Health-Related Stereotype Threat Predicts Health Services Delays Among Blacks

Stigma manifestations in cardiomyopathy care impact outcomes for black patients: a qualitative study

INTRODUCTION

Inequities in clinical care may contribute to racial disparities observed in studies of heart disease morbidity and cardiogenetic testing outcomes. There is a lack of research aimed at understanding the complexity of those inequities, but stigma likely contributes. This qualitative exploratory study helps close that gap in the literature by describing intersectional stigma manifestations perceived by the Black cardiomyopathy patient population at one academic medical center.

METHODS

Qualitative interviews were conducted with 14 Black cardiomyopathy patients. Interviews aimed to elicit patients' experiences with discrimination related to diagnosis, symptoms, genetic testing, knowledge of genetic results, genetic counseling, providers' actions, and providers' communication. The interview guide was informed by The Health Stigma and Discrimination Framework. Data were also collected about participant demographics, type of cardiomyopathy, age of diagnosis, documentation of relevant family history, and completion of genetic counseling and/or genetic testing.

RESULTS

More than half of participants reported intersectional stigma manifestations related to their race, age, and/or weight while receiving care from cardiologists, nurse practitioners, genetic counselors, or clinical support staff. Stigma manifestations included physical roughness during patient care, withholding diagnostically-relevant information from the patient, impersonal care, coercion, and use of offensive stereotyped language by providers. These stigma manifestations impacted access to care, uptake of genetic testing, timeline to diagnosis, patient emotion, patient-provider trust, and adherence to medical recommendations.

CONCLUSIONS

This study provides nuanced qualitative descriptions of stigma manifestations that affect patient and clinical outcomes in cardiology care and genetic services in one medical center in the Southeastern United States. The results of this study suggest that provider bias and stigma manifestations have an adverse effect on cardiogenetic and clinical outcomes among Black cardiomyopathy patients. Clinical interventions are suggested to assist health professionals in providing culturally-competent and respectful care. These results help inform patient-provider communication, clinical policies, and evidence-based practice in cardiology care and genetics. Continued study of this topic across more institutions and with a larger sample size is needed to confirm the generalizability of the conclusions.

Historical Primer on Obstetrics and Gynecology Health Inequities in America: A Narrative Review of Four Events

Four historical events provide context for racial injustices and inequities in medicine in the United States today: the invention of race as a social construct, enslavement in the Americas, the legal doctrine of Partus sequitur ventrem, and the American eugenics movement. This narrative review demonstrates how these race-based systems resulted in stereotypes, myths, and biases against Black individuals that contribute to health inequities today. Education on the effect of slavery in current health care outcomes may prevent false explanations for inequities based on stereotypes and biases. These historical events validate the need for medicine to move away from practicing race-based medicine and instead aim to understand the intersectionality of sex, race, and other social constructs in affecting the health of patients today.

Ethnicity, nativity, and the effects of stereotypes on cardiovascular health among people of African ancestry in the United States: internal versus external sources of racism

OBJECTIVE

The present study tests the hypothesis that ethnicity and nativity moderate the association of negative racial stereotypes versus perceived discrimination to cardiovascular health among Black respondents to the National Survey of American Life (NSAL). It is also hypothesized that the relationship is strongest in African Americans and weakest in foreign-born Caribbean Blacks with U.S.-born Caribbean Blacks falling in the middle. The same pattern of results is expected to occur for the correlation between perceived discrimination and cardiovascular health.

METHOD

A representative sample of 3570 (100%) African American and 1419 (87.4%) of 1623 Caribbean Black respondents to the NSAL had complete data for use in this study. The Caribbean subsample was divided by nativity into 373 (26.3%) U.S.-born and 1044 (73.7%) foreign-born participants. Structural equation modeling (SEM) tested the measurement model for effects of internalized racism and perceived racism on cardiovascular health mediated by perceived mastery and performance apprehension.

RESULTS

SEM analyses revealed that perceived discrimination had a much stronger effect on cardiovascular health than internalized racism for African Americans and foreign-born Caribbean Blacks, but the diametrically opposite pattern was the case for U.S.-born Caribbean Blacks who reported greater effects for internalized racism than perceived discrimination.

CONCLUSION

Interventions and policies to eliminate disparities in cardiovascular health for the U.S. Black population must address internal and external sources of racism by ethnicity and nativity.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

OBJECTIVES

Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.

METHODS

We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.

RESULTS

Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.

CONCLUSION

Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.

PRACTICE IMPLICATIONS

We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

Primary Care Women's Health Screening: A Case Study of a Community Engaged Human Centered Design Approach to Enhancing the Screening Process

PURPOSE

To apply a Human Centered Design (HCD) approach to co-designing a comprehensive women's health screening tool with community partners.

DESCRIPTION

Evidenced-based health screenings for behaviors and risks are important tools in primary health care and disease prevention, especially for women. However, numerous barriers limit the effective implementation of comprehensive health screenings, and often lead to excluding important risks such as intimate partner violence (IPV). Utilizing a human centered design approach (HCD), Mountain Area Health Education Center (MAHEC, NC USA) developed a community co-designed 9-topic health screening for women. Key end-users were recruited to participate in the design process, including women who identified IPV as a health issue in their community, Spanish speaking women, domestic violence program organizers, and MAHEC staff.

ASSESSMENT

A total of 21 participants collaborated during three design sessions on two specific goals: 1) creating a comprehensive women's health screening tool from the existing tools that were in use in our clinics at the time, and 2) incorporating IPV screening. Through the HCD sessions, participants highlighted the impact of what they termed "Triple T: time, trust and talk" on the effectiveness of women's health screening.

CONCLUSION

Our co-designed women's health screening tool is a first step towards addressing screening barriers from both primary care provider's and community women's perspectives. Future research will explore the facilitators of and barriers to implementing the tools in different primary care settings. Future work should also more systematically examine whether and how screening processes may reinforce or contribute to women's feelings of being stereotyped, and how screening processes can be designed to avoid stereotype threat, which has the potential to reduce the effectiveness of screenings intended to promote women's health.

Gendered racism and the sexual and reproductive health of Black and Latina Women

Objective: To understand health disparities, it is important to use an intersectional framework that examines unique experiences of oppression faced by particular groups due to their intersecting identities and social positions linked to societal structures. We focus on Black and Latina women and their experiences with 'gendered racism' - unique forms of oppression due to the intersection of race/ethnicity and gender - to foster understanding of disparities between Black and Latina versus White women in sexual and reproductive health outcomes in the U.S. Specifically, we focus on stereotype-related gendered racism (ongoing discrimination and stereotype threat based on historically-rooted stereotypes about Black and Latina women's sexuality and motherhood) and birth control-related mistrust (ongoing mistrust of the government and medical system related to birth control due to historical and current abuses).Design: We analyzed data from two survey studies with adult women in New York (Study 1: paper-and-pencil community data collection, N = 135, M_age= 43.35) and across the U.S. (Study 2: online data collection, N = 343, M_age= 29.49) who were currently pregnant or had at least one child and identified as Black, Latina, or White.Results: Black and Latina women reported greater frequency of and concern over stereotype-related gendered racism (F(3,131) = 17.90, p < .001 Study 1; F(3,339) = 22.23, p < .001 Study 2) and greater birth control-related mistrust (F(3,131) = 7.55, p < .001 Study 1; F(3,339) = 17.32, p < .001 Study 2) than White women did. In turn, stereotype-related gendered racism was positively associated with pregnancy-specific stress (ß = .40, p < .001 Study 1; ß = .33, p < .001 Study 2), and birth control-related mistrust was negatively associated with sexual relationship power (ß = -.19, p = .002 Study 2), which are factors known to contribute to birth outcomes and sexual risk, respectively.Conclusion: Findings suggest that gendered racism may play an important role in existing racial/ethnic disparities in women's sexual and reproductive health outcomes, and interventions addressing gendered racism at multiple levels are needed to promote health equity.

Measuring racial microaggression in medical practice

The purpose of this study was to validate the already existing Racial Microaggression in Counseling Scale (RMCS) when the term 'therapist' was replaced with 'physician', thus constituting the modification as the Racial Microaggression in Medical Practice Scale (RMMPS). Racial microaggressions work at reinforcing inferior social status on a cognitive level. Unlike overt racism, messages behind microaggression are subtler and more every day. A lack of acceptance, respect, and regard emerges from interactions in medical contexts as there are layers of in-group and out-group statuses at play (e.g. physician-patient, Black-White, expert-lay, and Westernized-alternative). The layer focused on in this study was that of race or skin color. A sample of racial minorities in the Northeast (n = 91) was investigated both quantitatively and qualitatively to validate the modification and future use of a RMMPS. The scale was related to the racial incongruence between patient and provider. Qualitative findings support the original concepts and themes used when developing the 10-item measure in a counseling setting. Psychometric findings for the scale also supported its factorial structure using generalizability theory estimates. Future implications of this research relate to health behavior, trustworthiness, and health outcomes of minority patients. Its potential for use among various practitioners, educators, and researchers is also discussed.

Race Dialogues in Group Psychotherapy: Key Issues in Training and Practice

Growing racial and ethnic diversity in the United States and globally requires culturally competent mental health professionals who can address ongoing racial tensions and experiences of racism and xenophobia. Attending to racial and ethnic issues and infusing race and ethnic dialogues in group psychotherapy can play a major role in addressing mental health problems, promoting racial harmony, and healing deep psychological wounds and trauma that are the result of racial tensions. This article describes seven key issues necessary to effectively address race and ethnicity in group psychotherapy.

Effects of Aging Stereotype Threat on Working Self-Concepts: An Event-Related Potentials Approach

Although the influence of stereotype threat (ST) on working self-concepts has been highlighted in recent years, its neural underpinnings are unclear. Notably, the aging ST, which largely influences older adults' cognitive ability, mental and physical health, did not receive much attention. In order to investigate these issues, electroencephalogram (EEG) data were obtained from older adults during a modified Stroop task using neutral words, positive and negative self-concept words in aging ST vs. neutral control conditions. Results showed longer reaction times (RTs) for identifying colors of words under the aging ST compared to the neutral condition. More importantly, the negative self-concept elicited more positive late P300 amplitudes and enhanced theta band activities compared to the positive self-concept or neutral words under the aging ST condition, whereas no difference was found between these self-concepts and neutral words in the control condition. Furthermore, the aging ST induced smaller theta band synchronization and enhanced alpha band synchronization compared to the control condition. Moreover, we also observed valence differences in self-concepts where the negative self-concept words reduced early P150/N170 complex relative to neutral words. These findings suggest that priming ST could activate negative self-concepts as current working self-concept, and that this influence occurred during a late neural time course.

Stereotypes of Black American Women Related to Sexuality and Motherhood

Intersectionality theorists and researchers suggest the importance of examining unique stereotypes associated with intersecting group identities. We focus on the unique stereotypes of Black women in the United States related to sexuality and motherhood. In an online experimental study, 435 undergraduates from a Northeastern U.S. university were randomly assigned to one of the four conditions in which they viewed a photograph and read a description of a target young woman. The target's race (Black vs. White) and pregnancy status (pregnant vs. no pregnancy information) were varied. A Black female target (pregnant or not) was perceived more negatively on items related to historically rooted societal stereotypes about sexual activity, sexual risk, motherhood status, and socioeconomic status than was a White female target, but there were no differences on items unrelated to societal stereotypes. A Black target described as pregnant was also perceived as more likely to be a single mother and to need public assistance than was a White target described as pregnant. Current findings, along with evidence that societal stereotypes have damaging effects, underscore the importance of diversifying images of Black women and increasing awareness of how stereotypes affect perceptions of Black women. Findings also highlight the value of research employing intersectionality to understand stereotypes.

Healthcare Stereotype Threat in Older Adults in the Health and Retirement Study

INTRODUCTION

Healthcare stereotype threat is the threat of being personally reduced to group stereotypes that commonly operate within the healthcare domain, including stereotypes regarding unhealthy lifestyles and inferior intelligence. The objective of this study was to assess the extent to which people fear being judged in healthcare contexts on several characteristics, including race/ethnicity and age, and to test predictions that experience of such threats would be connected with poorer health and negative perceptions of health care.

METHODS

Data were collected as part of the 2012 Health and Retirement Study (HRS). A module on healthcare stereotype threat, designed by the research team, was administered to a random subset (n=2,048 of the total 20,555) of HRS participants. The final sample for the present healthcare stereotype threat experiment consists of 1,479 individuals. Logistic regression was used to test whether healthcare stereotype threat was associated with self-rated health, reported hypertension, and depressive symptoms, as well as with healthcare-related outcomes, including physician distrust, dissatisfaction with health care, and preventative care use.

RESULTS

Seventeen percent of respondents reported healthcare stereotype threat with respect to one or more aspects of their identities. As predicted, healthcare stereotype threat was associated with higher physician distrust and dissatisfaction with health care, poorer mental and physical health (i.e., self-rated health, hypertension, and depressive symptoms), and lower odds of receiving the influenza vaccine.

CONCLUSIONS

The first of its kind, this study demonstrates that people can experience healthcare stereotype threat on the basis of various stigmatized aspects of social identity, and that these experiences can be linked with larger health and healthcare-related outcomes, thereby contributing to disparities among minority groups.