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Hascher K, Jaiswal J, LoSchiavo C, Ezell J, Duffalo D, Greene RE, Cox A, Burton WM, Griffin M, John T, Grin B, Halkitis PN. Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care. J Gen Intern Med 2024; 39:2023-2032. [PMID: 38308157 PMCID: PMC11306825 DOI: 10.1007/s11606-024-08635-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 01/16/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings. OBJECTIVE To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs. DESIGN Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018. PARTICIPANTS The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City. APPROACH Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts. KEY RESULTS Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers. CONCLUSIONS SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.
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Affiliation(s)
- Kevin Hascher
- Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Jessica Jaiswal
- Department of Family and Community Medicine, University of Alabama, Birmingham School of Medicine, Birmingham, AL, 35294, USA.
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, 06510, USA.
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA.
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294, USA.
| | - Caleb LoSchiavo
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, 08854, USA
| | - Jerel Ezell
- Department of Community Health Sciences, UC Berkeley, Berkeley, CA, 94720, USA
- Center for Cultural Humility, UC Berkeley, Berkeley, CA, 94720, USA
| | - Danika Duffalo
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Richard E Greene
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, 10001, USA
| | - Amanda Cox
- Culverhouse College of Business, University of Alabama, Tuscaloosa, AL, USA
| | - Wanda M Burton
- Capstone College of Nursing, University of Alabama, Tuscaloosa, AL, 35401, USA
| | - Marybec Griffin
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, 08854, USA
| | - Tejossy John
- Department of Family and Community Medicine, University of Alabama, Birmingham School of Medicine, Birmingham, AL, 35294, USA
| | - Benjamin Grin
- Department of Primary Care, Kansas City University College of Osteopathic Medicine, Kansas City, MO, 64106, USA
| | - Perry N Halkitis
- Center for Health, Identity, Behavior and Prevention Studies (CHIBPS), Rutgers School of Public Health, Newark, NJ, 07102, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, 08854, USA
- Department of Urban-Global Public Health, Rutgers School of Public Health, Newark, NJ, 07102, USA
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Ben-Zacharia AB, Smrtka J, Kalina JT, Vignos M, Smith S. Shared decision-making in underserved populations with multiple sclerosis: A systematic review. Mult Scler Relat Disord 2024; 90:105792. [PMID: 39121597 DOI: 10.1016/j.msard.2024.105792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/23/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND The concept of shared decision-making (SDM) is valuable to ensure patients receive individualized care. SDM occurs when healthcare providers engage patients in making personal healthcare decisions that could contribute to better long-term outcomes. With the ever-increasing landscape of treatment options available, SDM can be challenging but valuable for patients. Patients from underserved populations are potentially less likely to engage in SDM, impacting their long-term care. This systematic literature review aimed to explore SDM in these patient populations. METHODS Relevant articles were retrieved from PubMed using key search terms, without any restriction on publication date. All searches and data retrieval were conducted between May 25, 2022, and August 17, 2022, and abstracts were reviewed by two independent reviewers. A thematic analysis was used to present the data. RESULTS All search terms yielded 418 articles; 89 were included (33 involving patients with multiple sclerosis [MS]). Reported mean percentage of patients with MS (including from underserved populations) who preferred SDM was 52 % (range: 37.5-71.5; n = 4). Differences in racial/ethnic assimilation of information communicated by clinicians were reported, impacted by the lower literacy level and certain cultural health beliefs in groups of underserved populations. Primary care clinicians play a key role in providing information to patients in underserved populations. CONCLUSIONS There is a clear benefit for SDM for patients with MS, and without it, patients report dissatisfaction, decisional regret, and lack of confidence in the medical system. However, there are several challenges, including the need for further examination of social determinants of health, for underserved patient populations which still need to be addressed.
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Affiliation(s)
- Aliza Bitton Ben-Zacharia
- Hunter Bellevue School of Nursing and Mount Sinai Hospital; Hunter Bellevue School of Nursing, 425 E 25th St, New York, NY 10010, USA; Mount Sinai, 146 East 126 Street, New York, NY 10035, USA.
| | - Jen Smrtka
- Biogen, 225 Binney St, Cambridge, MA 02142, USA
| | | | | | - Stacyann Smith
- Judith Jaffe Multiple Sclerosis Center, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, USA
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Garvelink M, Mahboubian A, de Weerdt O, van der Nat P. MMpowerment: Empowering patients with multiple myeloma for shared decision-making by developing an intervention to integrate personal preferences into digital care pathways. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024; 187:53-60. [PMID: 38789345 DOI: 10.1016/j.zefq.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 03/12/2024] [Accepted: 04/27/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE As part of a quality improvement initiative in the context of value-based health care we aimed to optimize the shared decision-making (SDM) process in the care pathway for Multiple Myeloma as part of a digital care pathway (DCP). For this, more insight was needed in health care professionals' (HCPs') perspectives on SDM, and how SDM elements could be addressed in a DCP for MM to facilitate HCPs' performance of SDM. METHODS HCPs were interviewed as per the theory of planned behaviour and the model of organizational context and SDM (phase 1). Multidisciplinary development sessions were organized to discuss concepts of the solution with HCPs (phase 2). The solution was evaluated with two patients from the quality improvement team. RESULTS In phase 1, ten interviews were held. HCPs' attitudes and the subjective norm towards SDM were positive, and the intention to perform SDM was high. The clinical environment (physical context, disease characteristics, assumptions about patient characteristics, and workflows) for MM posed challenges on the actual SDM behavior. Education and use of the DCP to create awareness of SDM were seen as possible facilitators for SDM. A prepared and active patient would facilitate the SDM process. In phase 2, three concept solutions were developed before arriving at the final solution. The final solution consisted of three elements to incorporate SDM steps in the DCP: 1) creating patient awareness and activation with two questions about their preferences prior to a consultation, 2) visualisation of preferences centrally in the DCP to trigger HCP to discuss them, 3) monitoring and improving SDM with patient-questionnaires after decision-making. Patients and HCPs were willing to implement it. CONCLUSION HCPs intention to engage in SDM was high, but their actual behaviour was challenged by the clinical environment. A 3-element DCP-based intervention was developed to increase SDM. PATIENT OR PUBLIC CONTRIBUTION Input on the solution was obtained from end-users including two patients and ten healthcare professionals.
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Affiliation(s)
- Mirjam Garvelink
- Department of value-based healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands; IQ Health, RadboudUMC, Nijmegen, the Netherlands.
| | - Atena Mahboubian
- Department of value-based healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands; Vrije Universiteit Amsterdam, the Netherlands
| | - Okke de Weerdt
- Department of Internal medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Paul van der Nat
- Department of value-based healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands; IQ Health, RadboudUMC, Nijmegen, the Netherlands
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Morris SM, Gunter KE, Jia JL, Baig AA. Factors Influencing Shared Decision-Making Between Healthcare Providers and Lesbian, Gay, Bisexual, Transgender, and Queer People of Color About Intimate Partner Violence. JOURNAL OF INTERPERSONAL VIOLENCE 2024:8862605241248434. [PMID: 38666658 DOI: 10.1177/08862605241248434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Within the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, people of color (POC) disproportionately experience intimate partner violence (IPV). While shared decision-making (SDM)-a model of patient-provider communication-about IPV could benefit LGBTQ POC, its unique challenges merit consideration. This study identifies key factors affecting SDM between LGBTQ POC and healthcare providers surrounding IPV. LGBTQ POC participants (n = 217) in Chicago and San Francisco completed surveys about demographic information, healthcare utilization, and IPV history. Individual interviews and focus groups were then conducted with a Chicago-based subset of participants (n = 46) who identified as LGBTQ IPV survivors of color. Descriptive analyses were conducted of survey responses while focus group and interview transcripts were analyzed and thematically coded. Although 71% of survey participants experienced IPV, only 35% were asked about IPV in healthcare interactions within the previous year. Focus group and interview participants endorsed encounter-, patient-, and provider-centered factors affecting SDM around IPV. When IPV was discussed, patient-provider trust was essential while concordance of identities could either encourage or discourage IPV disclosure. Patients were hesitant to disclose IPV if they had never discussed their LGBTQ identity with their provider or thought providers would ignore their preferences for addressing IPV. Deterrents to SDM included providers denying the prevalence of IPV among LGBTQ individuals or lacking resources to support LGBTQ IPV survivors of color. This study highlights the identity-driven barriers that LGBTQ POC face in discussing IPV with providers. Utilizing SDM to discuss IPV with LGBTQ POC can better address the diverse health needs of this community. However, its success requires that providers acknowledge the diversity of experiences among this population, promote LGBTQ-inclusive practices, and identify resources welcome to LGBTQ POC.
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Seiger KW, McNamara B, Berrahou IK. Gynecologic Care for Sexual and Gender Minority Patients. Obstet Gynecol Clin North Am 2024; 51:17-41. [PMID: 38267126 DOI: 10.1016/j.ogc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Sexual and gender minority (SGM) people, including lesbian, gay, bisexual, transgender, and queer individuals, are a diverse population with a wide spectrum of gynecologic needs. Institutionalized cisheteronormativity, stigmatization, lack of provider training, and fear of discrimination contribute to health disparities in this patient population. In this article, we review key topics in the gynecologic care of SGM patients and provide strategies to enable gynecologists to provide SGM people with equitable and inclusive full spectrum reproductive health care.
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Affiliation(s)
- Kyra W Seiger
- Yale University School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
| | - Blair McNamara
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Iman K Berrahou
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, PO Box 208063, Suite 302 FMB, New Haven, CT 06520-806, USA.
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Noh M, Hughto JMW, Austin SB, Goldman RE, Potter J, Agénor M. Promoting equitable sexual health communication among patients with minoritized racial/ethnic, sexual orientation, and gender identities: Strategies, challenges, and opportunities. Soc Sci Med 2024; 344:116634. [PMID: 38394863 PMCID: PMC10947744 DOI: 10.1016/j.socscimed.2024.116634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/15/2023] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
People assigned female at birth (AFAB) with minoritized racial/ethnic, sexual orientation, and gender identities experience notable barriers to high-quality sexual healthcare. In confronting these barriers, patient-provider communication can be a crucial factor, influencing patients' experiences and access to relevant sexual health information and services by determining the quality of care. However, research that investigates this communication among AFAB patients with minoritized social positions is scarce, indicating a research gap regarding the perspectives and roles of healthcare providers in addressing such barriers to care for minoritized patients. Thus, we conducted a qualitative research study, using individual in-depth interviews, to explore the multi-level factors that influence providers' attitudes, knowledge, and skills regarding sexual health communication with AFAB patients with minoritized racial/ethnic, sexual orientation, and gender identities. Interpreting study findings within frameworks of person-centered care, intersectionality, and structural competency, we identified three cross-cutting themes. We found that providers frequently drew on their prior professional training, personal lived experiences, and population-level health disparities data when engaging in sexual health communication with minoritized AFAB patients. Participants reported minimal explicit training in anti-racist and lesbian, gay, bisexual, transgender, and queer (LGBTQ+)-competent care as a significant barrier to engaging in equitable sexual health communication with minoritized AFAB patients, which was exacerbated by many providers' lack of shared social positions and lived experiences with these patients. Providers also frequently applied population-level data to individual patients when formulating counseling and recommendations, which may undermine person-centered sexual health communication. Our findings suggest that critical anti-racist and LGBTQ+-competent provider training is urgently needed, and that health professional education and institutions must be transformed to better reflect and consider the experiences of patients with minoritized racial/ethnic, sexual orientation, and gender identities.
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Affiliation(s)
- Madeline Noh
- Department of Behavioral and Social Sciences, Brown University School of Public Health, USA; Center for Health Promotion and Health Equity, Brown University School of Public Health, USA.
| | - Jaclyn M W Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, USA; Center for Health Promotion and Health Equity, Brown University School of Public Health, USA; Department of Epidemiology, Brown University School of Public Health, USA; The Fenway Institute, Fenway Health, USA
| | - S Bryn Austin
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, USA; Department of Pediatrics, Harvard Medical School, USA; Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, USA
| | - Roberta E Goldman
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, USA; Warren Alpert Medical School, Brown University, USA
| | - Jennifer Potter
- The Fenway Institute, Fenway Health, USA; Department of Medicine, Harvard Medical School, USA; Division of General Medicine, Beth Israel Lahey Health, USA
| | - Madina Agénor
- Department of Behavioral and Social Sciences, Brown University School of Public Health, USA; Center for Health Promotion and Health Equity, Brown University School of Public Health, USA; Department of Epidemiology, Brown University School of Public Health, USA; The Fenway Institute, Fenway Health, USA
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Mehta TS, Thompson J, Applegate JM, Wahab RA. Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers. JOURNAL OF BREAST IMAGING 2023; 5:473-479. [PMID: 38416897 DOI: 10.1093/jbi/wbad012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Indexed: 03/01/2024]
Abstract
The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.
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Affiliation(s)
- Tejas S Mehta
- UMass Memorial Medical Center, Department of Radiology, Worcester, MA, USA
| | | | - Julia M Applegate
- The Ohio State University, Department of Women's, Gender and Sexuality Studies, Columbus, OH, USA
| | - Rifat A Wahab
- University of Cincinnati Medical Center, Department of Radiology, Cincinnati, OH, USA
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Rivera AS, Plank M, Davis A, Feinstein MJ, Rusie LK, Beach LB. Assessing widening disparities in HbA1c and systolic blood pressure retesting during the COVID-19 pandemic in an LGBTQ+-focused federally qualified health center in Chicago: a retrospective cohort study using electronic health records. BMJ Open Diabetes Res Care 2022; 10:10/6/e002990. [PMID: 36593660 PMCID: PMC9748509 DOI: 10.1136/bmjdrc-2022-002990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION To assess disparities in retesting for glycated hemoglobin (HbA1c) and systolic blood pressure (SBP) among people with diabetes mellitus (DM) and hypertension (HTN), respectively, we analyzed medical records from a lesbian, gay, bisexual, transgender, queer-specialized federally qualified health center with multiple sites in Chicago. RESEARCH DESIGN AND METHODS We identified people with DM seen in 2018 and 2019 then assessed if individuals had HbA1c retested the following year (2019 and 2020). We repeated this using SBP for people with HTN. Rates of retesting were compared across gender, sexual orientation, and race and ethnicity and across the 2 years for each categorization with adjustment for socioeconomic indicators. RESULTS Retesting rates declined from 2019 to 2020 for both HbA1c and SBP overall and across all groups. Cisgender women and transgender men with DM (vs cisgender men) and straight people (vs gay men) had significantly lower odds of HbA1c retesting for both years. There was evidence of widening of HbA1c retesting disparities in 2020 between gay men and other orientations. Cisgender women, straight people, and black people (vs white) with HTN had significantly lower odds of SBP retesting for both years. There was evidence of narrowing in the retesting gap between black and white people with HTN, but this was due to disproportionate increase in no retesting in white people rather than a decline in no retesting among black people with HTN. CONCLUSIONS Disparities in DM and HTN care according to gender, race, ethnicity, and sexual orientation persisted during the pandemic with significant widening according to sexual orientation.
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Affiliation(s)
- Adovich S Rivera
- Center for Education in Health Sciences, Institute for Public Health and Management, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Megan Plank
- Data, Evaluation, and Epidemiology, Howard Brown Health Center, Chicago, Illinois, USA
| | - Ash Davis
- Data, Evaluation, and Epidemiology, Howard Brown Health Center, Chicago, Illinois, USA
| | - Matthew J Feinstein
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura K Rusie
- Data, Evaluation, and Epidemiology, Howard Brown Health Center, Chicago, Illinois, USA
| | - Lauren B Beach
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern UniversityFeinberg School of Medicine, Chicago, IL, USA
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Chauhan A, Newman B, Walpola RL, Seale H, Manias E, Wilson C, Harrison R. Assessing the environment for engagement in health services: The Audit for Consumer Engagement (ACE) tool. Health Expect 2022; 25:3027-3039. [DOI: 10.1111/hex.13610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/07/2022] [Accepted: 09/10/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ashfaq Chauhan
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences Macquarie University North Ryde New South Wales Australia
| | - Bronwyn Newman
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences Macquarie University North Ryde New South Wales Australia
| | - Ramesh Lahiru Walpola
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney Kensington New South Wales Australia
| | - Holly Seale
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney Kensington New South Wales Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation Deakin University Melbourne Victoria Australia
| | - Carlene Wilson
- Olivia Newton‐John Cancer Wellness and Research Centre Austin Health Heidelberg Victoria Australia
- School of Psychology and Public Health La Trobe University Bundoora Victoria Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences Macquarie University North Ryde New South Wales Australia
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Reich AJ, Perez S, Fleming J, Gazarian P, Manful A, Ladin K, Tjia J, Semco R, Prigerson H, Weissman JS, Candrian C. Advance Care Planning Experiences Among Sexual and Gender Minority People. JAMA Netw Open 2022; 5:e2222993. [PMID: 35857322 PMCID: PMC9301514 DOI: 10.1001/jamanetworkopen.2022.22993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Advance care planning (ACP) can promote patient-centered end-of-life (EOL) care and is intended to ensure that medical treatments are aligned with patient's values. Sexual and gender minority (SGM) people face greater discrimination in health care settings compared with heterosexual, cisgender people, but it is unknown whether such discrimination occurs in ACP and how it might affect the ACP experiences of SGM people. OBJECTIVES To increase understanding of barriers and facilitators of ACP facing SGM individuals. DESIGN, SETTING, AND PARTICIPANTS This mixed-methods national study of ACP included a telephone survey of self-identified SGM and non-SGM participants in a nationally representative sample drawn from a larger omnibus national panel by SSRS. Qualitative interviews were conducted with a subset of survey participants who identified as SGM. Data were collected from October 2020 to March 2021. EXPOSURES Self-identified SGM. MAIN OUTCOMES AND MEASURES The survey included 4 items from the validated ACP Engagement Survey, adapted to capture experiences of discrimination. Interviews asked about participants' experiences with ACP, including the appointment of medical decision-makers, sharing preferences, and experiences within the health care system more broadly. RESULTS A total of 603 adults participated in the survey, with 201 SGM individuals (mean [SD] age, 45.7 [18.7] years; 101 [50.2%] female; 22 [10.9%] Black, 37 [18.4%] Hispanic, and 140 [69.7%] White individuals) and 402 non-SGM individuals (mean [SD] age, 53.7 [19.2] years; 199 [49.5%] female; 35 [8.7%] Black, 41 [10.2%] Hispanic, and 324 [80.6%] White individuals). Regarding reasons for not completing ACP, SGM respondents, compared with non-SGM respondents, were more likely to say "I don't see the need" (72 [73.5%] vs 131 [57.2%], P = .006) and "I feel discriminated against by others" (12 [12.2%] vs 6 [2.6%], P < .001). Of 25 completed interviews among SGM participants, 3 main themes were identified: how fear and experiences of discrimination affect selection of clinicians and whether to disclose SGM identity; concerns about whether EOL preferences and medical decision-makers would be supported; and a preference to discuss EOL decisions and values outside of clinical settings. CONCLUSIONS AND RELEVANCE This study found that fear of disclosing sexual orientation or gender identity information and discrimination are important barriers to ACP for SGM in clinical settings, but discussions of preferences and values still occur between many SGM people and medical decision-makers. More SGM-specific patient-centered care might better support these discussions within the health care system. Furthermore, health systems can facilitate improved engagement by supporting clinician sensitivity training, including guidance on documentation and requirements.
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Affiliation(s)
- Amanda Jane Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephen Perez
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | | | | | - Keren Ladin
- Department of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Jennifer Tjia
- University of Massachusetts School of Medicine, Worcester
| | | | - Holly Prigerson
- Center for Research on End-of-Life Care, Weill Cornell School of Medicine, New York City, New York
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Carey Candrian
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
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Zubizarreta D, Beccia AL, Trinh MH, Reynolds CA, Reisner SL, Charlton BM. Human papillomavirus vaccination disparities among U.S. college students: An intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA). Soc Sci Med 2022; 301:114871. [PMID: 35344774 DOI: 10.1016/j.socscimed.2022.114871] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/24/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
Abstract
We investigated how gender identity, sexual orientation, and race/ethnicity intersect to shape the social epidemiology of HPV vaccination initiation among U.S. college students. Cross-sectional survey data were from the National College Health Assessment (Fall, 2019-Spring, 2020; N = 65,047). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy by nesting participants within 36 social strata defined using gender identity, sexual orientation, and race/ethnicity. Bayesian multilevel logistic regression models with random intercepts for social strata were fit for HPV vaccination initiation. Intersectional models adjusted for the additive main effects to isolate intersectional interactions, controlling for age and geographic region. Social strata that included cisgender men, transgender women, and non-binary assigned-male-at-birth individuals and strata that included racial/ethnic minorities had a significantly lower likelihood of HPV vaccination initiation relative to strata including cisgender women and non-Hispanic White individuals, respectively, while strata including lesbian/gay and bisexual/pansexual/queer individuals had a significantly higher likelihood of HPV vaccination initiation relative to strata including heterosexual individuals. We also observed substantial between-stratum inequities in the predicted prevalence of HPV vaccination initiation, with estimates ranging from 59.2% for heterosexual, racial/ethnic minority, cisgender men to 87.1% for bisexual/pansexual/queer, racial/ethnic minority, non-binary assigned-female-at-birth individuals. That being said, the majority of the observed between-stratum variance was driven by additive rather than intersectional interaction effects and the discriminatory accuracy of intersectional stratification with respect to predicting HPV vaccination initiation was low. Collectively, our findings point to a need for more universal guidelines and clinician recommendations that promote HPV vaccine uptake for all adolescents, regardless of race/ethnicity, gender identity, sex-assigned-at-birth, or sexual orientation; however, utilizing an intersectional lens will ensure that resulting public health interventions address inequities and center the needs and experiences of multiply marginalized adolescents.
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Affiliation(s)
- Dougie Zubizarreta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Ariel L Beccia
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Mai-Han Trinh
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Colleen A Reynolds
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sari L Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Brittany M Charlton
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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12
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Agénor M, Geffen SR, Zubizarreta D, Jones R, Giraldo S, McGuirk A, Caballero M, Gordon AR. Experiences of and resistance to multiple discrimination in health care settings among transmasculine people of color. BMC Health Serv Res 2022; 22:369. [PMID: 35307008 PMCID: PMC8935683 DOI: 10.1186/s12913-022-07729-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/03/2022] [Indexed: 12/09/2023] Open
Abstract
BACKGROUND Research shows that transmasculine people experience discrimination based on their gender identity and/or expression (i.e., cissexism) while obtaining health care. However, studies examining the experience of other forms of discrimination in health care settings among diverse subgroups of transmasculine individuals, including those from minoritized racial/ethnic backgrounds, are very limited. METHODS Guided by intersectionality, we designed a qualitative research study to explore how transmasculine people of color experience-and resist-multiple, intersecting forms of discrimination in health care settings. Guided by a purposive sampling strategy, we selected 19 transmasculine young adults of color aged 18-25 years to participate in 5 mini-focus groups conducted between February and May 2019 in Boston, MA. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook. Coded text fragments pertaining to participants' experiences of health care discrimination were clustered into themes and sub-themes. RESULTS Transmasculine people of color described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. Further, participants discussed anticipating and experiencing multiple forms of interpersonal discrimination-both independently and simultaneously-in health care settings, including cissexism, racism, weight-based discrimination, and ableism. Moreover, participants described the negative impact of anticipating and experiencing multiple interpersonal health care discrimination on their health care utilization, quality of care, and mental and physical health. Lastly, participants discussed using various strategies to resist the multiple, intersecting forms of discrimination they encounter in health care settings, including setting boundaries with health care providers, seeking care from competent providers with shared social positions, engaging in self-advocacy, drawing on peer support during health care visits, and obtaining health information through their social networks. DISCUSSION Efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general to advance the health of transmasculine people of color and other multiply marginalized groups.
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Affiliation(s)
- Madina Agénor
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, USA.
- The Fenway Institute, Fenway Health, Boston, MA, USA.
| | - Sophia R Geffen
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Center for Health Equity Education and Advocacy, Cambridge Health Alliance, Cambridge, MA, USA
| | - Dougie Zubizarreta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Raquel Jones
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA
| | - Shane Giraldo
- Department of Sociology, Simmons University, Boston, MA, USA
- Youth Community Advisory Board, Tufts University, Medford, MA, USA
| | - Allison McGuirk
- Department of Counseling Psychology, University of Wisconsin Madison, Madison, WI, USA
| | - Mateo Caballero
- Youth Community Advisory Board, Tufts University, Medford, MA, USA
- Department of Communication Studies, Northeastern University, Boston, MA, USA
| | - Allegra R Gordon
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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13
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A Content Analysis of Osteopaths’ Attitudes for a More Inclusive Clinical Practice towards Transgender People. Healthcare (Basel) 2022; 10:healthcare10030562. [PMID: 35327040 PMCID: PMC8953530 DOI: 10.3390/healthcare10030562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/21/2022] [Accepted: 03/15/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives. The aim of this qualitative study was to explore the attitudes, beliefs, and preferences of Italian osteopaths regarding the management of transgender patients through a content analysis of emergent data from semi-structured interviews. Methods. This study was a content analysis based on the Standards for Reporting Qualitative Research guidelines. Purposive sampling of 10 Italian osteopaths was applied. Data were collected through semi-structured interviews, from March to April 2021, and subsequently transcribed verbatim with the content analysis carried out as an iterative process. Results. One participant was excluded during the first interview due to them being unsuitable for this study. Data saturation was reached after two interviews with the remaining nine participants. Data analysis revealed four main themes: microaggressions, acceptance and non-judgement, person-centered treatment, and education implementation. Conclusions. This study presents cisgender Italian osteopaths’ attitudes in the care of transgender people, revealing the desire to embrace and apply osteopathic tenets regardless of the patient’s gender identity.
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14
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Pérez AE, Agénor M. Racial/Ethnic and Sexual Orientation Identity Differences in the Receipt of a Sexual History Assessment from a Health Care Provider among Women in the United States. Womens Health Issues 2022; 32:156-164. [PMID: 34924267 DOI: 10.1016/j.whi.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Differential sexual history assessment, whereby certain groups are more or less likely to be asked questions about their sexual behavior by a health care provider, may lead to differential sexual health care and counseling. METHODS Using nationally representative data from the 2013 through 2019 waves of the National Survey of Family Growth, we examined racial/ethnic and sexual orientation identity differences in receiving a sexual history assessment from a health care provider in the last 12 months among U.S. women aged 15-44 years (N = 14,019). RESULTS Adjusting for survey wave, Black and Latina heterosexual women; White, Black, and Latina bisexual women; and Black or Latina lesbian women had higher odds (odds ratio range, 1.47 [Latina heterosexual] to 2.71 [Black bisexual]) of having received a sexual history assessment in the last 12 months compared with White heterosexual women. All differences except for those among Black or Latina lesbian women persisted after controlling for demographic, socioeconomic, and health care factors (odds ratio range, 1.43 [Latina heterosexual] to 2.14 [Black bisexual]). Of note, Black bisexual women, about whom providers may hold biased assumptions of promiscuity rooted in both racism and biphobia, had the highest predicted probability of being asked about their sexual behavior by a provider. CONCLUSIONS Person-centered, structurally competent, and anti-oppressive practices and programs aimed at combating bias, stigma, and discrimination in the health care system and facilitating an inclusive clinic environment for all patients are needed to address differences in the provision of sexual health services and promote sexual health equity.
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Affiliation(s)
- Ashley E Pérez
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California.
| | - Madina Agénor
- Department of Behavioral and Social Sciences, Brown University, Providence, Rhode Island
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15
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Agénor M, Zubizarreta D, Geffen S, Ramanayake N, Giraldo S, McGuirk A, Caballero M, Bond K. "Making a Way Out of No Way:" Understanding the Sexual and Reproductive Health Care Experiences of Transmasculine Young Adults of Color in the United States. QUALITATIVE HEALTH RESEARCH 2022; 32:121-134. [PMID: 34851198 PMCID: PMC10921419 DOI: 10.1177/10497323211050051] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Research focusing on the specific and unique sexual and reproductive health care experiences of transmasculine young adults of color are extremely scarce. We conducted five focus group discussions with 19 Black, Latinx, Asian, Native, and other transmasculine individuals of color aged 18-25 years in the greater Boston area. Using thematic analysis, we found that transmasculine young adults of color experienced cissexism, heterosexism, and racism in accessing and utilizing sexual and reproductive health services. These multiple forms of discrimination undermined participants' receipt of high-quality sexual and reproductive health information and care from competent health care providers who shared their lived experiences. Participants relied on support from their lesbian, gay, bisexual, transgender, and queer peers to obtain needed sexual and reproductive health resources and minimize harm during clinical encounters. Multilevel interventions are needed to promote access to person-centered and structurally competent sexual and reproductive health care among transmasculine young adults of color.
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Affiliation(s)
- Madina Agénor
- Department of Behavioral and Social Sciences, 174610Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Center for Health Promotion and Health Equity, Brown University School of Public Health, , Providence, RI, USA
| | - Dougie Zubizarreta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sophia Geffen
- 15851Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | - Shane Giraldo
- Department of Sociology, 1849Simmons University, Boston, MA, USA
| | - Allison McGuirk
- Department of Counseling Psychology, 1810University of Wisconsin at Madison, Madison, WI, USA
| | - Mateo Caballero
- Department of Communication Studies, 1848Northeastern University, Boston, MA, USA
| | - Keosha Bond
- Department of Community Health and Social Medicine, City University of New York School of Medicine, New York, NY, USA
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16
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Baker AM, Jahn JL, Tan AS, Katz-Wise SL, Viswanath K, Bishop RA, Agénor M. Sexual Health Information Sources, Needs, and Preferences of Young Adult Sexual Minority Cisgender Women and Non-Binary Individuals Assigned Female at Birth. SEXUALITY RESEARCH & SOCIAL POLICY : JOURNAL OF NSRC : SR & SP 2021; 18:775-787. [PMID: 34484461 PMCID: PMC8414874 DOI: 10.1007/s13178-020-00501-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 06/13/2023]
Abstract
BACKGROUND Young adult sexual minority women (SMW) have unique sexual health needs and higher rates of some poor sexual health outcomes compared to their heterosexual peers. Unequal access to relevant sexual health information may contribute to sexual orientation disparities in sexual health among women, but research on sexual health communication among SMW is sparse. METHODS In-depth interviews conducted in 2016-2017 investigated sexual health communication in a sample of 29 racially/ethnically diverse cisgender women and non-binary individuals assigned female at birth who were between 19 and 36 years of age and identified as a sexual minority. Data were analyzed using a thematic analysis approach that involved inductive and deductive coding to identify themes. RESULTS Three broad themes were identified: 1) sources of sexual health information; 2) sexual health information needs; and 3) preferences for sexual health information delivery. Participants discussed and critiqued the Internet, other mass media, health care providers, school-based sex education, family, and peers/partners as sources of sexual health information. Participants expressed a need for customized, non-heteronormative information pertaining to sexually transmitted infection risk and prevention. They preferred receiving information from health care providers, the Internet, and other mass media, and some also suggested school-based sex education and peer education as methods for delivering information. CONCLUSIONS Participants expressed clear desires for relevant, high-quality sexual health information delivered through a variety of channels, especially the Internet, other mass media, and health care providers. POLICY IMPLICATIONS Findings call for policies that improve provision of sexual health information through health care providers, online resources, and school-based sex education.
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Affiliation(s)
- Allison M. Baker
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jaquelyn L. Jahn
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andy S.L. Tan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabra L. Katz-Wise
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kasisomayajula Viswanath
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachel A. Bishop
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Executive Office of Health & Human Services, Commonwealth of Massachusetts, Boston, MA, USA
| | - Madina Agénor
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Community Health, Tufts University, Medford, MA, USA
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
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17
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Ghabowen IK, Bhandari N. Concordance and Patient-Centered Care in Medicaid Enrollees' Care Experience With Providers. J Patient Exp 2021; 8:23743735211034028. [PMID: 34350339 PMCID: PMC8295960 DOI: 10.1177/23743735211034028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patient-centered care is at the nexus of several overlapping institutional reforms to improve health care system performance. However, we know little regarding Medicaid patients' experience with their doctors along several key dimensions of patient-centered care, and how their experience compares with Medicare and privately insured patients. We studied 4 outcomes using the 2017 National Health Interview Survey: patient-provider concordance on racial/sexual/cultural identity, respectful provider attitude, solicitation of patient opinion/beliefs during the care encounter, and patient-centered communication (PCC). The primary independent variable was Medicaid enrollee status. We dichotomized responses and ran multivariate logistic regressions for each type of care experience outcome, controlling for sociodemographic factors, health care access, and health care utilization of respondents. Compared to Medicare and privately insured enrollees, Medicaid enrollees reported much lower odds of seeing providers who treated them with respect (OR = 1.91, P < .001; OR = 1.62, P < .01) and who offered PCC (OR = 1.35, P < .05; OR = 1.35, P < .01), but similar odds of seeing concordant providers (OR = 0.78, P = .96; OR = 0.96, P = .72). Importantly, Medicaid enrollees reported higher odds of seeing providers who solicited their opinion/beliefs/preferences than their Medicare or privately insured counterparts (OR = 0.82, P < .05; OR = 0.87 P < .10). Medicaid enrollees report less patient-centered experiences in some important facets of their provider interaction than their Medicare or privately insured counterparts. Federal, state, and local policies and practices directed at improving these facets of patient-provider interaction are needed and should be aimed squarely at Medicaid providers, especially those working in geographic areas and settings with a disproportionate number of racial, gender, cultural, and linguistic minorities.
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Affiliation(s)
| | - Neeraj Bhandari
- University of Nevada Las Vegas, School of Public Health, Las Vegas, NV, USA
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18
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Clark BA, Virani A, Marshall SK, Saewyc EM. Conditions for shared decision making in the care of transgender youth in Canada. Health Promot Int 2021; 36:570-580. [PMID: 32596730 DOI: 10.1093/heapro/daaa043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Information is lacking on the role shared decision making plays in the care of transgender (trans) youth. This qualitative, descriptive study explored how trans youth, parents and health care providers engaged or did not engage in shared decision-making practices around hormone therapy initiation and what conditions supported shared decision-making approaches in clinical practice. Semi-structured interviews were conducted with 47 participants in British Columbia, Canada, and analyzed using a constructivist grounded theory approach. While formal shared decision-making models were not used in practice, many participants described elements of such approaches when asked about their health care decision-making processes. Others described health care interactions that were not conducive to a shared decision-making approach. The key finding that emerged through this analysis was a set of five conditions for supporting shared decision making when making decisions surrounding initiation of hormone therapy with trans youth. Both supportive relationships and open communication were necessary among participants to support shared decision making. All parties needed to agree regarding what decisions were to be made and what role each person would play in the process. Finally, adequate time was needed for decision-making processes to unfold. When stakeholders meet these five conditions, a gender-affirming and culturally safer shared decision-making approach may be used to support decision making about gender-affirming care. Implications for clinical practice and future research are discussed.
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Affiliation(s)
- Beth A Clark
- School of Nursing, The University of British Columbia, T222-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
| | - Alice Virani
- Ethics Service, Provincial Health Services Authority, Department of Medical Genetics, 4480 Oak Street, Vancouver, BC V6H 3N1, Canada
| | - Sheila K Marshall
- School of Social Work, The University of British Columbia, 2080 West Mall, Room 336, Vancouver, BC V6T 1Z2, Canada
| | - Elizabeth M Saewyc
- School of Nursing, The University of British Columbia, T222-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
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19
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Pachankis JE, Clark KA, Jackson SD, Pereira K, Levine D. Current Capacity and Future Implementation of Mental Health Services in U.S. LGBTQ Community Centers. Psychiatr Serv 2021; 72:669-676. [PMID: 33882684 PMCID: PMC10374348 DOI: 10.1176/appi.ps.202000575] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Since the beginning of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) rights movement, LGBTQ community centers have been on the front lines of mental health care for sexual and gender minorities (SGMs) across the United States. However, little is known about what types of mental health services LGBTQ community centers currently offer and their anticipated future needs, including training in and delivery of evidence-based practice. METHODS Sixty executive directors and chief executive officers of LGBTQ community centers across the United States completed a survey regarding their centers' current treatment capacity, format, and type as well as perceived future needs. Survey items were supplemented with qualitative questions about perceived barriers to and facilitators of strengthening the capacity of mental health services. RESULTS Center directors perceived a high need for mental health care in their communities and strove to meet that need despite constrained resources. About half of the centers (52%) reported having fewer than five mental health staff; still, most reported providing support groups (98%) and individual psychotherapy (85%). Most centers (88%) reported providing general evidence-based care, such as cognitive-behavioral therapy (62%), and all reported high support for their staff to receive training in more specific types of evidence-based, LGBTQ-affirmative care. CONCLUSIONS LGBTQ community centers continue to play an important role in supporting the mental health of SGMs. The centers also offer a significant opportunity to lead the way in addressing the substantial unmet mental health needs still facing this population by implementing evidence-based, LGBTQ-affirmative practice through efficient and cost-effective service delivery.
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Affiliation(s)
- John E Pachankis
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Pachankis, Clark, Jackson, Pereira); CenterLink, The Community of LGBT Centers, Ft. Lauderdale, Florida (Levine)
| | - Kirsty A Clark
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Pachankis, Clark, Jackson, Pereira); CenterLink, The Community of LGBT Centers, Ft. Lauderdale, Florida (Levine)
| | - Skyler D Jackson
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Pachankis, Clark, Jackson, Pereira); CenterLink, The Community of LGBT Centers, Ft. Lauderdale, Florida (Levine)
| | - Kobe Pereira
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Pachankis, Clark, Jackson, Pereira); CenterLink, The Community of LGBT Centers, Ft. Lauderdale, Florida (Levine)
| | - Deborah Levine
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Pachankis, Clark, Jackson, Pereira); CenterLink, The Community of LGBT Centers, Ft. Lauderdale, Florida (Levine)
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20
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Peek ME, Vela MB, Chin MH. Practical Lessons for Teaching About Race and Racism: Successfully Leading Free, Frank, and Fearless Discussions. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:S139-S144. [PMID: 32889939 DOI: 10.1097/acm.0000000000003710] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Successfully teaching about race and racism requires a careful balance of emotional safety and honest truth-telling. Creating such environments where all learners can thrive and grow together is a challenge, but a consistently doable one. This article describes 12 lessons learned within 4 main themes: ground rules; language and communication; concepts of social constructs, intersectionality, and bidirectional biases; and structural racism, solutions, and advocacy. The authors' recommendations for how to successfully teach health professions students about race and racism come from their collective experience of over 60 years of instruction, research, and practice. Proficiency in discussing race and addressing racism will become increasingly relevant as health care institutions strive to address the social needs of patients (e.g., food insecurity, housing instability) that contribute to poor health and are largely driven by structural inequities. Having interprofessional team-based care, with teams better able to understand and counteract their own biases, will be critical to addressing the social and structural determinants of health for marginalized patients. Recognizing that implicit biases about race impact both patients and health professions students from underrepresented racial/ethnic backgrounds is a critical step toward building robust curricula about race and health equity that will improve the learning environment for trainees and reduce health disparities.
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Affiliation(s)
- Monica E Peek
- M.E. Peek is associate professor of medicine, Section of General Internal Medicine, member, Center for the Study of Race, Politics and Culture, and associate director, Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, Illinois
| | - Monica B Vela
- M.B. Vela is professor of medicine, Section of General Internal Medicine, member, Center for the Study of Race, Politics and Culture, and associate dean, Multicultural Affairs, The University of Chicago, Chicago, Illinois
| | - Marshall H Chin
- M.H. Chin is Richard Parrillo Family Professor of Healthcare Ethics, Department of Medicine, and director, Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, Illinois
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21
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Naal H, Abboud S, Harfoush O, Mahmoud H. Examining the Attitudes and Behaviors of Health-care Providers Toward LGBT Patients in Lebanon. JOURNAL OF HOMOSEXUALITY 2020; 67:1902-1919. [PMID: 31125288 DOI: 10.1080/00918369.2019.1616431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The present cross-sectional descriptive study examined the attitudes and behaviors of health-care providers toward LGBT patients in Lebanon. Participants (N = 141) generally showed positive attitudes and behaviors toward LGBT patients. Mental health providers were significantly less likely to believe that homosexuality is a mental health disorder or that it is unnatural to identify with a gender identity other than one's biological sex when compared to non-mental health providers. Mental health providers were also more likely to be willing to address transgender people by their gender pronouns, and to believe that homosexuality is a natural variation on the sexual orientation spectrum when compared to non-mental health providers. Findings show favorable attitudes and behaviors of health-care providers toward LGBT individuals when compared to previous investigations in Lebanon. Implications on the educational, research, and policy levels are discussed.
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Affiliation(s)
- Hady Naal
- Department of Psychology, Haigazian University , Beirut, Lebanon
- Lebanese Medical Association for Sexual Health , Beirut, Lebanon
| | - Sarah Abboud
- Lebanese Medical Association for Sexual Health , Beirut, Lebanon
- College of Nursing, University of Illinois at Chicago , Chicago, Illinois, USA
| | - Omar Harfoush
- Lebanese Medical Association for Sexual Health , Beirut, Lebanon
- Department of Internal Medicine, Medstar Health Internal Medicine Residency Program , Baltimore, Maryland, USA
| | - Hossam Mahmoud
- Department of Psychiatry, Tufts University School of Medicine , Boston, Massachusetts, USA
- Regroup Therapy , Chicago, Illinois, USA
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22
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Bi S, Vela MB, Nathan AG, Gunter KE, Cook SC, López FY, Nocon RS, Chin MH. Teaching Intersectionality of Sexual Orientation, Gender Identity, and Race/Ethnicity in a Health Disparities Course. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10970. [PMID: 32754634 PMCID: PMC7394350 DOI: 10.15766/mep_2374-8265.10970] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/28/2020] [Indexed: 05/30/2023]
Abstract
Introduction Intersectionality considers how different identities simultaneously affect an individual's experiences. Those of multiple minority statuses may experience effects of intersecting systems of oppression. Most health disparities curricula do not focus on intersectionality. We studied the impact of an innovative module teaching intersectionality of sexual orientation, gender identity, and race/ethnicity issues in the required Pritzker School of Medicine course Health Care Disparities: Equity and Advocacy. Methods A short lecture reviewed sexual and gender minority (SGM) health disparities, intersectionality, minority stress, and shared decision making (SDM) to establish shared language among 83 first-year medical students. Students then viewed four videos of SGM patients of color (POC) describing their health care experiences, each followed by moderated discussion about how compounded minority stress affects lived experiences and health and how to improve SDM for SGM POC. One video interviewee attended the session and answered students' questions. Evaluation was performed using pre- and postsurveys. Results Feeling somewhat/completely confident in defining intersectionality increased from 57% to 96%. Prior to the session, 62% of respondents reported feeling somewhat/completely confident in identifying barriers to care for SGM patients, and 92% after. Thirty-three percent felt somewhat/completely confident in asking SGM patients about their identities before the session, and 81% after. Eighty-four percent rated the session as very good or excellent. Discussion The session was well received, improved student knowledge of intersectionality, and improved confidence in communicating with and caring for SGM patients. Future iterations could include condensing the lecture and including a patient panel and/or small-group discussion.
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Affiliation(s)
- Stephanie Bi
- Student, University of Chicago Pritzker School of Medicine
| | - Monica B. Vela
- Professor, Department of Medicine, University of Chicago; Associate Dean for Multicultural Affairs, University of Chicago Pritzker School of Medicine
| | - Aviva G. Nathan
- Senior Research Project Manager, Department of Medicine, University of Chicago
| | | | - Scott C. Cook
- Clinical Psychologist, Department of Medicine, University of Chicago
| | - Fanny Y. López
- Project Manager, Office of Diversity, Equity and Inclusion, Dominican University; Adjunct Instructor, Office of Diversity, Equity and Inclusion, Dominican University
| | - Robert S. Nocon
- Senior Health Services Researcher, Department of Medicine, University of Chicago
| | - Marshall H. Chin
- Richard Parrillo Family Professor of Healthcare Ethics, Department of Medicine, University of Chicago
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Schuller KA, Crawford RP. Impact of interpersonal client–provider relationship on satisfaction with mental healthcare among the LGBTQ+ population. J Ment Health 2020; 31:634-641. [DOI: 10.1080/09638237.2020.1793126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Agénor M, Pérez AE, Tabaac AR, Bond KT, Charlton BM, Bowen DJ, Austin SB. Sexual Orientation Identity Disparities in Mammography Among White, Black, and Latina U.S. Women. LGBT Health 2020; 7:312-320. [PMID: 32668184 PMCID: PMC7475089 DOI: 10.1089/lgbt.2020.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose: Our goal was to examine sexual orientation identity disparities in mammography in relationship to race/ethnicity among U.S. women. Methods: Using nationally representative 2013-2017 National Health Interview Survey data, we used multivariable logistic regression to estimate the odds of receiving a mammogram in the past year in relationship to sexual orientation identity among White, Black, and Latina U.S. women 40-75 years of age (N = 45,031) separately, adjusting for demographic factors. We also assessed whether socioeconomic and health care factors attenuated sexual orientation identity disparities in mammography across racial/ethnic groups. Results: Among White women, bisexual women had significantly lower adjusted odds of mammography compared to heterosexual women (odds ratio = 0.70, 95% confidence interval: 0.50-0.99). Among Black women, the adjusted odds of mammography were significantly higher among bisexual women relative to heterosexual women (2.53, 1.08-5.92). Black lesbian women appeared to have lower adjusted odds of mammography compared to their heterosexual counterparts; however, this difference was not statistically significant (0.80, 0.46-1.38). Similarly, among Latina women, lesbian women also seemed to have lower adjusted odds of mammography relative to heterosexual women, but this disparity was also not statistically significant (0.64, 0.37-1.13). Adding socioeconomic factors completely attenuated the disparity between White bisexual and heterosexual women (0.76, 0.52-1.10). Conclusions: Sexual orientation identity disparities in receiving a mammogram in the past year differed in relationship to race/ethnicity among White, Black, and Latina U.S. women. Additional research with larger samples of Black and Latina lesbian and bisexual women is needed to more accurately estimate and explain observed differences.
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Affiliation(s)
- Madina Agénor
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ashley E. Pérez
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Ariella R. Tabaac
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Keosha T. Bond
- Department of Public Health, New York Medical College, Valhalla, New York, USA
| | - Brittany M. Charlton
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Deborah J. Bowen
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - S. Bryn Austin
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Agénor M. A Reproductive Justice Approach to Patient-Centered, Structurally Competent Contraceptive Care Among Diverse Sexual Minority US Women. Am J Public Health 2019; 109:1626-1627. [PMID: 31693413 PMCID: PMC6836799 DOI: 10.2105/ajph.2019.305382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Madina Agénor
- Madina Agénor is Gerald R. Gill Assistant Professor of Race, Culture, and Society in the Department of Community Health at Tufts University, Medford, MA
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Bi S, Gunter KE, Lopez FY, Anam S, Tan JY, Polin DJ, Jia JL, Xu LJ, Laiteerapong N, Pho MT, Kim KE, Chin MH. Improving Shared Decision Making For Asian American Pacific Islander Sexual and Gender Minorities. Med Care 2019; 57:937-944. [PMID: 31567862 PMCID: PMC7135924 DOI: 10.1097/mlr.0000000000001212] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Asian American Pacific Islander (AAPI) sexual and gender minorities (SGM) face unique challenges in mental health and accessing high-quality health care. OBJECTIVE The objective of this study was to identify barriers and facilitators for shared decision making (SDM) between AAPI SGM and providers, especially surrounding mental health. RESEARCH DESIGN Interviews, focus groups, and surveys. SUBJECTS AAPI SGM interviewees in Chicago (n=20) and San Francisco (n=20). Two focus groups (n=10) in San Francisco. MEASURES Participants were asked open-ended questions about their health care experiences and how their identities impacted these encounters. Follow-up probes explored SDM and mental health. Participants were also surveyed about attitudes towards SGM disclosure and preferences about providers. Transcripts were analyzed for themes and a conceptual model was developed. RESULTS Our conceptual model elucidates the patient, provider, and encounter-centered factors that feed into SDM for AAPI SGM. Some participants shared the stigma of SGM identities and mental health in their AAPI families. Their AAPI and SGM identities were intertwined in affecting mental health. Some providers inappropriately controlled the visibility of the patient's identities, ignoring or overemphasizing them. Participants varied on whether they preferred a provider of the same race, and how prominently their AAPI and/or SGM identities affected SDM. CONCLUSIONS Providers should understand identity-specific challenges for AAPI SGM to engage in SDM. Providers should self-educate about AAPI and SGM history and intracommunity heterogeneity before the encounter, create a safe environment conducive to patient disclosure of SGM identity, and ask questions about patient priorities for the visit, pronouns, and mental health.
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Affiliation(s)
- Stephanie Bi
- Pritzker School of Medicine, University of Chicago, Chicago, IL
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Kathryn E. Gunter
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | | | - Seeba Anam
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL
| | - Judy Y. Tan
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Danielle J. Polin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Justin L. Jia
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Lucy J. Xu
- Pritzker School of Medicine, University of Chicago, Chicago, IL
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Mai T. Pho
- Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
| | - Karen E. Kim
- Section of Gastroenterology, Hepatology, Nutrition and Center for Asian Health Equity, University of Chicago, Chicago, IL
| | - Marshall H. Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
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Nassif AG. Heterogeneity and centrality of “dark personality” within teams, shared leadership, and team performance: A conceptual moderated-mediation model. HUMAN RESOURCE MANAGEMENT REVIEW 2019. [DOI: 10.1016/j.hrmr.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Lesbian, Gay, Bisexual, and Transgender (LGBT) patients face significant dermatologic health disparities. LGBT patients are often discriminated against, refused healthcare, or otherwise have negative healthcare experiences that may deter future utilization of professional care. While a number of factors may mitigate these negative experiences, the present article focuses on improving organizational and institutional drivers specific to individual dermatology clinics. Clinic workflow and operations, emerging technologies and EHRs, clinic culture, clinic environment and resource availability, and provider and staff education are all characteristics of healthcare clinics that can be improved to better facilitate high-quality dermatologic care for LGBT patients.
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Affiliation(s)
- Justin L Jia
- Department of Dermatology, Stanford University School of Medicine, 455 Broadway Street, MC 8843, Redwood City, CA 94063, USA
| | - Danielle J Polin
- Department of Dermatology, Stanford University School of Medicine, 455 Broadway Street, MC 8843, Redwood City, CA 94063, USA
| | - Kavita Y Sarin
- Department of Dermatology, Stanford University School of Medicine, 455 Broadway Street, MC 8843, Redwood City, CA 94063, USA.
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MacCarthy S, Barreras JL, Mendoza-Graf A, Galvan F, Linnemayr S. Strategies for Improving Mobile Technology-Based HIV Prevention Interventions With Latino Men Who Have Sex With Men and Latina Transgender Women. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:407-420. [PMID: 31550198 PMCID: PMC9207815 DOI: 10.1521/aeap.2019.31.5.407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Mobile technology-based interventions show promise for conveying HIV prevention information to Latino men who have sex with men (LMSM) and Latina transgender women (LTGW); however, implementing such interventions can pose serious challenges. To understand how to adapt existing interventions for these populations, we conducted nine focus groups (N = 91 participants, 52 LMSM, 39 LTGW) in Los Angeles, California. We used a rapid assessment process to create narrative reports that we examined using thematic analysis to explore differences across sites and between LMSM and LTGW. Lessons learned: requiring smartphone use could diminish participation of poor participants; sending personalized messages on the same days and times can help participants anticipate receiving study information; working with community partners is essential for building trust; recognizing different language literacies and diverse countries of origin can improve the cultural competency of intervention materials. Addressing these challenges may enhance efforts to address the HIV prevention needs of these communities.
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Affiliation(s)
- Sarah MacCarthy
- Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California
| | | | | | - Frank Galvan
- Bienestar Human Services, Inc., Los Angeles, California
| | - Sebastian Linnemayr
- Economics, Sociology, and Statistics, RAND Corporation, Santa Monica, California
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Healthcare Experiences of Transgender People of Color. J Gen Intern Med 2019; 34:2068-2074. [PMID: 31385209 PMCID: PMC6816758 DOI: 10.1007/s11606-019-05179-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 12/11/2018] [Accepted: 04/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Transgender people and racial/ethnic minorities separately report poor healthcare experiences. However, little is known about the healthcare experiences of transgender people of color (TPOC), who are both transgender and racial/ethnic minorities. OBJECTIVE To investigate how TPOC healthcare experiences are shaped by both race/ethnicity and gender identity. DESIGN AND PARTICIPANTS Semi-structured, in-depth individual interviews (n = 22) and focus groups (2; n = 17 total); all taken from a sample of TPOC from the Chicago area. All participants completed a quantitative survey (n = 39). APPROACH Interviews and focus groups covered healthcare experiences, and how these were shaped by gender identity and/or race/ethnicity. The interviews and focus groups were audio recorded, transcribed verbatim, and imported into HyperRESEARCH software. At least two reviewers independently coded each transcript using a codebook of themes created following grounded theory methodology. The quantitative survey data captured participants' demographics and past healthcare experiences, and were analyzed with descriptive statistics. KEY RESULTS All participants described healthcare experiences where providers responded negatively to their race/ethnicity and/or gender identity. A majority of participants believed they would be treated better if they were cisgender or white. Participants commonly cited providers' assumptions about TPOC as a pivotal factor in negative experiences. A majority of participants sought out healthcare locations designated as lesbian, gay, bisexual, and transgender (LGBT)-friendly in an effort to avoid discrimination, but feared experiencing racism there. A minority of participants expressed a preference for providers of color; but a few reported reluctance to reveal their gender identity to providers of their own race due to fear of transphobia. When describing positive healthcare experiences, participants were most likely to highlight providers' respect for their gender identity. CONCLUSIONS TPOC have different experiences compared with white transgender or cisgender racial/ethnic minorities. Providers must improve understanding of intersectional experiences of TPOC to improve quality of care.
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Fix GM, Hyde JK, Bolton RE, Parker VA, Dvorin K, Wu J, Skolnik AA, McInnes DK, Midboe AM, Asch SM, Gifford AL, Bokhour BG. The moral discourse of HIV providers within their organizational context: An ethnographic case study. PATIENT EDUCATION AND COUNSELING 2018; 101:2226-2232. [PMID: 30131263 PMCID: PMC7819576 DOI: 10.1016/j.pec.2018.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. METHODS Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. RESULTS We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges. CONCLUSIONS AND PRACTICE IMPLICATIONS When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Justeen K Hyde
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Brandeis University, The Heller School for Social Policy and Management, Waltham, MA, USA
| | - Victoria A Parker
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Peter T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - Juliet Wu
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - Avy A Skolnik
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto, CA, USA; Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Moore CL, Kaplan SL. A Framework and Resources for Shared Decision Making: Opportunities for Improved Physical Therapy Outcomes. Phys Ther 2018; 98:1022-1036. [PMID: 30452721 DOI: 10.1093/ptj/pzy095] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 08/09/2018] [Indexed: 02/09/2023]
Abstract
Shared decision making (SDM) is a collaborative approach between clinicians and patients, where the best available evidence is integrated with patients' values and preferences for managing their health problems. Shared decision making may enhance patient-centered care and increase patients' satisfaction, engagement, adherence, and ability to self-manage their conditions. Despite its potential benefits, SDM is underutilized by physical therapists, and frequent mismatches between patients' and therapists' rehabilitation goals have been reported. Physical therapists can use evidence-based strategies, tools, and techniques to address these problems. This paper presents a model for SDM and explains its association with improved patient outcomes and relevance to situations commonly encountered in physical therapy. It describes freely available resources, including health literacy universal precautions, teach-back, motivational interviewing, decision aids, and patient-reported outcome measures that can help physical therapists integrate SDM into their clinical practices. This paper also explains SDM facilitators and barriers, suggests a theoretical framework to address them, and highlights the need for SDM promotion within physical therapy practice, education, administration, and research.
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Affiliation(s)
- Cindy L Moore
- Holy Redeemer HomeCare, 160 E 9th Ave, Runnemede, NJ 08708 (USA)
| | - Sandra L Kaplan
- Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey
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Pérez-Stable EJ, El-Toukhy S. Communicating with diverse patients: How patient and clinician factors affect disparities. PATIENT EDUCATION AND COUNSELING 2018; 101:2186-2194. [PMID: 30146407 PMCID: PMC6417094 DOI: 10.1016/j.pec.2018.08.021] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 05/09/2023]
Abstract
OBJECTIVE Patient-clinician communication (PCC) may generate or reduce healthcare disparities. This paper is based on the 2017 International Conference on Communication in Healthcare keynote address and reviews PCC literature as a research area for the National Institute on Minority Health and Health Disparities (NIMHD). METHODS A narrative review of selected evidence on disparities in PCC experienced by race and ethnic minorities, associations between PCC and poor health outcomes, and patient and clinician factors related to PCC. RESULTS Factors associated with poor quality PCC on the patient level include being a member of racial/ethnic minority, having limited English proficiency, and low health and digital literacy; on the clinician level, being less culturally competent, lacking communication skills to facilitate shared decision-making, and holding unconscious biases. Recommendations include offering patient- and/or clinician-targeted interventions to guard against unconscious biases and improve PCC, screening patients for health literacy and English proficiency, integrating PCC in performance processes, and leveraging health information technologies to address unconscious biases. CONCLUSION EffectivePCC is a pathway to decrease health disparities and promote health equity. PRACTICE IMPLICATIONS Standardized collection of social determinants of health in the Electronic Health Record is an importantfirst step in promoting more effective PCC.
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Affiliation(s)
- Eliseo J Pérez-Stable
- National Institute on Minority Health and Health Disparities, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Sherine El-Toukhy
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, USA.
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Goldhammer H, Maston ED, Kissock LA, Davis JA, Keuroghlian AS. National Findings from an LGBT Healthcare Organizational Needs Assessment. LGBT Health 2018; 5:461-468. [PMID: 30383473 DOI: 10.1089/lgbt.2018.0118] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE LGBT populations require expanded access to healthcare that meets their unique needs. This article presents the primary findings of a training and technical assistance needs assessment conducted with healthcare organizations in geographically diverse areas of the United States to help determine gaps in LGBT health familiarity, preparedness, comfort, and practices. METHODS A total of 5980 staff members and 638 leaders from 18 healthcare organizations participated in online needs assessment surveys. Cross-sectional findings and significance were evaluated using descriptive statistics and two-sample t-tests. RESULTS Significantly more clinicians agreed that they were familiar with lesbian, gay, and bisexual health needs compared with being familiar with transgender health needs (81.7% vs. 68.3%, p = 0.005). The majority of clinicians rarely or never talked to their patients about sexual orientation (55.4%) or gender identity (71.9%), mostly due to believing that the topics were not relevant to care, concerns with making the patient uncomfortable or offending the patient, lack of experience, and not knowing the appropriate language for talking about the subjects. Nearly one-third of staff respondents did not know if sexual orientation or gender identity/expression was included in organizational nondiscrimination patient policies. CONCLUSION Although clinicians may self-report that they are familiar with LGBT health issues, gaps in practice and knowledge indicate the need for more training, especially in transgender health and in talking to patients about sexual orientation and gender identity. Healthcare organizations also need support in ensuring that their organizations create inclusive environments by educating staff and leadership on nondiscrimination policies.
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Affiliation(s)
- Hilary Goldhammer
- 1 National LGBT Health Education Center at The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Essence D Maston
- 1 National LGBT Health Education Center at The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Laura A Kissock
- 1 National LGBT Health Education Center at The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - John A Davis
- 2 Division of Infectious Diseases, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Alex S Keuroghlian
- 1 National LGBT Health Education Center at The Fenway Institute, Fenway Health, Boston, Massachusetts.,3 Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,4 Harvard Medical School, Boston, Massachusetts
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Physician–patient shared decision making in the treatment of primary immunodeficiency: an interview-based survey of immunologists. LYMPHOSIGN JOURNAL 2018. [DOI: 10.14785/lymphosign-2018-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Patient–physician shared decision making (SDM) can result in better care as well as reduced treatment costs. A better understanding of the factors predicting when physicians implement SDM during the treatment of primary immunodeficiency (PID) could provide insight for making recommendations to improve outcomes and reduce healthcare costs in PID and other long-term chronic conditions. Method: This study made use of grounded theory and was based on the interview responses of 15 immunologists in the United States. It focused on their decision making in the diagnosis and treatment of PID, how they interact with patients, and the circumstances under which they encourage SDM with patients. Results: All invited immunologists took part in the interviews and were included in the study. All but one had 10 or more years of experience in treating PID. The study found that SDM is bounded/limited by “nudging” bias, power balance considerations, and consideration of patient health literacy alignment. Immunologists also reported that they were mainly responsible for coordinating care and for allowing sufficient time for consultations. Conclusion: SDM occurs between the physician and patient throughout the treatment of PID. The study also shows the ways physicians influence SDM by guiding patients through the process. Statement of novelty: Little is known about the factors that influence SDM in the long-term management of chronic diseases. The present study investigated the extent to which immunologists experienced in the treatment of patients with PID include SDM in clinical practice. Findings such of these may be of use when formulating treatment guidelines and improving the effectiveness of long-term management of PID.
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Werbrouck A, Swinnen E, Kerckhofs E, Buyl R, Beckwée D, De Wit L. How to empower patients? A systematic review and meta-analysis. Transl Behav Med 2018; 8:660-674. [DOI: 10.1093/tbm/iby064] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Amber Werbrouck
- Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Rehabilitation Research (RERE), Vrije Universiteit Brussel, Brussel, Belgium
| | - Eva Swinnen
- Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Rehabilitation Research (RERE), Vrije Universiteit Brussel, Brussel, Belgium
| | - Eric Kerckhofs
- Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Rehabilitation Research (RERE), Vrije Universiteit Brussel, Brussel, Belgium
| | - Ronald Buyl
- Department of Biostatistics and Medical Informatics, Vrije Universiteit Brussel, Brussel, Belgium
| | - David Beckwée
- Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Rehabilitation Research (RERE), Vrije Universiteit Brussel, Brussel, Belgium
- Frailty in Ageing Research Department, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Liesbet De Wit
- Department of Public Health, Vrije Universiteit Brussel, Brussel, Belgium
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Agénor M, Pérez AE, Peitzmeier SM, Potter J, Borrero S. Human Papillomavirus Vaccination Initiation Among Sexual Orientation Identity and Racial/Ethnic Subgroups of Black and White U.S. Women and Girls: An Intersectional Analysis. J Womens Health (Larchmt) 2018; 27:1349-1358. [PMID: 29957092 DOI: 10.1089/jwh.2017.6768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Human papillomavirus (HPV) vaccination, which is recommended for U.S. women and girls aged 11-26 years, effectively prevents cervical cancer. Researchers have identified HPV vaccination disparities among groups of women and girls defined in relation to sexual orientation identity or race/ethnicity. However, no study has used an intersectional approach to ascertain HPV vaccine uptake among sexual orientation identity and racial/ethnic subgroups of U.S. women and girls. METHODS Using 2011-2015 National Survey of Family Growth data, we used multivariable logistic regression to estimate differences in the odds of HPV vaccination initiation (i.e., ≥ one dose) across sexual orientation identity and racial/ethnic subgroups of black and white U.S. women aged 15-24 years (N = 2,413), adjusting for demographic factors. We also assessed whether socioeconomic and health care factors helped explain observed disparities. RESULTS The overall prevalence of HPV vaccination initiation was 47.7%. Compared to white heterosexual women, black lesbians (odds ratio [OR] = 0.16; 95% confidence interval [95% CI]: 0.06-0.46) had the lowest adjusted odds of HPV vaccination initiation, followed by white lesbians (OR = 0.33; 95% CI: 0.13-0.82) and black heterosexual women (OR = 0.63; 0.47-0.85). Including socioeconomic factors in the model only slightly attenuated the HPV vaccination initiation odds ratios for black lesbians (OR = 0.19; 95% CI: 0.06-0.56), white lesbians (OR = 0.37; 95% CI: 0.15-0.90), and black heterosexual women (OR = 0.70; 95% CI: 0.52-0.93) compared to white heterosexual women. Adding health care factors only slightly additionally attenuated the odds ratio comparing black lesbians and white heterosexual women (OR = 0.21; 95% CI: 0.07-0.67). CONCLUSIONS Our findings identified black lesbians as a particularly underserved subgroup and suggest that sexual orientation identity and race/ethnicity may have a compounding effect on HPV vaccination initiation among black and white U.S. women and girls. Evidence-based interventions that are adapted to the specific needs and experiences of black lesbians and other multiply marginalized groups are needed to promote equity in HPV-related outcomes.
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Affiliation(s)
- Madina Agénor
- 1 Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health , Boston, Massachusetts
| | - Ashley E Pérez
- 2 Department of Social and Behavioral Sciences, University of California San Francisco School of Nursing , San Francisco, California
| | - Sarah M Peitzmeier
- 3 Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing , Ann Arbor, Michigan
| | - Jennifer Potter
- 4 Department of Medicine, Harvard Medical School , Boston, Massachusetts.,5 Division of General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Sonya Borrero
- 6 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,7 Center for Health Equity Research and Promotion , VA Pittsburgh Health care System, Pittsburgh, Pennsylvania
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High Stakes for the Health of Sexual and Gender Minority Patients of Color. J Gen Intern Med 2017; 32:1390-1395. [PMID: 28798997 PMCID: PMC5698216 DOI: 10.1007/s11606-017-4138-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 05/09/2017] [Accepted: 07/07/2017] [Indexed: 12/19/2022]
Abstract
As clinicians, educators, and researchers, our ability to provide the best possible care to our patients who are sexual and gender minority (SGM) people of color is increasingly challenged. Relative to the general population, SGM patients often have worse health outcomes, and among SGM patients, racial and ethnic minorities are particularly vulnerable. Healthcare policies proposed by the current administration, along with an increasingly hostile and dangerous social climate, have the potential to seriously harm SGM patients of color. In this paper, we discuss these key policy issues impacting the health of SGM patients of color. We then suggest questions for clinicians to consider to help them decide which advocacy activities are right for them, recommending self-examination, skills development, and political action. We end by outlining concrete, actionable steps to advocate for SGM patients of color in patient care, healthcare organizations, medical education, research, and public policy.
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Butler PD, Familusi O, Serletti JM, Fox JP. Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates. Am J Surg 2017; 215:987-994. [PMID: 29103529 DOI: 10.1016/j.amjsurg.2017.09.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study evaluates the rates of immediate breast reconstruction (IBR) among racial and insurance status subgroups, in the setting of a changing plastic surgeon workforce. METHODS Using state level inpatient and ambulatory surgery data, we identified discharges for adult women who underwent mastectomy for breast cancer. This information was supplemented with plastic surgeon workforce data and aggregated to the health service area-level (HSA). Hierarchical linear models were used to risk standardized IBR rates for 8 race-payer subgroups. RESULTS The final cohort included 65,246 women treated across 67 HSAs. The plastic surgeon density per 100,000 population directly related to the IBR rate. While all subgroups saw a modest increase in IBR rates, Caucasian women with private insurance realized the largest absolute increase (46%) while African-American and Asian women with public insurance saw the smallest increase (6%). CONCLUSION Significant disparities persist in the provision of IBR according to the form of insurance a patient possesses. Of heightened concern is the novel finding that even within privately insured patients, women of color have significantly lower IBR rates compared to Caucasian women.
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Affiliation(s)
- Paris D Butler
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Olatomide Familusi
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Justin P Fox
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Chin MH. Movement Advocacy, Personal Relationships, and Ending Health Care Disparities. J Natl Med Assoc 2016; 109:33-35. [PMID: 28259213 DOI: 10.1016/j.jnma.2016.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/01/2016] [Accepted: 11/10/2016] [Indexed: 12/29/2022]
Abstract
Deep-rooted structural problems drive health care disparities. Compounding the difficulty of attaining health equity, solutions in clinics and hospitals require the cooperation of clinicians, administrators, patients, and the community. Recent protests over police brutality and racism on campuses across America have opened fresh wounds over how best to end racism, with lessons for achieving health equity. Movement advocacy, the mobilizing of the people to raise awareness of an injustice and to advocate for reform, can break down ingrained structural barriers and policies that impede health equity. However, simultaneously advocates, clinicians, and health care organizations must build trusting relationships and resolve conflict with mutual respect and honesty. Tension is inherent in discussions about racial and ethnic disparities. Yet, tension can be constructive if it forces self-examination and spurs systems change and personal growth. We must simultaneously advocate for policy reform, build personal relationships across diverse groups, and honestly examine our biases.
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Affiliation(s)
- Marshall H Chin
- Section of General Internal Medicine, Department of Medicine, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, USA.
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Baig AA, Lopez FY, DeMeester RH, Jia JL, Peek ME, Vela MB. Addressing Barriers to Shared Decision Making Among Latino LGBTQ Patients and Healthcare Providers in Clinical Settings. LGBT Health 2016; 3:335-41. [PMID: 27617356 PMCID: PMC5073213 DOI: 10.1089/lgbt.2016.0014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons' culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient-provider experiences with SDM and develop tools that can better facilitate SDM in this patient population.
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Affiliation(s)
- Arshiya A. Baig
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois
| | - Fanny Y. Lopez
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Rachel H. DeMeester
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- Robert Wood Johnson Foundation Finding Answers: Solving Disparities through Payment and Delivery System Reform Program Office, University of Chicago, Chicago, Illinois
| | - Justin L. Jia
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- The College, University of Chicago, Chicago, Illinois
| | - Monica E. Peek
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois
- The MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
- The Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, Illinois
| | - Monica B. Vela
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- The MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
- The Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, Illinois
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Peek ME, Lopez FY, Williams HS, Xu LJ, McNulty MC, Acree ME, Schneider JA. Development of a Conceptual Framework for Understanding Shared Decision making Among African-American LGBT Patients and their Clinicians. J Gen Intern Med 2016; 31:677-87. [PMID: 27008649 PMCID: PMC4870421 DOI: 10.1007/s11606-016-3616-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Enhancing patient-centered care and shared decision making (SDM) has become a national priority as a means of engaging patients in their care, improving treatment adherence, and enhancing health outcomes. Relatively little is known about the healthcare experiences or shared decision making among racial/ethnic minorities who also identify as being LGBT. The purpose of this paper is to understand how race, sexual orientation and gender identity can simultaneously influence SDM among African-American LGBT persons, and to propose a model of SDM between such patients and their healthcare providers. METHODS We reviewed key constructs necessary for understanding SDM among African-American LGBT persons, which guided our systematic literature review. Eligible studies for the review included English-language studies of adults (≥ 19 y/o) in North America, with a focus on LGBT persons who were African-American/black (i.e., > 50 % of the study population) or included sub-analyses by sexual orientation/gender identity and race. We searched PubMed, CINAHL, ProQuest Dissertations & Theses, PsycINFO, and Scopus databases using MESH terms and keywords related to shared decision making, communication quality (e.g., trust, bias), African-Americans, and LGBT persons. Additional references were identified by manual reviews of peer-reviewed journals' tables of contents and key papers' references. RESULTS We identified 2298 abstracts, three of which met the inclusion criteria. Of the included studies, one was cross-sectional and two were qualitative; one study involved transgender women (91 % minorities, 65 % of whom were African-Americans), and two involved African-American men who have sex with men (MSM). All of the studies focused on HIV infection. Sexual orientation and gender identity were patient-reported factors that negatively impacted patient/provider relationships and SDM. Engaging in SDM helped some patients overcome normative beliefs about clinical encounters. In this paper, we present a conceptual model for understanding SDM in African-American LGBT persons, wherein multiple systems of social stratification (e.g., race, gender, sexual orientation) influence patient and provider perceptions, behaviors, and shared decision making. DISCUSSION Few studies exist that explore SDM among African-American LGBT persons, and no interventions were identified in our systematic review. Thus, we are unable to draw conclusions about the effect size of SDM among this population on health outcomes. Qualitative work suggests that race, sexual orientation and gender work collectively to enhance perceptions of discrimination and decrease SDM among African-American LGBT persons. More research is needed to obtain a comprehensive understanding of shared decision making and subsequent health outcomes among African-Americans along the entire spectrum of gender and sexual orientation.
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Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, , The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
- Chicago Center for Diabetes Translation Research, , The University of Chicago, Chicago, IL, USA.
- MacLean Center for Clinical Medical Ethics, , The University of Chicago, Chicago, IL, USA.
| | - Fanny Y Lopez
- Section of General Internal Medicine, , The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
- Chicago Center for Diabetes Translation Research, , The University of Chicago, Chicago, IL, USA
| | - H Sharif Williams
- Center for Culture, Sexuality and Spirituality, , Goddard College, Plainfield, VT, USA
- Undergraduate Programs, , Goddard College, Plainfield, VT, USA
| | - Lucy J Xu
- Section of General Internal Medicine, , The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Moira C McNulty
- Section of Infectious Diseases, , The University of Chicago, Chicago, IL, USA
| | - M Ellen Acree
- Section of Infectious Diseases, , The University of Chicago, Chicago, IL, USA
| | - John A Schneider
- Section of Infectious Diseases, , The University of Chicago, Chicago, IL, USA
- Department of Public Health Sciences, , University of Chicago, Chicago, IL, USA
- Chicago Center for HIV Elimination, , University of Chicago, Chicago, IL, USA
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Nathan AG, Marshall IM, Cooper JM, Huang ES. Use of Decision Aids with Minority Patients: a Systematic Review. J Gen Intern Med 2016; 31:663-76. [PMID: 26988981 PMCID: PMC4870418 DOI: 10.1007/s11606-016-3609-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND One potential approach to reducing health disparities among minorities is through the promotion of shared decision making (SDM). The most commonly studied SDM intervention is the decision aid (DA). While DAs have been extensively studied, we know relatively little about their use in minority populations. We conducted a systematic review to characterize the application and effectiveness of DAs in racial, ethnic, sexual, and gender minorities. METHODS We searched PubMed for randomized controlled trials (RCTs) evaluating DAs between 2004 and 2013. We included trials that enrolled adults (> 18 years of age) with > 50 % representation by minority patients. Four reviewers independently assessed 597 initially identified articles, and those with inconclusive results were discussed to consensus. We abstracted decision quality, patient-doctor communication, and clinical treatment decision outcomes. Results were considered significantly modified by the DA if the study reported p < 0.05. RESULTS We reviewed 18 RCTs of DA interventions in minority populations. The majority of interventions (78 %) addressed cancer screening. The most common mode of delivery for the DAs was personal counseling (46 %), followed by multi-media (29 %), and print materials (25 %). Most of the trials studied racial (78 %) or ethnic (17 %) minorities with only one trial focused on sexual minorities and none on gender minorities. Ten studies tailored their interventions for their minority populations. Comparing intervention vs. control, decision quality outcomes improved in six out of eight studies and patient-doctor communication improved in six out of seven studies. Of the 15 studies that reported on clinical decisions, eight demonstrated significant changes in decisions with DAs. DISCUSSION DAs have been effective in improving patient-doctor communication and decision quality outcomes in minority populations and could help address health disparities. However, the existing literature is almost non-existent for sexual and gender minorities and has not included the full breadth of clinical decisions that affect minority populations.
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Affiliation(s)
- Aviva G Nathan
- Section of General Internal Medicine, , University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
| | - Imani M Marshall
- Section of General Internal Medicine, , University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Jennifer M Cooper
- Section of General Internal Medicine, , University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Elbert S Huang
- Section of General Internal Medicine, , University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
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45
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Tan JY, Xu LJ, Lopez FY, Jia JL, Pho MT, Kim KE, Chin MH. Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap. LGBT Health 2016; 3:327-34. [PMID: 27158858 DOI: 10.1089/lgbt.2015.0143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered.
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Affiliation(s)
- Judy Y Tan
- 1 Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Lucy J Xu
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,3 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
| | - Fanny Y Lopez
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois
| | - Justin L Jia
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,4 The College, University of Chicago , Chicago, Illinois
| | - Mai T Pho
- 5 Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago , Chicago, Illinois
| | - Karen E Kim
- 6 Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago , Chicago, Illinois.,7 Center for Asian Health Equity, University of Chicago , Chicago, Illinois
| | - Marshall H Chin
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,8 Robert Wood Johnson Foundation Finding Answers: Solving Disparities through Payment and Delivery System Reform Program Office, University of Chicago , Chicago, Illinois
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