Advancing health disparities research within the health care system: a conceptual framework

Decolonizing Global Health Research: Perspectives from US and International Global Health Trainees

Background

"Decolonizing global health" (DGH) may help global health trainees understand and remediate the effects of historical colonialism on global health, but little is known regarding how trainees perceive DGH. Understanding their perspectives is critical for designing educational interventions tailored to their needs.

Objectives

To understand how trainees perceive DGH research and to determine if perspectives differ between trainees from high- (HICs) versus low- and middle-income countries (LMICs).

Methods

An online survey of all 2017-2022 pre-doctoral and post-doctoral trainees (n = 111) and mentors (n = 91) within a multi-university program that supports US and international investigators in one-year mentored global health research. The survey evaluated individuals' self-reported knowledge and attitudes toward DGH and their perceptions of historical colonialism's impact on eight aspects of global health.

Findings

The response rate to trainee surveys was 56%. Trainees from LMICs were less aware of the concept of DGH; 5/25 (20%) had never heard of DGH and 16/25 (64%) reported that they "know a little," whereas all HIC trainees had heard of DGH and 29/36 (81%) reported that they "know a little" (p = 0.019). For three aspects of global health (i.e., which research questions get asked; development of collaborative relationships; and data/statistical analyses), trainees from LMICs were more likely to report positive effects of colonialism. However, in open-ended responses, no thematic differences existed between how LMIC and HIC trainees defined DGH (i.e., actively eliminating power imbalances; prioritizing local needs; promoting local leadership; providing equitable opportunities; and ensuring programs are culturally appropriate).

Conclusions

Different perspectives surrounding what DGH means suggest a shared understanding may be needed and is arguably prerequisite to designing educational interventions to help global health trainees recognize, understand, and act in global health. Future research is needed to understand perspectives on decolonization across diverse contexts with attention to constructs such as race, ethnicity, and gender.

Geospatial analysis of patients' social determinants of health for health systems science and disparity research

Social context matters for health, healthcare processes/quality and patient outcomes. The social status and circumstances we are born into, grow up in and live under, are called social determinants of health; they drive our health, and how we access and experience care; they are the fundamental causes of disease outcomes. Such circumstances are influenced heavily by our location through neighborhood context, which relates to support networks. Geography can influence proximity to resources and is an important dimension of social determinants of health, which also encompass race/ethnicity, language, health literacy, gender identity, social capital, wealth and income. Beginning with an explanation of social determinants, we explore the use of Geospatial Analysis methods and geocoding, including the importance of collaborating with geography experts, the pitfalls of geocoding, and how geographic analysis can help us to understand patient populations within the context of Social Determinants of Health. We then explain mechanisms and methods of geospatial analysis with two examples: (1) Bayesian hierarchical regression with crossed random effects and (2) discontinuity regression i.e., change point analysis. We leveraged the local University of Utah and Yale cohorts of the Multicenter Perioperative Outcomes Group (MPOG.org ), a perioperative electronic health registry; we enriched the Utah cohort with US-census tract level social determinants of health after geocoding patient addresses and extracting social determinants of health from the National Neighborhood Database (NaNDA). We explain how to investigate the impact of US-census tract level community deprivation indices and racial/ethnic composition on (1) individual clinicians’ administration of risk-adjusted perioperative antiemetic prophylaxis, (2) patients’ decisions to defer cataract surgery at the cusp of Medicare eligibility and finally (3) methods to further characterize patient populations at risk through publicly available datasets in the context of public transit access. Our examples are not rigorous analyses, and our preliminary inferences should not be taken at face value, but rather seen as illustration of geospatial analysis processes and methods. Our worked examples show the potential utility of geospatial analysis, and in particular the power of geocoding patient addresses to extract US-census level social determinants of health from publicly available databases to enrich electronic health registries for healthcare disparity research and targeted health system level countermeasures.

Socioeconomic Status and Medication Use in Rheumatoid Arthritis: A Scoping Review

OBJECTIVE

Socioeconomic status (SES) influences disease outcomes in rheumatoid arthritis (RA) patients. Differences in medication use may partly explain this association. A scoping review was used to identify research conducted on this topic and determine what knowledge gaps remain.

METHODS

Medline, Embase, and PsychInfo were searched from their inception until February 2022 for studies that assessed SES and medication use as an outcome variable. Data was extracted on the use of specific SES measures, medication use, and whether differences in SES variables were associated with differences in medication use.

RESULTS

We identified 2,103 studies, of which 81 were selected for inclusion. Included studies originated most frequently from the US (42%); the mean ± SD age of participants was 55.9 ± 6.8 years, and most were female (75%). Studies measured a median of 4 SES variables (interquartile range 3-6), with educational, area-level SES, and income being the most frequent measurements used. Patients' race and/or ethnicity were documented by 34 studies. Studies primarily assessed the likelihood of prescription of disease-modifying antirheumatic drugs or dispensation, medication adherence, or treatment delays. A majority of studies documented at least 1 SES measure associated with a difference in medication use.

CONCLUSION

There is some evidence that SES affects use of medications in patients with RA; however, multiple definitions of SES have been utilized, making comparisons between studies difficult. Prospective studies with consistently defined SES will be needed to determine whether differences in medication use accounts for the poorer outcomes experienced by patients of lower SES.

The role of gender and veteran status in healthcare access among a national sample of U.S. adults with unhealthy alcohol use

Background: Routine healthcare access is critical to reduce drinking and its effects, yet little is known about Veteran and gender differences in routine healthcare access among unhealthy drinkers. The current study examined differences in routine healthcare access, stratified by Veteran status and gender, among a national sample of adults endorsing unhealthy drinking. Method: Using data from the Centers for Disease Control and Prevention's 2019 Behavioral Risk Factor Surveillance System National Survey, we identified adults who endorsed unhealthy drinking over the past month (N = 58,816; 41.4% female; 2.7% female Veterans). Bivariate and multivariable analyses modeled associations between gender, Veteran status, and their interaction in predicting routine healthcare access. All multivariable models adjusted for sociodemographic characteristics. Results: Veterans with unhealthy alcohol use reported high rates of routine healthcare access (e.g., >86% sought care in the past 2 years) and were less likely to experience a cost barrier to care (aOR = 0.75, 95% CI = 0.62-0.92). Females were more likely than males to report better access to care but also to experience a cost barrier (aOR = 1.2, 95% CI = 1.10-1.37). The interaction between Veteran status and gender was non-significant. Conclusions: Overall, healthcare access was better for Veterans and females with unhealthy alcohol use compared to civilians and males with unhealthy alcohol use. However, given that females were more likely to report a cost barrier, future implementation research aiming to improve equity in care may want to explore reasons for cost barriers and develop strategies to help reduce these barriers in order to eliminate gender disparities in primary care-based alcohol-related care.

Community Health Workers and Stigma Associated with Mental Illness: An Integrative Literature Review

Community health workers (CHWs) are facilitators between health services and service users, providing essential and effective support to those seeking health care. However, stigmatizing attitudes towards people with mental illness also exist among CHWs and are based on prejudicial and biasedopinions. This integrative review critically assessed evidence regarding CHWs approaches for addressing mental health issues. In total, 19 studies were included in this review. The results revealed that CHWs have limited knowledge about mental illness and also stigmatizing attitudes towards people with mental illness or substance use problems. Despite feeling unprepared, CHWs are favorable resources for mental health care and can contribute to reducing stigma due to the similarities they share with the communities that they serve. Task-sharing between health professionals and CHWs is an important strategy to improve access to health services and reducing stigma towards people with mental illness, provided that receive adequate training to perform the duties.

Climate change, the environment, and rhinologic disease

BACKGROUND

The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases.

METHODS

Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed.

RESULTS

The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected.

CONCLUSIONS

We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs.

Determinants of Pre-exposure Prophylaxis (PrEP) Implementation in Transgender Populations: A Qualitative Scoping Review

We conducted a scoping review of contextual factors impeding uptake and adherence to pre-exposure prophylaxis in transgender communities as an in-depth analysis of the transgender population within a previously published systematic review. Using a machine learning screening process, title and abstract screening, and full-text review, the initial systematic review identified 353 articles for analysis. These articles were peer-reviewed, implementation-related studies of PrEP in the U.S. published after 2000. Twenty-two articles were identified in this search as transgender related. An additional eleven articles were identified through citations of these twenty-two articles, resulting in thirty-three articles in the current analysis. These thirty-three articles were qualitatively coded in NVivo using adapted constructs from the Consolidated Framework for Implementation Research as individual codes. Codes were thematically assessed. We point to barriers of implementing PrEP, including lack of intentional dissemination efforts and patience assistance, structural factors, including sex work, racism, and access to gender affirming health care, and lack of provider training. Finally, over 60% of articles lumped cisgender men who have sex with men with trans women. Such articles included sub-samples of transgender individuals that were not representative. We point to areas of growth for the field in this regard.

Influencing Appropriate Statin Use in a Charity Care Primary Clinic

According to the American College of Cardiology/American Heart Association (ACC/AHA) new cholesterol management guidelines in 2019, statin regimen was prescribed to only about 46.4% and 30% of diabetes (DM) patients and patients with atherosclerotic cardiovascular disease (ASCVD), respectively. Atherosclerotic cardiovascular disease accounts for most deaths and disabilities in North America. This study argues that a systematic approach to identifying targeted interventions to adhere to the statin regimen for ASCVD is sparse in previous studies. This study seeks to address the research gap. Besides, the study argues that the statin regimen could improve cholesterol management with the enablers of pharmacy, providers, electronic medical records (E.M.R.), and patients. It paves the way for future research on cardiovascular and statin regimens from different perspectives. Current study has adopted the Qualitative observation method. Accordingly, the study approached the charity care primary clinic serving a large population in the northeastern part of the United States, which constitutes the project's setting. The facility has 51 internal medicine residents. The facility has E.H.R., which is used by the clinical staff. Besides, providers use electronic medication prescribing (E-Scribe). Four PDSA cycles were run in six months. Here, the interventions were intensified during each subsequent cycle. The interventions were then incorporated into routine clinical practice. Based on the observation, the study found a 25% relative improvement by six months based on the baseline data of the appropriate intensity statin prescription for patients with ASCVD or DM by medical resident trainees in our single-center primary care clinic. A total of 77% of cardiovascular disease patients were found to be on an appropriate statin dose at baseline. On the other hand, the proportion of patients with DM who were on proper dose statin was 80.4%. According to the study's findings, PDSA could result in a faster uptake and support of the ACC/AHA guidelines. Evidence indicates that overmedication of persons at low risk and time constraints are some of the most significant impediments to the greater use of prescription medications. Proactive panel management can help improve statins' use by ensuring they are used appropriately.

Community Member and Health Care Provider Perspectives on Communication With Chinese American Patients With Cancer: A Qualitative Study

PURPOSE

Effective health care provider-patient discussions of cancer diagnoses and prognoses are essential to enhance health outcomes in oncology. Chinese Americans have been designated an underserved population in oncology by the National Institutes of Health. We explored the perspectives of Boston Chinese American community members and health care providers regarding communication preferences and decision making in oncology care.

METHODS

In this inductive, qualitative study, we conducted virtual, semi-structured interviews with 21 health care providers with experience in caring for Chinese American patients with cancer and 25 older Boston Chinatown community members who self-identify as Chinese or Chinese American. Thematic analysis was performed.

RESULTS

Two major themes were identified. First, provider communication should incorporate a gentle but truthful approach, careful word choice, authority-led style, and professionalism. Second, the family plays a large role in medical and nonmedical settings, and a family-centered approach to communication should be used.

CONCLUSION

Our study builds on and challenges current knowledge regarding oncologic communication with Chinese American patients. A focus on the improvement of provider-patient cancer communication for Chinese Americans will improve care quality and satisfaction among patients and clinicians alike and serve to decrease disparities in care.

Toolkit article: Approaches to measuring social inequities in health in human biology research

Across populations, human morbidity and mortality risks generally follow clear gradients, with socially-disadvantaged individuals and groups tending to have higher morbidity and mortality at all life stages relative to those more socially advantaged. Anthropologists specialize in understanding the proximate and ultimate factors that shape variation in human biological functioning and health and are therefore well-situated to explore the relationships between social position and health in diverse ecological and cultural contexts. While human biologists have developed sophisticated methods for assessing health using minimally-invasive methods, at a disciplinary level, we have room for conceptual and methodological improvement in how we frame, measure, and analyze the social inequities that might shape health inequities. This toolkit paper elaborates on some steps human biologists should take to enhance the quality of our research on health inequities. Specifically, we address: (1) how to frame unequal health outcomes (i.e., inequalities vs. disparities vs. inequities) and the importance of identifying our conceptual models of how these inequities emerge; (2) how to measure various axes of social inequities across diverse cultural contexts, and (3) approaches to community collaboration and dissemination. We end by discussing (4) future directions in human biology research of health inequities, including understanding the ultimate causes of sensitivity to social inequities and transitioning from research to action.

Racial/Ethnic Differences in Psychiatric and Medical Diagnoses Among Autistic Adults

Background

Racial/ethnic disparities in access to diagnostic services are pervasive for autistic children. However, a few studies have examined racial/ethnic health disparities among autistic adults, who commonly experience higher rates of health conditions than non-autistic adults. We aimed at examining the intersection of autism and race/ethnicity in association with psychiatric and medical diagnoses.

Methods

The study population included adult members of Kaiser Permanente Northern California enrolled from 2008 to 2012. We ascertained 1507 adults who had an autism diagnosis documented in their electronic medical records. We sampled a matched control group of adults without an autism diagnosis (N = 15,070) at a 10:1 ratio. Our sample was 46% White, 17% Hispanic, 16% Asian, 7% Black, and 14% other race/ethnicity. We compared health diagnoses (a) between autistic and non-autistic adults within strata of race/ethnicity and (b) across race/ethnicity within strata of autistic and non-autistic adults. Lastly, we examined the interaction between autism and race/ethnicity on both multiplicative and additive scales.

Results

Autistic adults were more likely to be diagnosed with most medical and psychiatric conditions compared with their non-autistic counterparts of the same race/ethnicity. Among autistic adults, Black, Hispanic, and Asian adults were less likely to be diagnosed with psychiatric conditions and Black and Hispanic autistic adults were more likely to be diagnosed with obesity than their White counterparts. In interaction models, we found that adults who were Black and autistic were disproportionately less likely to be diagnosed with psychiatric conditions and autoimmune disease and more likely to be diagnosed with hypertension than expected.

Conclusion

Health vulnerabilities may be compounded at the intersection of autism and race/ethnicity. Future research should continue to apply an intersectional lens toward understanding and addressing these disparities. Our findings likely underestimate the health disparities that exist in uninsured autistic adults and those living in other parts of the United States.

Adherence and Self-management Interventions among Systemically Marginalized and Underserved Youth with Asthma

Objective

Asthma disproportionately impacts youth who have been systemically marginalized and underserved, henceforth termed underserved for brevity. Disparities are driven by systemic and structural racism and social determinants of health. We aimed to synthesize findings from interventions delivered among youth who have been underserved, highlight effective intervention strategies, and provide recommendations to promote health equity. To demonstrate, we also present a case example of clinical application.

Methods

We conducted a systematic literature search of randomized trials among youth (≤18 years old) who are often underserved, delivered in clinical, community, or home-based settings with medication adherence and/or self-management behaviors as an intervention outcome. We used descriptive statistics to synthesize study characteristics and outcomes.

Results

Twenty four articles, representing 21 unique interventions, met inclusion criteria. Forty-six percent reported significant improvements in adherence or self-management for the intervention group. Self-management interventions focused on symptom recognition and monitoring demonstrated the greatest percentage of significant intervention findings (71.4%); controller medication adherence interventions demonstrated the fewest (33.3%).

Conclusions

Interventions are not consistently effective for youth who have been underserved. Findings suggest that pediatric psychologists can help patients from underserved backgrounds by bolstering symptom recognition and monitoring skills, providing self-management skill education, and problem-solving ways to reduce triggers through individually tailored, multicomponent approaches. Pediatric psychologists should simultaneously strive to consider and address systemic, structural, and social determinants of asthma disparities in their work.

Perspectives of Wisconsin Providers on Factors Influencing Receipt of Post-Mastectomy Breast Reconstruction

BACKGROUND

The objective is to determine perspectives of general surgeons, plastic surgeons, and cancer navigators on factors contributing to breast cancer patients' decision for post-mastectomy reconstruction, especially for women facing financial hardship.

METHODS

We mailed Wisconsin general and plastic surgeons who performed >5 breast cancer procedures annually a survey, including a postcard inviting cancer navigators to participate. Descriptive statistics summarize item responses. McNemar's chi-squared tests evaluated surgeons' perspectives of factors influencing reconstruction for all women compared to women facing financial hardship.

RESULTS

Respondents include 70 general surgeons, 18 plastic surgeons, and 9 navigators. Respondents perceived preference-related factors as important, including "does not want more surgery" (85% reported it important overall and 77% for financial hardship women) and "reconstructed breast is not important to her" (77% vs. 61%). Surgeons perceived logistical factors were more important for women facing financial hardship, including "capacity to be away from work or home responsibilities for recovery" (30% reported important overall and 60% for financial hardship women), "concerned about out-of-pocket costs" (26% vs. 57%), and "frequent visits to complete reconstruction too burdensome" (27% vs. 49%).

CONCLUSION

Our findings demonstrate Wisconsin surgeons and cancer navigators perceive logistical concerns influence reconstruction decisions for women facing financial hardship.

Impact of COVID-19 on a Community Health Coalition and Its Residents in Allegheny County, Pennsylvania: Insights Into Adaptation From Focus Groups and Evaluation Reports

Live Well Allegheny: Lifting Wellness for African Americans (LWA2) is a coalition in Allegheny County, Pennsylvania, funded by the Centers for Disease Control and Prevention’s (CDC) Racial and Ethnic Approaches to Community Health (REACH) initiative. LWA2 consists of partner organizations addressing chronic disease prevention in six Black communities through nutrition, physical activity, and community–clinical linkage strategies. This analysis focuses on qualitative data exploring the influence of COVID-19 on coalition functioning and communities. We conducted focus groups with residents in REACH communities and collected evaluation reports from partner organizations. Three focus groups assessed awareness of and participation in the REACH initiative, feedback, and the impact of COVID-19 when applicable. An additional focus group included questions related to flu vaccine messaging and the COVID-19 vaccine. These data sources provided insight regarding how COVID-19 affected planned tasks. Evaluation team members analyzed focus groups and collated summaries as part of a larger comprehensive evaluation. Partner organizations experienced an increase in food stamp applications, delays in opening farmers’ markets, a shift to virtual preventive health programs, canceled in-person events, and programmatic interruptions that shifted long-term goals. Community resident concerns included difficulty accessing public transportation, decreased physical activity, fear of in-person interactions, and increased wait times for mental health services. Coalition members developed methods to continue functioning and sustaining program activities. Residents were able to engage differently with chronic illness prevention techniques. Reports from the ongoing analysis will be used to adapt coalition functioning.

"When you have an immune disease like HIV and there is a pandemic, you still have to pay your bills": COVID-19-related challenges among people living with HIV and lessons for care delivery

COVID-19 has disrupted routine medical care and increased psychosocial and economic stressors on a global scale, yet the full impact on people living with HIV (PLWH) and the HIV continuum of care remains unknown. As the pandemic continues to pose a significant threat to PLWH and their care, this research qualitatively aimed to elicit COVID-19-related challenges and perspectives of PLWH during the early phase of the pandemic and to identify lessons learned and impactful strategies for facilitating HIV care. We recruited 32 PLWH who receive care at a large academic medical center for semi-structured remote interviews to assess psychological/structural stressors experienced during the pandemic and to discern strategies for improving care. Most participants identified as Black (91%) and heterosexual (56%). Overall, PLWH reported exacerbated mental health stressors (e.g., anxiety, depression, substance use). Most participants cited no issues with antiretroviral therapy (ART) adherence or retention in care, yet five participants reported appointment cancellations or physician inaccessibility. Participants provided specific feedback for facilitating continued engagement in care during the pandemic, including telemedicine and education/patient empowerment. By seeking participant-provided solutions, this study centered on PLWH's experiences and emphasized proactive HIV care strategies for prioritizing patient empowerment and healthcare adaptability during a rapidly evolving pandemic.

Conceptualisation of health inequalities by local healthcare systems: A document analysis

In 2019, local healthcare systems in England were asked to develop formal plans to reduce health inequalities. Here, we explore plans to understand how local healthcare systems conceptualise health inequalities and why. A broad Internet search and targeted search of NHS websites were conducted to identify all publicly accessible healthcare planning documents (National Health Service (NHS) Long-Term Plan (LTP) response documents) produced by local health partnerships in England. A thematic document analysis of the accessible plans was undertaken in NVivo by coding text relating to health inequalities. Of the 44 documents developed, 13 were publicly accessible. These 13 local plans were submitted to NHS England for review between September 2019 and January 2020 and averaged 167 pages (range: 41-273 pages). Only one document contained a chapter dedicated to health inequalities. After analysis, five themes were identified: (1) variation and (2) vagueness explained how health inequalities were conceptualised and (3) use of value judgements, (4) lack of prior conceptualisation and approach and (5) a lack of commitment to action in the documents to reduce health inequalities explained what led to the overall vagueness and variation. Local healthcare systems were found to conceptualise health inequalities in a vague and varying manner, and their conceptualisations did not reflect established health inequalities frameworks. A clear conceptual national framework for addressing health inequalities is needed to support local healthcare systems, so they can address health inequalities meaningfully and sustainably.

Striving Toward Equity in Health Care for People With Communication Disabilities

PURPOSE

Approximately 10% of the U.S. adult population has a speech, language, and/or voice disability, collectively referred to as communication disabilities. An increasing number of studies demonstrate that persons with communication disabilities have worse health and health care outcomes as compared to those without communication disabilities. Understanding the state of the science, including potential contributing factors is critical to begin to address the disparities.

METHOD

Applying a historical lens and integrating multiple models of disability provide a comprehensive perspective of the health and health care outcomes of persons with communication disabilities.

RESULTS

Three phases for addressing health care disparities exist: detecting, understanding, and reducing. Results from a 2012 National Health Interview Survey provide compelling population-level results of the health and health care disparities experienced by persons with communication disabilities. To understand the disparities, factors within the health care system, such as availability of communication aids and services, as well as provider and staff biases, assumptions, and lack of knowledge need to be considered. To date, few interventions exist to address disparities in care for persons with communication disabilities. Consequently, researchers need to engage with stakeholders in innovative study designs and methods to facilitate the rapid development, implementation, and dissemination of interventions that address the disparities.

CONCLUSION

To ensure equity for the large and growing population of persons with communication disabilities, researchers, policy makers, patients, and health care systems need to collaborate in identifying and addressing the factors contributing to health and health care disparities. Presentation Video: https://doi.org/10.23641/asha.21215804.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Barriers to Service Access for Immigrant Families of Children With Developmental Disabilities: A Scoping Review

This scoping review explores (a) barriers faced by immigrant families of children with intellectual and developmental disabilities (IDD) when accessing healthcare-related services in the United States, (b) where research stands based on the health disparity research framework, and (c) implications for future health disparities research with this population. Our scoping review found 26 empirical studies published between 2000 and 2020 that met our inclusion criteria. Data were extracted and synthesized based on the stages of research outlined in the health disparity research framework. Overall, immigrant families experienced barriers on multiple levels including patient, provider, and healthcare system levels. Studies focusing on detecting and reducing disparities are emerging. We conclude with recommendations for future research and practice with immigrant families of children with IDD.

Fulfillment of Desired Postpartum Permanent Contraception: a Health Disparities Issue

Women of color experience marked disparities in fulfillment of desired postpartum permanent contraception. While many attribute the disparity to the required Medicaid sterilization consent form and 30-day waiting period established in response to forced and coerced sterilizations, the policy does not entirely explain the disparity; racial and ethnic disparities persist even within strata of insurance type. We therefore propose framing postpartum permanent contraception as a health disparities issue that requires multi-level interventions to address. Based on the literature, we identify discrete levels of barriers to postpartum permanent contraception fulfillment at the patient, physician, hospital, and policy levels that interact and compound within and between individual levels, affecting each individual patient differently. At the patient level, sociodemographic characteristics such as age, race and ethnicity, and parity impact desire for and fulfillment of permanent contraception. At the physician level, implicit bias and paternalistic counseling contribute to barriers in permanent contraception fulfillment. At the hospital level, Medicaid reimbursement, operating room availability, and religious affiliation influence fulfillment of permanent contraception. Lastly, at the policy level, the Medicaid consent form and waiting period pose a known barrier to fulfillment of desired postpartum permanent contraception. Unpacking each of these discrete barriers and untangling their collective impact is necessary to eliminate racial and ethnic disparities in permanent contraception fulfillment.

Interpersonal and self-directed violence among sexual and gender minority populations: Moving research from prevalence to prevention

Purpose of review

This scoping review of reviews aimed to detail the breadth of violence research about sexual and gender minorities (SGM) in terms of the three generations of health disparities research (i.e., documenting, understanding, and reducing disparities).

Recent findings

Seventy-three reviews met inclusion criteria. Nearly 70% of the reviews for interpersonal violence and for self-directed violence were classified as first-generation studies. Critical third-generation studies were considerably scant (7% for interpersonal violence and 6% for self-directed violence).

Summary

Third-generation research to reduce or prevent violence against SGM populations must account for larger scale social environmental dynamics. Sexual orientation and gender identity (SOGI) data collection has increased in population-based health surveys, but administrative datasets (e.g., health care, social services, coroner and medical examiner offices, law enforcement) must begin including SOGI to meet the needs of scaled public health interventions to curb violence among SGM communities.

Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders

Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09-7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2-3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors.

Promoting Racial/Ethnic Equity in Psychosocial Treatment Outcomes for Child and Adolescent Anxiety and Depression

Anxiety and depression are the most prevalent and least treated pediatric mental health problems. Racial/ethnic minority youths face greater risks for developing anxiety and depression and experience higher burden as they are less likely to receive adequate mental health services for these conditions or to have their needs met. Further, standard evidence‐based interventions for youth anxiety and depression may show diminished effects with racial/ethnic minority youths and with families of lower socioeconomic status. While community‐level interventions to combat structural racism and reduce population‐level risk are sorely needed, many youths will continue to require acute treatment services for anxiety and depression and interventionists must understand how to bring equity to the forefront of care. In this review, we adopt a health system framework to examine racial/ethnic disparities in system‐, intervention‐, provider‐, and patient‐level factors for psychosocial treatment of pediatric anxiety and depression. Current evidence on disparities in access and in efficacy of psychosocial intervention for anxious and depressed youths is summarized, and we use our work in primary care as a case example of adapting an intervention to mitigate disparities and increase equity. We conclude with recommendations for disparity action targets at each level of the health system framework and provide example strategies for intervening on these mechanisms to improve the outcomes of racial/ethnic minority youths.

Racial/ethnic minority youths face greater risks for developing anxiety and depression and experience higher burden from disorder as they are less likely to receive adequate mental health services for these conditions or to have their needs met.

Increasing access to services for anxiety and depression is of critical and immediate importance for racial/ethnic minority families. Issues of access may be associated with the physical location of services (e.g., primary care or telehealth) or with barriers of language, income, or financing.

Both service settings and research treatment protocols frequently require families of ethnic/racial minority youths to fit themselves to the demands of care, in ways that may not be culturally compatible (e.g., little parent involvement in treatment) or practically feasible (i.e., weekly sessions during parent working hours). Whenever possible, non‐essential aspects of intervention should be freed to match patient preferences and constraints, and interventions for anxiety and depression should be adopted that have broad impacts and options for personalization of goals.

Healthcare professionals' experiences and perspectives of team-based interdisciplinary pain rehabilitation with immigrants requiring an interpreter. A qualitative study

PURPOSE

There is a lack of knowledge about interprofessional rehabilitation for culturally diverse patients with chronic pain. This study explores experiences of healthcare professionals developing and working with rehabilitation with patients in need of an interpreter and their experience of working with interpreters.

METHODS

Twelve healthcare professionals at two Swedish specialist rehabilitation centres were interviewed. Grounded theory principles were used for the data collection and analysis.

RESULTS

The main category "Demanding and Meaningful Work" represents three concurrently interacting categories: "Frustration" includes the informants' doubts regarding the benefits of the rehabilitation, lack of care for patients and cultural dissonance between professionals and patients. "Challenges" describes problems in the rehabilitation work due to the need for interpreted mediated communication, the complexity in health status and social aspects among the patients. "Solutions" represents practical working methods and personal approaches developed by the informants for managing frustrations and challenges.

CONCLUSIONS

The informants' frustration and challenges when working with a new group of patients, vulnerable and different in their preconceptions, led to new solutions in working methods and approaches. When starting a pain rehabilitation programme for culturally diverse patients, it is important to consider the rehabilitation team's need for additional time and support.IMPLICATIONS FOR REHABILITATIONHealthcare professionals who encounter immigrants with chronic pain need resources to develop their own skills in order to handle complex ethical questions as the patients represent a vulnerable patient group with many low status identitiesIn order to adapt rehabilitation programmes to patient groups with different languages and pre-understandings of chronic pain, there is a need for a team with specific qualities, i.e., close cooperation, an innovative atmosphere, time and also support from expertsFor appropriate language interpretation it is important to have a professional interpreter and a healthcare professional who are aware of and adopt the rules, possibilities and restrictions of interpretationThe rehabilitation of patients in need of language interpretation needs more time and organisation compared to the rehabilitation of patients who speak the national language.

Study protocol of a multiphase optimization strategy trial (MOST) for delivery of smoking cessation treatment in lung cancer screening settings

BACKGROUND

There is widespread agreement that the integration of cessation services in lung cancer screening (LCS) is essential for achieving the full benefits of LCS with low-dose computed tomography (LDCT). There is a formidable knowledge gap about how to best design feasible, effective, and scalable cessation services in LCS facilities. A collective of NCI-funded clinical trials addressing this gap is the Smoking Cessation at Lung Examination (SCALE) Collaboration.

METHODS

The Cessation and Screening to Save Lives (CASTL) trial seeks to advance knowledge about the reach, effectiveness, and implementation of tobacco treatment in lung cancer screening. We describe the rationale, design, evaluation plan, and interventions tested in this multiphase optimization strategy trial (MOST). A total of 1152 screening-eligible current smokers are being recruited from 18 LCS sites (n = 64/site) in both academic and community settings across the USA. Participants receive enhanced standard care (cessation advice and referral to the national Quitline) and are randomized to receive additional tobacco treatment components (motivational counseling, nicotine replacement patches/lozenges, message framing). The primary outcome is biochemically validated, abstinence at 6 months follow-up. Secondary outcomes are self-reported smoking abstinence, quit attempts, and smoking reduction at 3 and 6 months. Guided by the Implementation Outcomes Framework (IOF), our evaluation includes measurement of implementation processes (reach, fidelity, acceptability, appropriateness, sustainability, and cost).

CONCLUSION

We will identify effective treatment components for delivery by LCS sites. The findings will guide the assembly of an optimized smoking cessation package that achieves superior cessation outcomes. Future trials can examine the strategies for wider implementation of tobacco treatment in LDCT-LCS sites.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03315910.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

BACKGROUND

Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention.

METHODS

Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis.

DISCUSSION

This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Understanding perinatal patient's health preferences and patient-provider relationships to prevent congenital syphilis in California and Louisiana

Background

Congenital syphilis (CS) has reemerged as a global maternal and child health crisis. Kern County, California and East Baton Rouge Parish, Louisiana are among the highest CS morbidity regions in the United States. We previously reported on social-ecological and structural barriers to prenatal care and maternal syphilis testing and treatment in these two regions. The aim of this study was to examine perinatal patient’s health preferences and perceptions of patient-provider relationships in the prenatal care clinic setting.

Methods

Between May 2018 and January 2019 we conducted 20 in-depth qualitative interviews with prenatal providers and 8 focus group discussions with pregnant and postpartum individuals in Kern County and East Baton Rouge Parish. We applied an adapted health services framework to analyze participants’ understanding of health disparities and vulnerable populations; perinatal patient’s health and prenatal care preferences; and participants’ perspectives of clinical encounters in the context of prenatal care and maternal syphilis testing and treatment.

Results

Site-specific determinants of syphilis infection emerged but participants from both locations felt CS prevention efforts should be prioritized among youth, racial/ethnic minority populations, people experiencing socioeconomic limitations and people with other commonly occurring health conditions. Although perinatal patients expressed clear health preferences, they reported inconsistent receipt of respectful, patient-centered care. Inconsistencies were connected with limited ethnic and cultural competence among providers, and implicit, negative attitudes toward patients using substances, experiencing homelessness, or engaging in sex work. Providers clearly aimed to offer high quality prenatal care. However, some clinic and health systems level factors were thought to reduce positive and communicative patient-provider relationships, contributing to gaps in use of prenatal care and syphilis testing and treatment.

Conclusions

Our findings suggest that interventions tailored to address setting-specific determinants (including clinic and health system factors) of disparities in CS risk could improve pregnant people’s access to prenatal care and ensure they and their sex partners receive timely syphilis screening and treatment. We recommend all prenatal care providers receive training on how to identify and mitigate implicit biases and provide competent and compassionate patient-centered care.

Perinatal Education Participation: Description and Identification of Disparities

While perinatal education programs are designed to help nulliparous women prepare for childbirth and care of a newborn, many women in the United States do not attend such programs. This article presents partial data from a longitudinal study of 2,884 women aged 18-35 years who birthed their first child in Pennsylvania from 2009-2011. These partial data focused on women's participation in perinatal education and identify disparities in attendance. Overall, 79.1% reported attending one or more perinatal education programs. Women who were White, college educated, aged 30 years or older, and not in poverty were more likely to attend perinatal education programs. These results suggest a need for improved efforts to provide free or low-cost perinatal education to women across the socioeconomic spectrum in the U.S, especially in Pennsylvania.

Socioeconomic disparities in rates of facial fracture surgeries for women and men at a regional tertiary care centre in Australia

BACKGROUND

Assault is the most common mechanism of injury in patients presenting with facial trauma in Australia. For women, there is a propensity for maxillofacial injuries to stem from intimate partner violence (IPV). Those with a low socioeconomic status have higher rates of IPV. This study examines variations in the proportion of surgical procedures that are due to facial trauma for Australian women and men by employment status and residential socioeconomic status.

METHODS

A single centre retrospective study was conducted (2008-2018). The proportion of operative patients presenting with facial fractures was examined. Multivariable logistic regression adjusting for year and age, was performed for women and men.

RESULTS

Facial fractures comprised 1.51% (1602) of all surgeries, patients had a mean age of 32, and 81.3% were male. Unemployed patients were more likely to require surgery for a facial fracture (OR 2.36 (2.09-2.68), P <0.001), and there were no significant variations by index of economic resources (IER). Unemployed males had higher rates of facial fractures (OR 2.09 (1.82-2.39), P <0.001). Unemployed and disadvantaged IER females had higher rates of facial fractures (OR 5.02 (3.73-6.75), P <0.001 and OR 2.31(1.63-3.29), P <0.001).

CONCLUSIONS

This study found disparities in rates of surgery for facial fractures; unemployment increased the rates for men and women, whereas disadvantaged IER increased rates for women. Studies have demonstrated higher rates of IPV for unemployed and low socioeconomic status women. Further research ascertaining the aetiology of these disparities is important both for primary prevention initiatives and to enable treating clinicians to better understand and address the role of IPV and alcohol consumption in these injuries.

"They don't do anything" contextual factors influencing Turkish-Dutch individuals' perceptions of general practitioners and medical specialists in the Netherlands and Turkey

OBJECTIVE

Intercultural difficulties between GPs and patients are important contributors to health disparities. Framed in an interpretivist paradigm, this paper's thematic analysis examined how Turkish-Dutch patients' expectations of Dutch GPs may result in intercultural communication difficulties.

METHODS

Five focus group discussions were conducted with 21 participants of Turkish-Dutch background. Participants were asked to discuss perceived differences between GP-patient encounters in the Netherlands and Turkey.

RESULTS

Our study revealed that Turkish-Dutch patients regularly expect Dutch GPs to show other behavior than they perceive to obtain on two themes, 1) dealing with patients' symptoms and 2) communication. In general, Turkish-Dutch patients expect Dutch GPs to show faster, more decisive and informative behavior in diagnostics and treatment. These expectations seem based on their experiences with practitioners in Turkey and on differences between health care systems.

CONCLUSIONS

GP-patient difficulties appear primarily the result of underlying frustrations rather than clashes resulting from differences in explanatory models of illness or cultural values.

PRACTICE IMPLICATIONS

Whereas systemic differences are more difficult to alter, difficulties in the communication are more readily amenable to change. Patient-centered communication and information about the reasons for being restrictive in diagnosing and treating on symptoms could alleviate these frustrations.

Moving the Dial Toward Equity in Parkinson's Disease Clinical Research: a Review of Current Literature and Future Directions in Diversifying PD Clinical Trial Participation

PURPOSE OF REVIEW

Parkinson's disease (PD), the second most common neurodegenerative disease, has a worldwide prevalence projected at 12 million by 2040. While PD has been extensively researched, our understanding of the disease is based on research studies that include mostly participants of European descent. The lack of diversity in clinical trial enrollment has limited the generalizability of scientific discoveries in the field. Here, we discuss contributors to racial and ethnic disparities in PD clinical research enrollment, summarize recently proposed and tested interventions, and propose next steps to increase equity and representation in PD research.

RECENT FINDINGS

Enrollment in PD clinical research is vulnerable to upstream disparities and inequities from PD awareness to access to specialized PD centers. While additional research is still needed, recent studies have identified some potential strategies for increasing underrepresented minority (URM) recruitment including increasing the availability of linguistically and culturally diverse research materials and team members, partnering with community organizations, and forming relationships with URM-serving community physicians. To move the dial toward equity in PD research, it will be necessary to implement known successful strategies and further investigate additional contributors to the underrepresentation of URMs in PD clinical research while developing and testing interventions to address these factors.

"Even if I'm undetectable, I just feel like I would die": a qualitative study to understand the psychological and socioeconomic impacts of the COVID-19 pandemic on women living with HIV (WLWH) in Chicago, IL

BACKGROUND

The COVID-19 pandemic has affected the health and well-being of people worldwide, yet few studies have qualitatively examined its cumulative effects on ciswomen living with HIV (WLWH). We aimed to explore how the pandemic has impacted WLWH, including challenges related to HIV care, employment, finances, and childcare. We also investigated how HIV status and different psychosocial stressors affected their mental health.

METHODS

We performed 25 semi-structured qualitative interviews with WLWH regarding the ways in which COVID-19 impacted their social determinants of health and physical well-being during the pandemic. 19 WLWH who received care at the University of Chicago Medicine (UCM) and 6 women who received care at Howard Brown Health, a federally qualified health center (FQHC) in Chicago, were interviewed remotely from June 2020 to April 2021. All interviews were audio recorded and transcribed. Interviews were thematically analyzed for commonalities regarding HIV-specific and general experiences of WLWH during the pandemic.

RESULTS

The majority of participants reported COVID-19 impacted their HIV care, such as appointment cancellations and difficulties adhering to antiretroviral therapy. In addition to HIV care obstacles, almost all participants described perceived heightened vulnerability to or fear of COVID-19. The pandemic also affected the socioeconomic well-being of participants, with reported financial strains and employment disruptions. Some mothers took on additional childcare responsibilities, such as homeschooling. Increased mental health concerns and negative psychological effects from the social isolation associated with the pandemic were also experienced by most participants.

CONCLUSIONS

We gained invaluable insight into how WLWH were challenged by and adapted to the COVID-19 pandemic, including its destabilizing effects on their HIV care and mental health. Women described how they undertook additional childcare responsibilities during the pandemic and how their HIV status compounded their concerns (e.g., perceived heightened vulnerability to COVID-19). Strategies to better support WLWH in maintaining their overall health throughout the pandemic include childcare assistance, access to affordable mental health services, support groups, and education from HIV care providers. These findings have significant implications for examining future health crises through the perspective of potential gender inequalities.

Grounding implementation science in health equity for cancer prevention and control

BACKGROUND

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

DISCUSSION

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Effects of ethnicity and socioeconomic status on surgical outcomes from inflammatory bowel disease

PURPOSE

Evidence suggests that ethnicity and socioeconomic status of patients with chronic diseases influence their healthcare outcomes. The aim of this study was to assess the impact of these factors on the surgical outcome of patients with inflammatory bowel disease (IBD) over a 15-year period.

METHODS

A retrospective observational study investigated IBD patients operated on at an NHS Trust between 2000-2015, with follow-up data until 2020. Logistic regression models were used to determine the relationship between ethnic minority background and Index of Multiple Deprivation (IMD) on outcomes including requirement for intra-abdominal surgery, permanent stoma, re-do surgery and surgical complications, accounting for age, gender, smoking history and biologic treatment.

RESULTS

There were 1,620 patients (56.7% ulcerative colitis (UC) and 43.3% Crohn's disease (CD)). Median age was 32 years, and 49.6% were female. Patients with an ethnic minority background accounted for 20.6%. Within 5 years of first presentation, 369 patients required intra-abdominal surgery, 95 permanent stomas and 107 re-do surgery. For CD patients, younger age at diagnosis, female patients, those with an ethnic minority background, higher IMD quintile, smoking history and biologic treatment were more likely to have intra-abdominal surgery. Ethnic minority background and higher IMD score were further associated with surgical complications for CD but not UC patients.

CONCLUSION

Ethnic minority status and socioeconomic deprivation were associated with worse surgical outcomes within our cohort of IBD patients. These findings may stimulate discourse regarding the strategic planning of equitable healthcare services.

Causes of health inequities

PURPOSE OF REVIEW

A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions.

RECENT FINDINGS

Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death.

SUMMARY

Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).

Implementing a Statewide Speakers Bureau to Address Maternal Morbidity and Mortality

OBJECTIVE

To implement a speakers bureau to educate providers, health caregivers, and staff practicing within Tennessee hospitals on evidence-based practice recommendations related to opioid use disorder in pregnancy, postpartum hemorrhage, maternal hypertension, and implicit bias.

DESIGN

Quality improvement project.

SETTING/LOCAL PROBLEM

Multiple health care facilities throughout Tennessee, where rates of pregnancy-related mortality are greater than the national average and where Black women are three times as likely as White women to die of pregnancy complications.

PARTICIPANTS

Speakers (n = 47) included obstetricians, advanced practice providers, and nurses. Program attendees (n = 369) included providers and caregivers representing five health care facilities.

INTERVENTION/MEASUREMENTS

Speakers were provided standardized training to disseminate best practice methods. Current evidence-based presentations regarding the top maternal mortality concerns were formatted for educational events at five Tennessee health care facilities. Independent outcome measures using electronic survey instruments were collected for speakers and audience participants. Speakers evaluated training methods, and participants evaluated the quality and efficacy of the information provided.

RESULTS

Based on speaker evaluations, 70.59% rated the quality of training as 5 of 5, and 76.47% rated the relevance of training as 5 of 5. Overall, 16 of 17 (94.1%) speakers stated that adequate training was provided. Analysis of participant evaluations reported that 57.5% were very confident (5/5) that the information learned through the speakers bureau will improve their care of pregnant and postpartum people. Additionally, 71% were very likely (5/5) to apply the information to their practice.

CONCLUSION

This project showed the dissemination of best practices by promoting knowledge, supporting practice change, and improving retained information in maternity providers and caregiver participants. Implementation of speakers bureaus to educate providers and caregivers within health care facilities has the potential to influence practice change and decrease maternal morbidity and mortality rates in the state of Tennessee.

The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance

OBJECTIVE

To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease.

STUDY SETTING

NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma.

STUDY DESIGN

The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration.

CONCLUSIONS

The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

A national survey on adaptations by perinatal psychiatry access programs to promote perinatal mental healthcare equity

OBJECTIVE

Perinatal Psychiatry Access Programs ("Access Programs") are system-level interventions that aim to build the capacity of perinatal healthcare professionals to address mental health, and thereby improve access to perinatal mental healthcare. Access Programs are widely implemented and positioned to promote health equity in perinatal mental healthcare, but little is known about the adaptations being made to the model in response to calls to promote health equity.

METHODS

One respondent from each of the 14 Access Programs (n = 14) completed an online survey that queried on adaptations made to promote perinatal mental healthcare equity.

RESULTS

Twelve of the 14 Access Program team members (86%) indicated implementation of at least one new equity initiative. The average number of initiatives that a single Access Program implemented was 3.5 (range 0-10). Two Access Programs (14%) implemented 8.5 initiatives (range: 7-10), indicating that a small cohort is leading promotion of equity among Access Programs.

CONCLUSION

Efforts to further expand the capacity and services of Access Programs to address perinatal mental healthcare inequities are needed. These adaptations may provide a robust opportunity for implementation initiatives to promote health equity through a system-level intervention.

Moving Beyond Detection: Charting a Path to Eliminate Health Care Disparities in Otolaryngology

The coronavirus pandemic has illuminated long-standing inequities in America's health care system and societal structure. While numerous studies have identified health care disparities within our specialty, few have progressed beyond detection. Otolaryngologists have the opportunity and the responsibility to act. Within this article, leaders from otolaryngology share their experience and perspective on health care disparities, including (1) a discussion of disparities in otolaryngology, (2) a summary of health care system design and incentives, (3) an overview of implicit bias, and (4) practical recommendations for providers to advance their awareness of health care disparities and the actions to mitigate them. While the path forward can be daunting, it should not be a deterrent. Throughout the course of this article, numerous resources are provided to support these efforts. To move ahead, our specialty needs to advance our level of understanding and develop, implement, and disseminate successful interventions toward the goal of eliminating health care disparities.

Disparities in surgical outcomes for low socioeconomic status patients in Australia

Background

There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self‐reported unemployment and neighbourhood level socioeconomic status in Australia.

Methods

A retrospective administrative data review was conducted at a tertiary care centre over a 10‐year period (2008–2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed.

Results

106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50–2.82), OR 1.37 (1.15–1.64)), all complications (OR 1.43 (1.31–1.56), OR 1.21 (1.14–1.28)), failure to rescue (OR 2.03 (1.39–2.95), OR 1.38 (1.11–1.72)) and return to theatre (OR 1.42 (1.27–1.59), OR 1.24 (1.14–1.36)) (P < 0.005 for all).

Conclusions

Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

Racial and Ethnic Disparities in the Management of Postdural Puncture Headache With Epidural Blood Patch for Obstetric Patients in New York State

IMPORTANCE

Characterizing and addressing racial and ethnic disparities in peripartum pain assessment and treatment is a national priority.

OBJECTIVE

To evaluate the association of race and ethnicity with the provision and timing of an epidural blood patch (EBP) for management of postdural puncture headache in obstetric patients.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used New York State hospital discharge records from January 1, 1998, to December 31, 2016, from mothers 15 to 49 years of age with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth. Statistical analysis was performed from February 2020 to February 2022.

EXPOSURES

Patients' race and ethnicity (reported as provided by each participating hospital; the method of determining race and ethnicity [ie, self-reported or not] cannot be determined from the data) were categorized into non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other race and ethnicity (including Asian and Pacific Islander, American Indian, Alaskan Native, and other).

MAIN OUTCOMES AND MEASURES

The primary outcome was the rate of EBP use. The secondary outcome was the interval (days) between hospital admission and provision of EBP. Odds ratios (ORs) and 95% CIs of EBP use associated with race and ethnicity were estimated using mixed-effect logistic regression models, adjusting for patient and hospital characteristics.

RESULTS

During the study period, 8921 patients (mean [SD] age, 30 [6] years; 1028 [11.5%] Black; 1301 [14.6%] Hispanic; 4960 [55.6%] White; and 1359 [15.2%] other race and ethnicity) with postdural puncture headache were identified among 1.9 million deliveries with a neuraxial procedure. Of these 8921 patients, 4196 (47.0%; 95% CI, 46.0%-48.1%) were managed with an EBP. A total of 2650 White patients (53.4%; 95% CI, 52.0%-54.8%) used an EBP; this rate was significantly higher than that among Hispanic patients (41.7% [543]; 95% CI, 39.9%-44.5%), Black patients (35.7% [367]; 95% CI, 32.8%-38.7%), or patients of other race and ethnicity (35.2% [478]; 95% CI, 32.6%-37.8%). Timing of EBP was at a median of 2 days (IQR, 2-3 days) after hospital admission for White patients compared with a median of 3 days (IQR, 2-4 days) for Hispanic patients, Black patients, and patients of other race and ethnicity (P < .001 for the comparison with White patients). After adjustment for patient and hospital characteristics, the EBP rate was not different between White and Hispanic patients (adjusted OR, 1.11; 95% CI, 0.94-1.30). It was significantly lower for Black patients (adjusted OR, 0.80; 95% CI, 0.67-0.94) and patients of other races and ethnicities (adjusted OR, 0.85; 95% CI, 0.73-0.99).

CONCLUSIONS AND RELEVANCE

In this study, significant racial and ethnic disparities in the management of postdural puncture headache with EBP were observed, with both lower rates and delayed timing, which may be associated with long-term adverse effects.

Evidence-Based Medicine in Otolaryngology, Part XIII: Health Disparities Research and Advancing Health Equity

OBJECTIVE

To provide a contemporary resource for clinicians and researchers on health equity research and implementation strategies to mitigate or eliminate disparities in health care.

DATA SOURCES

Published studies and literature on health disparities, applicable research methodologies, and social determinants of health in otolaryngology.

REVIEW METHODS

Literature through October 2021 was reviewed, including consensus statements, guidelines, and scientific publications related to health care equity research. This research focus provides insights into existing disparities, why they occur, and the outcomes of interventions designed to resolve them. Progress toward equity requires intentionality in implementing quality improvement initiatives, tracking data, and fostering culturally competent care. Priority areas include improving access, removing barriers to care, and ensuring appropriate and effective treatment. Although research into health care disparities has advanced significantly in recent years, persistent knowledge gaps remain. Applying the lens of equity to data science can promote evidence-based practices and optimal strategies to reduce health inequities.

CONCLUSIONS

Health disparities research has a critical role in advancing equity in otolaryngology-head and neck surgery. The phases of disparities research include detection, understanding, and reduction of disparities. A multilevel approach is necessary for understanding disparities, and health equity extensions can improve the rigor of evidence-based data synthesis. Finally, applying an equity lens is essential when designing and evaluating health care interventions, to minimize bias.

IMPLICATIONS FOR PRACTICE

Understanding the data and practices related to disparities research may help promote an evidence-based approach to care of individual patients and populations, with the potential to eventually surmount the negative effects of health care disparities.

Disparities in opioid treatment access and retention among women based on pregnancy status from 2006 to 2017

Background:

The purpose of this study is to assess differences in wait time and retention in opioid use disorder (OUD) treatment among a sample of pregnant and non-pregnant women from low-income urban communities in Los Angeles, California.

Methods:

Data were collected in 9 waves consisting of consecutive years from 2006 to 2011, and then including 2013, 2015, and 2017. The sample consisted of 12,558 women, with 285 being pregnant and 12,273 being non-pregnant. We compared pregnant women with non-pregnant women at admission on key characteristics and relied on two multilevel negative binomial regressions analyses to examine factors related to access (days on the waiting list) and retention (days in treatment).

Results:

We detected disparities existed in access and retention. Pregnant women spent less time waiting to initate treatment than non-pregnant women and, once in treatment, had longer treatment episodes. Among pregnant women, clients identifying as Latina or Other waited longer to enter treatment compared to clients identifying as non-Latina White or Black. Women entering residential waited longer than those entering methadone or counseling services. Pregnant women were more likely to be in treatment longer if they had mental health issues, greater parenting responsibilities (number of children less than 18), and greater SUD severity (number of prior treatment episodes).

Conclusions:

Findings suggest pregnant women’s access and retention can be improved through Medicaid coverage and through the implementation of a standard of care that includes MOUD (methadone) along with ancillary health and social services.

Electronic Health Records as Biased Tools or Tools Against Bias: A Conceptual Model

Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy.

CONTEXT

Health care delivery is now inextricably linked to the use of electronic health records (EHRs), which exert considerable influence over providers, patients, and organizations.

METHODS

This article offers a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. Using structuration theory, the model demonstrates how a social structure, like an EHR, creates a cyclical relationship between the environment and people, either advancing or undermining important social values.

FINDINGS

The model illustrates how the implicit bias of individuals, both developers and end-user clinical providers, influence the platform and its associated information. Biased information can then lead to inequitable outcomes in clinical care, organizational decisions, and public policy. The biased information also influences subsequent users, amplifying their own implicit biases and potentially compounding the level of bias in the information itself. The conceptual model is used to explain how this concern is fundamentally a matter of quality. Relying on the Donabedian model, it explains how elements of the EHR design (structure), use (process), and the ends for which it is used (outcome) can first be used to evaluate where bias may become embedded in the system itself, but then also identify opportunities to resist and actively challenge bias.

CONCLUSIONS

Our conceptual model may be able to redefine and improve the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy. For EHRs to do this, further work is needed to develop measures that assess bias in structure, process, and outcome, as well as policies to persuade vendors and health systems to prioritize systemic equity as a core goal of EHRs.

A Framework for Anti-Racist Publication in Palliative Care: Structures, Processes, and Outcomes

Systemic or structural racism describes an embedded pattern of explicit and implicit racial biases that, through policy and action, systematically confer advantage to white people and disadvantage Black, indigenous, and other people of color. Hospice and palliative care journals participate in this broader system of racial discrimination. Building on palliative care's explicit focus on patients' goals and values, which may in and of itself comprise a form of social justice in healthcare, palliative care journals and their publishers have an opportunity to lead others in cultivating anti-racist practices and explicitly promoting equity. The publication life cycle of submission and solicitation, manuscript peer-review, and publication provide a framework for examining the structures, processes, and outcomes by which palliative care and other journals might address systemic racism. We describe the current academic publishing landscape, which diminishes the voices and experiences of racial and ethnic minority patients and undermines the careers of under-represented scholars. We then propose reforms that we believe will improve publication equity and quality as well as healthcare outcomes. These include an Equity in Publication checklist, solicitation of manuscripts on equity-relevant topics, promotion of scholars through editorial structures and peer review processes, and a standard Equity Rating for publications. Greater efforts to include non-dominant voices in every aspect of publication, through appropriate recognition of their scholarship and remuneration for their efforts, will drive equity in health outcomes. By pursuing an anti-racist and equity-focused publishing agenda, hospice and palliative medicine journals and their publishers have an opportunity to transform healthcare.

A Preliminary Analysis of Parent-Child Interaction Therapy Plus Natural Helper Support to Increase Treatment Access and Engagement for Low-Income Families of Color

Disparities in care for low-income children of color call for innovative culturally and linguistically responsive solutions to better engage marginalized populations in evidence-based interventions. In partnership with a community organization, the addition of natural helper support as an adjunct to Parent-Child Interaction Therapy (PCIT+NH) was examined as a strategy to increase recruitment, engagement, and retention in PCIT for families historically unreached by a university-based clinic. Natural helpers provided home-based skills practice and support for forty-two families whose parents were more racially and linguistically diverse and had lower income and lower caregiver education than the typical population served by the same program (i.e., program population). Families who received PCIT+NH had comparable or higher rates of engagement and improvements in clinical outcomes (i.e., decreased child externalizing and internalizing behaviors, increased child compliance, decreased caregiver stress, increased caregiver parenting skills) relative to the program population. Furthermore, higher doses of natural helper support were associated with higher rates on most measures of treatment engagement (i.e., treatment completion, completion of the Child Directed Interaction phase of treatment, PCIT sessions, homework in the Parent Directed Interaction phase of treatment), with the exception of homework in the Child Directed Interaction phase of treatment and overall session attendance rate. Next steps for testing the treatment engagement and clinical outcome effects of the PCIT+NH model are discussed.