Voter Engagement in a Family Medicine Residency Clinic

Social determinants shape health and are important factors in health inequities in the United States.¹ These inequities have largely been created by policy choices and elected leaders over time.^2-4 Marginalized communities and areas with worse health outcomes have lower voting rates and greater barriers to voting which contributes to ongoing inequity.^3,5,6 To address this concern, voter registration has been integrated into health care settings.^7,8 Prior to the 2024 election, we considered the possibility of engaging our patients in conversations about voting and health and improving voting access.

We were intrigued by the approach described by Nakamura and colleagues⁹ that used QR codes and posters in exam rooms to verify voter registration or link to registration. The authors of that study noted 20 interactions in 2 months with signs in over 50 exam rooms. We wondered if direct interaction with patients would lead to more opportunities to register patients.

With this in mind, we interviewed a convenience sample of adult patients in our family medicine residency clinic prior to the 2024 Arizona voter registration deadline. Our project was approved by the University of Arizona IRB (#00004708); 98.5% of our family medicine residency clinic patients have health insurance; 33.3% of visits are covered by Medicaid plans.

We completed full interviews with 239 patients ages 18-89 years in our office; 179 patients (75%) were registered to vote and 59 (25%) were not registered; 28 unregistered were ineligible to vote. Of the 29 people who were not registered to vote and were eligible, 20 (69%) agreed to voter registration assistance using the nonpartisan resource vot-er.org. Two hundred-fourteen of 239 interviewees (90%) agreed it is acceptable for a primary care team to help register people to vote. Our patients think voting can influence health. One hundred eighty-two of 240 interviewees (76%) thought their vote was very likely or somewhat likely to lead to elected people or new policies that will improve the health of people like them in the community.

We are not the first project team to directly contact patients in a primary care office in an effort to increase civic engagement. One group contacted 304 patients in two Bronx, New York federally-qualified health centers, and 38% accepted registration assistance¹⁰; 65% of the patients registered were under 40 years old. The second study engaged 120 youth aged 18-22 years at an urban primary care clinic and 43 (36%) registered to vote.¹¹ Registration differences across these projects vary based on setting, patient ages, and insurance status.

In our single-site feasibility project we show that patients can be registered to vote successfully with direct engagement. Patients are aware voting impacts health and are supportive of registration by members of the primary care team. Most in our clinic were already registered to vote, which limited the yield of our efforts. A limitation of our study includes a likely social desirability bias as patients were interviewed by family physicians, residents, and medical students. We did not study the feasibility of incorporating voting conversations in the flow of a regular clinic visit.

Based on our findings, we encourage leaders of family medicine clinics, especially those in underserved areas and serving young adults, to engage patients in conversations about voting and assist patient registration. Increased civic engagement can lead to election outcomes that improve health equity.^1-6