstructured":"Tefera GM, Yu M. Immigrant women\u2019s access to healthcare services in the United States: a qualitative meta-synthesis. J Soc Service Res. 2022;48(2):285\u201399. https:\/\/doi.org\/10.1080\/01488376.2022.2035300","journal-title":"J Soc Service Res"},{"issue":"1","key":"13853_CR45","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1177\/1043659611423828","volume":"23","author":"N Hill","year":"2012","unstructured":"Hill N, Hunt E, Hyrk\u00e4s K. Somali immigrant women\u2019s health care experiences and beliefs regarding pregnancy and birth in the United States. J Transcult Nurs. 2012;23(1):72\u201381. https:\/\/doi.org\/10.1177\/1043659611423828","journal-title":"J Transcult Nurs"},{"issue":"6","key":"13853_CR46","doi-asserted-by":"publisher","first-page":"1168","DOI":"10.1007\/s10903-010-9369-x","volume":"13","author":"AC Sanchez-Birkhead","year":"2011","unstructured":"Sanchez-Birkhead AC, Kennedy HP, Callister LC, Miyamoto TP. Navigating a new health culture: experiences of immigrant Hispanic women. J Immigr Minor Health. 2011;13(6):1168\u201374. https:\/\/doi.org\/10.1007\/s10903-010-9369-x","journal-title":"J Immigr Minor Health"},{"key":"13853_CR47","doi-asserted-by":"publisher","first-page":"100565","DOI":"10.1016\/j.tra.2022.03.010","volume":"13","author":"L Oluyede","year":"2022","unstructured":"Oluyede L, Cochran AL, Prunkl L, Wang J, Wolfe M, McDonald NC. Unpacking transportation barriers and facilitators to accessing health care: interviews with care coordinators. Transp Res Interdiscip Perspect. 2022;13:100565. https:\/\/doi.org\/10.1016\/j.tra.2022.03.010","journal-title":"Transp Res Interdiscip Perspect"},{"issue":"2","key":"13853_CR48","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1016\/j.pec.2011.04.010","volume":"86","author":"SA McLachlan","year":"2012","unstructured":"McLachlan SA, Clements A, Austoker J. Patients\u2019 experiences and reported barriers to colonoscopy in the screening context\u2014a systematic review of the literature. Patient Educ Couns. 2012;86(2):137\u201346. https:\/\/doi.org\/10.1016\/j.pec.2011.04.010","journal-title":"Patient Educ Couns"},{"key":"13853_CR49","unstructured":"Long M, Frederiksen B, Ranji U, Salganicoff A. Women\u2019s health care utilization and costs: findings from the 2020 KFF Women\u2019s Health Survey. Kaiser Family Foundation; 2021 Apr 21. Available from: https:\/\/www.kff.org\/womens-health-policy\/womens-health-care-utilization-and-costs-findings-from-the-2020-kff-womens-health-survey\/"},{"issue":"6","key":"13853_CR50","doi-asserted-by":"publisher","first-page":"466","DOI":"10.3322\/caac.21695","volume":"71","author":"KD Miller","year":"2021","unstructured":"Miller KD, Ortiz AP, Pinheiro PS, Bandi P, Minihan A, Fuchs HE, et al. Cancer statistics for the US Hispanic\/Latino population, 2021. CA Cancer J Clin. 2021;71(6):466\u201387. https:\/\/doi.org\/10.3322\/caac.21695","journal-title":"CA Cancer J Clin"},{"issue":"1","key":"13853_CR51","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1097\/JAC.0000000000000316","volume":"43","author":"EE Brown","year":"2020","unstructured":"Brown EE, Schwartz M, Shi C, Carter T, Shea JA, Grande D, et al. Understanding why urban, low-income patients miss primary care appointments: insights from qualitative interviews of West Philadelphians. J Ambul Care Manag. 2020;43(1):30\u201340. https:\/\/doi.org\/10.1097\/JAC.0000000000000316","journal-title":"J Ambul Care Manag"},{"issue":"10","key":"13853_CR52","doi-asserted-by":"publisher","first-page":"1177","DOI":"10.1111\/tmi.13651","volume":"26","author":"B Dawkins","year":"2021","unstructured":"Dawkins B, Renwick C, Ensor T, Shinkins B, Jayne D, Meads D. What factors affect patients\u2019 ability to access healthcare? An overview of systematic reviews. Trop Med Int Health. 2021;26(10):1177\u201388. https:\/\/doi.org\/10.1111\/tmi.13651","journal-title":"Trop Med Int Health"},{"issue":"12","key":"13853_CR53","doi-asserted-by":"publisher","first-page":"1547","DOI":"10.1176\/ps.2007.58.12.1547","volume":"58","author":"E Nadeem","year":"2007","unstructured":"Nadeem E, Lange JM, Edge D, Fongwa M, Belin T, Miranda J. Does stigma keep poor young immigrant and U.S.-born Black and Latina women from seeking mental health care? Psychiatr Serv. 2007;58(12):1547\u201354. https:\/\/doi.org\/10.1176\/ps.2007.58.12.1547","journal-title":"Psychiatr Serv"},{"issue":"1","key":"13853_CR54","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1186\/s12905-018-0609-x","volume":"18","author":"HC Hong","year":"2018","unstructured":"Hong HC, Lee H, Collins EG, Park C, Quinn L, Ferrans CE. Factors affecting trust in healthcare among middle-aged to older Korean American women. BMC Womens Health. 2018;18(1):109. https:\/\/doi.org\/10.1186\/s12905-018-0609-x","journal-title":"BMC Womens Health"},{"issue":"5","key":"13853_CR55","doi-asserted-by":"publisher","first-page":"484","DOI":"10.1093\/fampra\/cmh503","volume":"21","author":"VB Sheppard","year":"2004","unstructured":"Sheppard VB, Zambrana RE, O\u2019Malley AS. Providing health care to low-income women: a matter of trust. Fam Pract. 2004;21(5):484\u201391. https:\/\/doi.org\/10.1093\/fampra\/cmh503","journal-title":"Fam Pract"},{"issue":"3","key":"13853_CR56","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1097\/MLR.0000000000000644","volume":"55","author":"EM Allen","year":"2017","unstructured":"Allen EM, Call KT, Beebe TJ, McAlpine DD, Johnson PJ. Barriers to care and health care utilization among the publicly insured. Med Care. 2017;55(3):207\u201314. https:\/\/doi.org\/10.1097\/MLR.0000000000000644","journal-title":"Med Care"},{"issue":"6","key":"13853_CR57","doi-asserted-by":"publisher","first-page":"777","DOI":"10.1016\/j.ypmed.2004.01.018","volume":"38","author":"AS O\u2019Malley","year":"2004","unstructured":"O\u2019Malley AS, Sheppard VB, Schwartz M, Mandelblatt J. The role of trust in use of preventive services among low-income African-American women. Prev Med. 2004;38(6):777\u201385. https:\/\/doi.org\/10.1016\/j.ypmed.2004.01.018","journal-title":"Prev Med"},{"key":"13853_CR58","doi-asserted-by":"publisher","unstructured":"Armour M, Rivaux SL, Bell H. Using context to build rigor: application to two hermeneutic phenomenological studies. Qual Social Work. 2009;8(1):101\u201322. https:\/\/doi.org\/10.1177\/1473325008100424","DOI":"10.1177\/1473325008100424"},{"issue":"1","key":"13853_CR59","doi-asserted-by":"publisher","first-page":"163","DOI":"10.1186\/s12939-016-0450-5","volume":"15","author":"C Davy","year":"2016","unstructured":"Davy C, Harfield S, McArthur A, Munn Z, Brown A. Access to primary health care services for Indigenous peoples: a framework synthesis. Int J Equity Health. 2016;15(1):163. https:\/\/doi.org\/10.1186\/s12939-016-0450-5","journal-title":"Int J Equity Health"},{"key":"13853_CR60","unstructured":"Tong M, Hinton E. California efforts to address behavioral health and SDOH: a look at Whole Person Care Pilots. Kaiser Family Foundation; 2022. Available from: https:\/\/www.kff.org\/mental-health\/california-efforts-to-address-behavioral-health-and-sdoh-a-look-at-whole-person-care-pilots\/"},{"issue":"8","key":"13853_CR61","doi-asserted-by":"publisher","first-page":"884","DOI":"10.1111\/j.1525-1497.2006.00544.x","volume":"21","author":"MK Paasche-Orlow","year":"2006","unstructured":"Paasche-Orlow MK, Schillinger D, Greene SM, Wagner EH. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006;21(8):884\u201387. https:\/\/doi.org\/10.1111\/j.1525-1497.2006.00544.x","journal-title":"J Gen Intern Med"},{"key":"13853_CR62","doi-asserted-by":"publisher","unstructured":"National Academies of Sciences, Engineering, and Medicine. Implementing high-quality primary care: rebuilding the foundation of health care. Washington, DC: National Academies Press; 2021. https:\/\/doi.org\/10.17226\/25983","DOI":"10.17226\/25983"},{"key":"13853_CR63","doi-asserted-by":"publisher","DOI":"10.17226\/12875","volume-title":"Committee on understanding and eliminating racial and ethnic disparities in health Care","author":"Institute of Medicine","year":"2003","unstructured":"Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities In Health Care. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press; 2003. https:\/\/doi.org\/10.17226\/12875"}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-025-13853-9","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-025-13853-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-025-13853-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T23:05:26Z","timestamp":1781651126000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12913-025-13853-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,4]]},"references-count":63,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["13853"],"URL":"https:\/\/doi.org\/10.1186\/s12913-025-13853-9","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,4]]},"assertion":[{"value":"1 August 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"2 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 February 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethical approval for this study was granted by the Institutional Review Board at San Francisco State University, San Francisco, California 94132, U.S. (X21-018R1) and the Faculty of Health and Medicine Research Ethics Committee at Lancaster University, Lancaster, Lancashire, England, United Kingdom according to the United Kingdom Data Protection Act (2018), General Data Protection Regulation principles, and the Code of Federal Regulations (CFR) \u2013 Title 45 CFR Part 46 (2018), and Title 21 CFR Parts 50 and 56. All research participants underwent a consent process, and written or recorded verbal consent was obtained before participation in the research study. All research participants were informed they were free to withdraw from the study at any time. Before starting the interview, the researcher asked all participants whether they consented to be part of the study and if they were willing to have the interview recorded using a digital recorder or audio or video recorded using secure video conference software. The informed consent form template is available upon request. Pseudonyms were given to all research participants to protect their anonymity. All data was anonymised, and personal data was collected, managed, and stored according to the United Kingdom Data Protection Act (2018), General Data Protection Regulation principles, the Code of Federal Regulations \u2013 Title 45 CFR Part 46 (2018), and Title 21 CFR Parts 50 and 56.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"AG was a doctoral candidate at the Division of Health Research, Faculty of Health and Medicine, Lancaster University at the time this research was conducted, and is an Assistant Professor at the College of Health and Social Services, San Francisco State University, California, U.S. PH is a Senior Lecturer and FA is a Lecturer at the Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Authors\u2019 information (optional)"}},{"value":"The authors declare that they have no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"331"}}