Despite increasing attention on addressing unmet social needs to improve chronic disease management,1, 2 patient perspectives on which social needs are most important and how these needs affect health are lacking. This knowledge is essential to optimizing medical care for the most vulnerable patients. Thus we sought to explore which unmet social needs are most influential and how these needs affect individuals’ decisions regarding medical treatment and self-management of health needs among community-dwelling low-income adults.


We conducted 12 focus groups in English and Spanish among 55 adults seeking assistance at Crossroads Community Services in downtown Dallas, Texas, from July to November 2016. Crossroads is the largest non-profit food redistribution organization affiliated with the North Texas Food Bank. Participants were purposively recruited from the Crossroads waiting area. Focus groups were conducted in private using a semi-structured guide and were digitally recorded, transcribed, and translated. We conducted thematic analysis of transcripts using the constant comparative method. Data collection and analysis were conducted concurrently so that analytical insights could inform recruitment and ongoing data collection. Disagreements were resolved by negotiated consensus. We ceased recruitment upon reaching thematic saturation. The study was approved by the UT Southwestern institutional review board.


Most participants were in their 40s and 50s; 67% were women; 5% were white, 38% black, and 56% Hispanic. The one recurrent and unifying theme among participants was that financial strain, rather than a specific need, was the single most important factor influencing health decision-making. Financial strain resulted in daily weighing of trade-offs with every spending decision, not only health-related ones (Table 1). Although participants valued and prioritized adherence to physician-recommended therapies when possible, they employed alternative and/or self-prescribed treatments when resources were lacking.

Table 1 Influence of Financial Strain on Health Decision-Making

Within this overarching theme, three key subthemes emerged:

  1. 1)

    Trade-offs between household and individual needs. Except in urgent or emergency situations, participants prioritized household needs such as food, rent, and utilities rather than paying for medical care for themselves.

  2. 2)

    Alternative remedies used as affordable substitutes. Participants did not view alternative remedies as superior to allopathic medicine, but rather as stopgaps to abate progression or attempt symptom relief before pursuing more costly medical care.

  1. 3)

    Reluctance to discuss financial strain in clinical settings. Participants perceived a lack of openness and concern about affordability in doctors’ offices. Embarrassment and perceived stigma contributed to their reluctance to discuss financial strain.


We found that financial strain, rather than any single social need, was the most important factor in health decision-making among the underserved adults we studied, and may result in non-adherence to medical recommendations that could appear to reflect lack of engagement in care. However, deviations from physician-prescribed therapies are more often the result of rational and difficult trade-offs to cope with financial strain, than a lack of interest or deficit in knowledge. Thus, patient education and counseling, while necessary, may be insufficient for improving adherence and chronic disease management in underserved populations without increased attention to also improving affordability and access to care.

A limitation of our single-site study is uncertain generalizability to different regions and to low-income individuals receiving other forms of assistance (i.e., housing) or no services at all.

Though clinical–community linkages are important in addressing social needs,3,4,5 our findings highlight overlooked opportunities for intervention within clinical settings (Table 2). First, routine screening for financial strain in clinical settings may help patients overcome reluctance to discussing costs as a barrier to care. Positive screening for financial strain should be communicated to physicians to inform and prioritize treatment recommendations that are affordable and high-value in order to maximize adherence. Second, physicians should seek to reduce the potential harms of non-adherence due to financial strain by 1) explicitly counseling patients on which medications are more versus less important and which would be safer to skip or stretch if necessary, and 2) discussing with patients the option to forego evaluation or treatment of less acute issues or lower-value care until economic conditions improve. These pragmatic approaches aim to help patients prioritize high-value care and achieve adequate adherence within their financial means, rather than encouraging perfect but unattainable adherence. These strategies are foundational to addressing social needs, and to delivering truly personalized medicine to all patients.

Table 2 Opportunities for Physicians to Mitigate Potential Health-Related Harms by Addressing Financial Strain