Perceived discrimination in U.S. healthcare: Charting the effects of key social characteristics within and across racial groups

Correlates of Lifestyle Physical Activity Among Young Arab American Women

BACKGROUND

Young Arab American women are at risk for cardiovascular disease, but there is limited data on their physical activity (PA) engagement.

OBJECTIVES

The aim of this study was to examine the relationship between PA and its correlates in young Arab American women. The objectives of this study were to: (1) describe self-reported lifestyle PA behaviors of young Arab American women and (2) examine the relationship between their self-reported lifestyle PA, device-measured lifestyle PA (combined moderate/vigorous and steps), and potentially associated factors (demographics, physical measures, individual factors, and behavior cognition factors).

METHODS

This cross-sectional study was conducted with women 18 to 35 years of age and Arab American (n = 50) in the Midwest Region of the United States. Participants wore ActiGraph GT3X-BT monitors for 7 days; self-report measures included the International Physical Activity Questionnaire, demographics, acculturation, discrimination, religiosity, self-efficacy, and social support.

RESULTS

The mean age of participants was 25.5 years (SD: 5.5; range: 18-35). Per ActiGraph, the average daily steps were 5946 (SD: 2783); only 24% met the moderate-intensity PA guidelines. Self-efficacy was significantly associated with increased moderate-to-vigorous PA (B = 0.37; P = .012).

CONCLUSION

The average daily steps for the young Arab American women in this study were of low active classification. More than 75% of the women failed to meet the recommended weekly moderate/vigorous PA guidelines. Our study supports the importance of targeting and tailoring PA interventions on young Arab American women who have low self-efficacy for overcoming barriers to lifestyle PA.

Societal Discrimination, Vigilance, and Patient-Provider Relationships Among Perinatal Women: A Mixed Methods Study

INTRODUCTION

In the United States, maternal mortality is high and patterned by race and socioeconomic status (SES). Patient-provider relationships and societal discrimination have been separately associated with poor maternal outcomes, but it is not clear how such mechanisms may be interrelated. Thus, the present study investigates how societal experiences of discrimination are associated with and manifest in patient-provider relationship quality among perinatal women.

METHODS

The study uses a mixed methods design with an explanatory-sequential approach. First, a path analysis using structural equation modeling of a cross-sectional representative survey of 244 perinatal women in Kalamazoo County, Michigan, was conducted. Second, a thematic qualitative analysis was conducted of focus groups composed of survey participants (n = 34).

RESULTS

In the quantitative analyses, race and SES were associated with experiences of societal discrimination in the expected directions (race: b, 1.87; SE, 0.58; P = .001; SES: b, 2.18; SE, 0.60; P < .001), discrimination positively predicted vigilant behaviors (b, 0.81; SE, 0.15; P < .001), and more vigilant behaviors predicted worse patient-provider relationship quality (b, 0.18; SE, 0.07; P < .001). In the qualitative findings, we found detailed accounts linking provider discrimination, vigilance, and patient-provider relationships among focus groups composed of only women of color (n = 9).

DISCUSSION

Overall, the quantitative analyses find support for the conceptual model showing race and SES are associated with societal discrimination, which is associated with vigilant behaviors and, in turn, quality of patient-provider relationships. The qualitative analyses provide preliminary evidence for how these pathways manifest in care settings and demonstrate the importance of establishing trust in patient-provider relationships, especially among women of color.

Gender, Race/Ethnicity, and Patient-Therapist Matching on Gender and Race/Ethnicity: Predictors/Moderators of the Effectiveness of Trust/Respect Feedback

A plethora of studies has exhibited the effectiveness of using measurement-based care feedback systems within mental health services to improve treatment outcomes; however, patient gender/race and patient-therapist matching on gender and race remain relatively unexplored as predictors/moderators in feedback studies. We conducted predictor/moderator analyses focusing on the relation of gender, race/ethnicity, and patient-therapist gender and race/ethnicity matching on two outcomes: patient self-reported levels of (1) functioning and (2) trust/respect within the therapeutic relationship. We used data from a randomized controlled trial studying the effectiveness of a feedback system comparing patient-reported levels of trust and respect towards their provider (together with symptom feedback) in comparison to symptom only feedback. We found that men improved in functioning more than women when their therapists received trust/respect feedback compared to symptom only feedback (F[1, 902] = 9.79, p = .002, d = 0.21). We also found that dyads matched on race/ethnicity but not gender, and those matched on gender but not race/ethnicity, improved in functioning over time more than dyads mismatched on both gender and race/ethnicity and those matched on both gender and race/ethnicity (F[1, 897] = 8.63, p = .0034, d = 0.20). On trust/respect outcomes, we found a gender difference over time (F[1, 759] = 6.61, p = .01, d = 0.19), a gender matching difference by feedback condition interaction (F[1, 757] = 5.25, p = .02, d = 0.17), and a racial/ethnic matching difference on trust/respect scores over time (F[1, 785] = 3.89, p = .049, d = 0.14). Male patients showed an initial decrease followed by a steady increase in trust/respect over time while female patients showed an initial increase followed by a steady decrease. Gender-matched therapeutic dyads showed higher levels of trust/respect compared to mismatched dyads when therapists received symptom only feedback, but this difference was not apparent when trust/respect feedback was provided. Dyads mismatched on race/ethnicity improved steadily in trust/respect over time, but matched dyads decreased in trust/respect after an initial increase. Future research should focus on the use of feedback systems to enhance outcomes for patients with specific gender and racial/ethnic identities.

Development of a novel healthcare discrimination measure: PreDict

Introduction

Patient reported quality of care measures are widely recognized tools for healthcare system performance assessment. Yet, there are few existing patient reported quality of care measures regarding health equity, and none to specifically collect patient experiences of discrimination in health care.

Objective

To develop an item pool to measure patient experiences of healthcare discrimination-the Patient-Reported Experiences of Discrimination in Care Tool (PreDict).

Methods

Utilizing a multistage, exploratory sequential mixed methods study design, we conducted qualitative interviews (n=73) and expert panel consensus analysis to develop items to capture patient experiences of discrimination. This process plus systematic literature review identified extant items and informed de novo items for inclusion in the item pool. Items were developed in English and Spanish and were not represented by extant items. Following identification of the initial item pool (n=125), candidate items underwent cognitive interview testing with English (n=113) and Spanish (n=70) speaking participants to evaluate items for clarity and comprehensiveness. English and Spanish items were also evaluated by a bilingual expert panel to recommend pool items for inpatient field testing.

Results

One hundred and three items underwent cognitive interview testing and fifty-nine items were retained. Lack of clarity was the most cited factor for removal or revision of items. Expert panel review resulted in the removal of one additional item and the revision of seven items.Fifty-eight candidate items were retained for inclusion in field testing and future analyses using item response theory modeling.

Conclusion

PreDict fills an important gap in measurement of discrimination, which is known to influence patient health outcomes. Development and testing to date demonstrate evidence of validity in characterizing the complex phenomenon of healthcare discrimination.

Nurses' experiences of discrimination in health care: A qualitative study in Iran

BACKGROUND

Justice in health is one of the main concerns of health organizations, and discrimination in health care is one of the negative outcomes to achieving this goal. Hence, a full understanding of the phenomenon of discrimination in health care and adopting strategies to eliminate it is necessary. The present study was conducted to explore and describe the experiences of nurses of discrimination in health care.

MATERIALS AND METHODS

The present qualitative content analysis study was conducted between 2019 and 2020. Data were collected through semi-structured interviews with 18 participants (two physicians, three nursing supervisors, two head nurses, four clinical nurses, two nursing assistants, and three hospitalized patients) in one public and one private hospital in the city of Tehran. The participants were selected by purposive sampling, which continued until saturation of data. Data obtained were analyzed using the Graneheim and Lundman method.

RESULTS

Four main categories and 14 subcategories were extracted from data analysis: 1) habitual discrimination (everyday discrimination in health centers, ignoring patient rights, low levels of trust in medical staff); 2) interpersonal relationships (expectations of associates, respect for colleagues and friends, the possibility of the occurrence of similar situations, reciprocating people's favors); 3) shortage of health-care resources (shortage of medical equipment, heavy workload, infrastructure of medical centers, lack of access to physicians); and 4) favoritism (ethnicity, favoritism as a common method, and favoritism as the ultimate solution to treatment problems).

CONCLUSION

The present study revealed certain dimensions of discrimination in health care that remain hidden in many quantitative studies. It appears that health system managers will be able to move toward eliminating discrimination in health care. Thus, designing effective models to reduce discrimination in health care based on the underlying concepts of this study is recommended.

Asian American Self-Reported Discrimination in Healthcare and Having a Usual Source of Care

BACKGROUND

Self-reported racial or ethnic discrimination in a healthcare setting has been linked to worse health outcomes and not having a usual source of care, but has been rarely examined among Asian ethnic subgroups.

OBJECTIVE

We examined the association between Asian ethnic subgroup and self-reported discrimination in a healthcare setting, and whether both factors were associated with not having a usual source of care.

DESIGN

Using the California Health Interview Survey (CHIS) 2015-2017, we used logistic regression models to assess associations among Asian ethnic subgroup, self-reported discrimination, and not having a usual source of care. Interactions between race and self-reported discrimination, foreign-born status, poverty level, and limited English proficiency were also analyzed.

PARTICIPANTS

Respondents represented adults age 18 + residing in California who identified as White, Black, Hispanic, American Indian/Alaska Native, Asian (including Chinese, Filipino, Japanese, Korean, Vietnamese, and Other Asian), and Other.

MAIN MEASURES

We examined two main outcomes: self-reported discrimination in a healthcare setting and having a usual source of care.

KEY RESULTS

There were 62,965 respondents. After survey weighting, Asians (OR 1.78, 95% CI 1.19-2.66) as an aggregate group were more likely to report discrimination than non-Hispanic Whites. When Asians were disaggregated, Japanese (3.12, 1.36-7.13) and Koreans (2.42, 1.11-5.29) were more likely to report discrimination than non-Hispanic Whites. Self-reported discrimination was marginally associated with not having a usual source of care (1.25, 0.99-1.57). Koreans were the only group associated with not having a usual source of care (2.10, 1.23-3.60). Foreign-born Chinese (ROR 7.42, 95% CI 1.7-32.32) and foreign-born Japanese (ROR 4.15, 95% CI 0.82-20.95) were more associated with self-reported discrimination than being independently foreign-born and Chinese or Japanese.

CONCLUSIONS

Differences in self-reported discrimination in a healthcare setting and not having a usual source of care were observed among Asian ethnic subgroups. Better understanding of these differences in their sociocultural contexts will guide interventions to ensure equitable access to healthcare.

Understanding the relationship between perceived discrimination and mortality in United States adults

OBJECTIVE

To understand the relationship between mortality and three types of perceived discrimination (lifetime, daily, chronic job) using a nationally representative sample of U.S. adults.

METHODS

Data from 4562 adults in the Midlife in the United States (MIDUS) between 2004 and 2006 (MIDUS II and MIDUS African American sample) were analyzed. Unadjusted associations between primary independent discrimination variables (lifetime, chronic job, daily) and mortality were analyzed using univariate Cox's proportional hazards regression models. Covariates were added to the models by group: predisposing (sex, age, race/ethnicity, education, marital status); enabling (household income, employment status, insurance status); and need factors (body mass index, diabetes, hypertension, stroke, cancer) to estimate hazard ratios.

RESULTS

After adjusting for all covariates, hazard ratios for lifetime discrimination (HR: 1.09, p = 0.034) and daily discrimination (HR: 1.03, p = 0.030) were statistically significant. There was no relationship between mortality and chronic job discrimination (HR:1.03, p = 0.15).

CONCLUSIONS

Adults experiencing lifetime and daily discrimination had significantly increased risk of mortality after adjusting for predisposing, enabling, and need factors. The findings highlight the importance of screening patients during clinical encounters for experiences of discrimination and providing appropriate resources to mitigate the negative impact of discriminatory events on mortality. Future research should work to fully understand the mechanism by which discrimination increases risk of mortality. These future findings should be used to develop targets for interventions designed to decrease mortality among adults who have experienced discrimination.

Resident Willingness to Participate in Digital Contact Tracing in a COVID-19 Hotspot: Findings From a Detroit Panel Study

BACKGROUND

Digital surveillance tools and health informatics show promise in counteracting diseases but have limited uptake. A notable illustration of the limits of such tools is the general failure of digital contact tracing in the United States in response to COVID-19.

OBJECTIVE

We investigated the associations between individual characteristics and the willingness to use app-based contact tracing in Detroit, a majority-minority city that experienced multiple waves of COVID-19 outbreaks and deaths since the start of the pandemic. The aim of this study was to examine variations among residents in the willingness to download a contact tracing app on their phones to provide public health officials with information about close COVID-19 contact during summer 2020.

METHODS

To examine residents' willingness to participate in digital contact tracing, we analyzed data from 2 waves of the Detroit Metro Area Communities Study, a population-based survey of Detroit, Michigan residents. The data captured 1873 responses from 991 Detroit residents collected in June and July 2020. We estimated a series of multilevel logit models to gain insights into differences in the willingness to participate in digital contact tracing across a variety of individual attributes, including race/ethnicity, degree of trust in the government, and level of education, as well as interactions among these variables.

RESULTS

Our results reflected widespread reluctance to participate in digital contact tracing in response to COVID-19, as less than half (826/1873, 44.1%) of the respondents said they would be willing to participate in app-based contact tracing. Compared to White respondents, Black (odds ratio [OR] 0.45, 95% CI 0.23-0.86) and Latino (OR 0.32, 95% CI 0.11-0.99) respondents were significantly less willing to participate in digital contact tracing. Trust in the government was positively associated with the willingness to participate in digital contact tracing (OR 1.17, 95% CI 1.07-1.27), but this effect was the strongest for White residents (OR 2.14, 95% CI 1.55-2.93). We found similarly divergent patterns of the effects of education by race. While there were no significant differences among noncollege-educated residents, White college-educated residents showed greater willingness to use app-based contact tracing (OR 6.12, 95% CI 1.86-20.15) and Black college-educated residents showed less willingness (OR 0.46, 95% CI 0.26-0.81).

CONCLUSIONS

Trust in the government and education contribute to Detroit residents' wariness of digital contact tracing, reflecting concerns about surveillance that cut across race but likely arise from different sources. These findings point to the importance of a culturally informed understanding of health hesitancy for future efforts hoping to leverage digital contact tracing. Though contact tracing technologies have the potential to advance public health, unequal uptake may exacerbate disparate impacts of health crises.

Stress and Mental Health: A Focus on COVID-19 and Racial Trauma Stress

In the United States, COVID-19 unfolded alongside profound racial trauma. Drawing on a population representative sample of 20-60 year-olds who were married or cohabiting, the National Couples' Health and Time Study (N =3,642), we examine two specific sources of stress: COVID-19 and racial trauma. We leverage the fully powered samples of respondents with racial/ethnic and sexual minority identities and find that COVID-19 and racial trauma stress were higher among individuals who were not White or heterosexual most likely due to racism, xenophobia, and cis-heterosexism at the individual and structural levels. Both COVID-19 and racial trauma stress were associated with poorer mental health outcomes even after accounting for a rich set of potential mechanistic indicators, including discrimination and social climate. We argue that the inclusion of assessments of stress are critical for understanding health and well-being among individuals impacted by systemic and interpersonal discrimination.

Occupational Therapy's Role in Chronic Conditions

It is the position of the American Occupational Therapy Association (AOTA) that occupational therapy practitioners are distinctly qualified to address the impact of chronic conditions on occupational performance and participation across the life span. The purpose of this position statement is twofold. First, it defines chronic conditions and describes the multiple factors associated with the development of one or more chronic conditions. Second, it provides an overview of how the field of occupational therapy has a distinct impact on improving the health and wellness of persons, groups, and populations with or at risk for chronic conditions through health promotion, disease prevention, and intervention.

The competing effects of racial discrimination and racial identity on the predicted number of days incarcerated in the US: A national profile of Black, Latino/Latina, and American Indian/Alaska Native populations

OBJECTIVE

Racial discrimination and racial identity may compete to influence incarceration risk. We estimated the predicted days incarcerated in a national US sample of Black, Latino/Latina, and American Indian/Alaska Native (AI/AN) individuals.

METHODS

We used the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (n = 14,728) to identify individual incarceration history. We used zero-inflated Poisson regression to predict the number of days incarcerated across racial discrimination and racial identity scores.

RESULTS

Racial discrimination and identity varied between races/ethnicities, such that racial discrimination exposure was highest among Hispanic individuals, while racial identity was highest among Black individuals. Racial discrimination was positively associated with days incarcerated among Black individuals (β = 0.070, p<0.0001) and AI/AN individuals (β = 0.174, p<0.000). Racial identity was negatively associated with days incarcerated among Black individuals (β = -0.147, p<0.0001). The predicted number of days incarcerated was highest among Black individuals (130 days) with high discrimination scores.

CONCLUSION

Racial discrimination and racial identity were associated with days incarcerated, and the association varied by racial/ethnic sub-group. Informed by these findings, we suggest that intervention strategies targeting incarceration prevention should be tailored to the unique experiences of racial/ethnic minoritized individuals at the greatest risk. Policies aimed at reversing mass incarceration should consider how carceral systems fit within the wider contexts of historical racism, discrimination, and structural determinants of health.

Artificial Intelligence and Medical Humanities

The use of artificial intelligence in healthcare has led to debates about the role of human clinicians in the increasingly technological contexts of medicine. Some researchers have argued that AI will augment the capacities of physicians and increase their availability to provide empathy and other uniquely human forms of care to their patients. The human vulnerabilities experienced in the healthcare context raise the stakes of new technologies such as AI, and the human dimensions of AI in healthcare have particular significance for research in the humanities. This article explains four key areas of concern relating to AI and the role that medical/health humanities research can play in addressing them: definition and regulation of "medical" versus "health" data and apps; social determinants of health; narrative medicine; and technological mediation of care. Issues include data privacy and trust, flawed datasets and algorithmic bias, racial discrimination, and the rhetoric of humanism and disability. Through a discussion of potential humanities contributions to these emerging intersections with AI, this article will suggest future scholarly directions for the field.

Everyday discrimination in later life: A social network approach

What factors shape everyday discrimination among older adults? Existing perspectives focus on individual identities and social group membership (e.g., race/ethnicity, age) as key determinants of perceived discrimination. This paper examines the idea that individuals' broader social contexts - including their personal social networks - also shape perceived discrimination, and in ways that may differ across racial groups. Using data from Round 3 of the National Social Life, Health, and Aging Project (N = 3312), I consider how properties of personal networks are associated with how frequently older adults report everyday discrimination. Results indicate that more kin-centric personal networks protect against more frequent everyday discrimination, but that this protective effect may be stronger among White older adults. I propose why more kin-centric networks may play a different role in the perceived discrimination of White and Black older adults, and close by suggesting that social network composition may be a source of heterogeneity in the link between everyday discrimination and inequality in later life outcomes such as health.

Perceived Discrimination During Prenatal Care at a Community Health Center

Introduction

Discrimination in healthcare is associated with fetal growth restriction, preterm birth, and postpartum depression. A community-based participatory research study was designed to measure perceived discrimination and healthcare quality during prenatal care and delivery by a community health center, where the majority of patients served belong to historically marginalized ethnic and racial groups.

Methods

A 34-question phone survey was administered to women 18 years and older who received prenatal care at the study site during 2020–2021. The primary outcome was perceived discrimination during obstetric care, measured by the 7-question Discrimination in the Medical Setting (DMS) survey. Secondary outcomes included the association of race with perceived discrimination, quality of care, trust of healthcare providers, and perceived control over medical choices.

Results

Ninety-seven women completed the survey, 95 of whom were women of color. The sample was dichotomized into Black (n = 49) and non-Black (n = 46). Perceived discrimination for all participants was 21% (20/95), with 31% (15/49) of Black women reporting any discrimination during prenatal care and delivery. Compared to other women of color, Black women reported higher rates of perceived discrimination (31% vs 11%, aOR 3.9 [1.2–12.1], p < 0.05), lower control over health choices (84% vs 98%, aOR 0.1 [0.0–0.8], p < 0.05), and were more likely to perceive lack of respect (12% vs 2%, p = 0.045).

Conclusion

Although perceived discrimination at this community health center was low compared to prior studies, Black women experienced higher rates of discrimination than other women of color.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-022-01315-5.

Men's psychiatric distress in context: Understanding the impact of masculine discrepancy stress, race, and barriers to help-seeking

This study examined perceived barriers to help-seeking as mechanisms by which masculinity may generate risk for psychiatric distress in men. An online sample of 558 men completed self-report measures of masculine discrepancy stress (i.e. distress about one's perceived gender nonconformity), barriers to help-seeking, and psychiatric distress. A significant indirect effect of masculine discrepancy stress on psychiatric distress emerged through perceived barriers to help-seeking; notably, this effect was stronger among Men of Color (vs White men). The promotion of optimal psychiatric functioning in men may necessitate interventions that target the effects of masculine socialization and race-related stress on help-seeking attitudes.

Differences in Barriers to Healthcare and Discrimination in Healthcare Settings Among Undocumented Immigrants by Deferred Action for Childhood Arrivals (DACA) Status

Undocumented immigrants face barriers to and discrimination in healthcare, but those with Deferred Action for Childhood Arrivals (DACA) status may fare better. This analysis uses the cross-sectional BRAVE Study of young undocumented Latinx and Asian immigrants to examine differences in barriers to and discrimination in healthcare by DACA status. A majority of respondents experienced financial, language, and cultural barriers, and up to half experienced documentation status barriers, discrimination when seeking healthcare or by a health provider, and negative experiences related to documentation status. In multivariable analyses, DACA recipients have over 90% lower odds of language and cultural barriers, approximately 80% lower odds of discrimination when seeking healthcare and by a health provider, and approximately 70% lower odds of documentation status barriers and negative experience related to documentation status compared to nonrecipients. These findings indicate that DACA recipients experience fewer barriers to healthcare and discrimination in healthcare compared to nonrecipients.

Reporting of Discrimination by Health Care Consumers Through Online Consumer Reviews

IMPORTANCE

Little is known about how discrimination in health care relates to inequities in hospital-based care because of limitations in the ability to measure discrimination. Consumer reviews offer a novel source of data to capture experiences of discrimination in health care settings.

OBJECTIVE

To examine how health care consumers perceive and report discrimination through public consumer reviews.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study assessed Yelp online reviews from January 1, 2011, to December 31, 2020, of 100 randomly selected acute care hospitals in the US. Word filtering was used to identify reviews potentially related to discrimination by using keywords abstracted from the Everyday Discrimination Scale, a commonly used questionnaire to measure discrimination. A codebook was developed through a modified grounded theory and qualitative content analysis approach to categorize recurrent themes of discrimination, which was then applied to the hospital reviews.

EXPOSURES

Reported experiences of discrimination within a health care setting.

MAIN OUTCOMES AND MEASURES

Perceptions of how discrimination in health care is experienced and reported by consumers.

RESULTS

A total of 10 535 reviews were collected. Reviews were filtered by words commonly associated with discriminatory experiences, which identified 2986 reviews potentially related to discrimination. Using the codebook, the team manually identified 182 reviews that described at least 1 instance of discrimination. Acts of discrimination were categorized by actors of discrimination (individual vs institution), setting (clinical vs nonclinical), and directionality (whether consumers expressed discriminatory beliefs toward health care staff). A total of 53 reviews (29.1%) were coded as examples of institutional racism; 89 reviews (48.9%) mentioned acts of discrimination that occurred in clinical spaces as consumers were waiting for or actively receiving care; 25 reviews (13.7%) mentioned acts of discrimination that occurred in nonclinical spaces, such as lobbies; and 66 reviews (36.3%) documented discrimination by the consumer directed at the health care workforce. Acts of discrimination are described through 6 recurrent themes, including acts of commission, omission, unprofessionalism, disrespect, stereotyping, and dehumanizing.

CONCLUSIONS AND RELEVANCE

In this qualitative study, consumer reviews were found to highlight recurrent patterns of discrimination within health care settings. Applying quality improvement tools, such as the Plan-Do-Study-Act cycle, to this source of data and this study's findings may help inform assessments and initiatives directed at reducing discrimination within the health care setting.

'I'm not a chance taker': A mixed methods exploration of factors affecting prostate cancer treatment decision-making

OBJECTIVES

African American prostate cancer survivors experience post-treatment decisional regret more often than European Americans, which can lead to negative long-term effects on quality of life. A prominent driver of health-related decision-making is emotion, yet little work has examined the impact emotions may have on decisional regret. The goal of this study was to explore experiences, perceptions, and emotions of prostate cancer survivors in relation to their diagnostic and treatment decision-making processes, prostate cancer treatment, and outcomes. Additionally, we sought to identify factors that might explain differences in prostate cancer outcomes between African and European Americans.

DESIGN

This mixed-methods study utilized a convergent parallel design, in which quantitative and qualitative data were collected simultaneously and then integrated to more robustly explain relationships between variables. Survivors were eligible for the study if they had been previously diagnosed with localized prostate cancer and were no more than six months post-treatment. The study was guided by the Risk as Feelings Model, which predicts the relationship between emotion and cognition in high-risk decision-making.

RESULTS

No men experienced decisional regret following treatment, even if they experienced side effects. While all men reported being surprised about their prostate cancer diagnosis, strong negative emotions were more common among men under 65. Family support and spirituality appeared to mitigate negative emotions. Perceived authenticity of provider communication was the most influential mediator in men's decision-making and positive perceptions of their outcomes.

CONCLUSIONS

To mitigate the impact emotional responses have on decision-making and post-treatment regret, providers should explore alternate therapies (e.g. counseling for men diagnosed with prostate cancer at a young age) and include family members in prostate cancer treatment discussions. Most importantly, providers should be aware of the importance of quality communication on men's cognitive and emotional processes and their perceptions of treatment outcomes.

Examining the Association of Pain and Financial Hardship Among Older Men by Race in the United States

Pain associated with financial hardship among older men varies by race. The purpose of this study was to examine the association of financial hardship with the presence of pain in men 50 years and older by race. Using the Health and Retirement Study (HRS) 2010 wave, bivariate and multivariate logistic regression models were used to assess the association between four financial hardship indicators and total financial hardship as a composite score, and the presence of pain by race. Among White men, the association between the presence of pain and hardship controlling for demographic factors was statistically significant across four indicators and one composite score: ongoing financial hardship (OR = 1.29, 95% CI [1.02, 1.64]), food insecurity (OR = 2.55, 95% CI [1.51, 4.31]), taking less medication due to cost (OR = 2.12, 95% CI [1.40, 3.22]), difficulty paying bills (OR = 1.36, 95% CI [1.07, 1.73]), and total financial hardship (OR = 1.27, 95% CI [1.12, 1.44]). Among African American men, the association between the presence of pain and taking less medication due to cost (OR = 2.99, 95% CI [1.31, 6.85]) was significant. With increasing comorbidities among older adults, particularly African Americans, it is imperative to fully understand the mechanisms of this underexplored area in both the pain and financial hardship literature.

Mistreatment in Medical Care and Psychological Distress among Asian Americans

Although studies have shown that discrimination is linked to poor mental health, less is known about this relationship in the context of healthcare and how it varies for different Asian subgroups. The aim of this study was to examine the relationships between mistreatment in medical care and psychological distress among a diverse sample of Asian Americans. Data were drawn from the 2015-2017 California Health Interview Survey. A series of regression models were estimated to test the association between mistreatment in medical care and psychological distress. Various Asian subgroups showed different levels of psychological distress. Mistreatment in medical care was also linked to worse mental health. Findings, however, did not show significant differences in the interaction between mistreatment and ethnicity on psychological distress. This study advances knowledge on the experiences of Asian Americans and contributes to the literature showing the impact of discrimination on mental health.

Patient-provider communication patterns among Asian American immigrant subgroups in New York City

OBJECTIVES

Patient-provider communication is essential for patient-centered care, yet Asian American immigrant populations face barriers. We aim to describe: 1) patient-reported communication-related characteristics for 16 disaggregated Asian American subgroups; and 2) the association of patient comprehension of provider communication with socio-demographics, language proficiency and concordance, and perceived cultural sensitivity in this population.

METHODS

Descriptive statistics are presented for 1269 Asian American immigrants responding to cross-sectional, venue-sampled surveys conducted in New York City. Logistic regression models examine predictors of low comprehension of provider communication.

RESULTS

Approximately 11% of respondents reported low comprehension of provider communication: lowest among South Asians and highest among Southeast Asians. Eighty-four percent were language-concordant with their provider, 90.1% agreed that their provider understood their background and values, and 16.5% felt their provider looked down on them. Low comprehension of provider communication was significantly associated with Southeast Asian subgroup, less education, limited English proficiency, public health insurance, patient-provider language discordance, and perceived low cultural understanding.

CONCLUSION

Among our sample, language and cultural sensitivity are associated with comprehension of provider communication.

PRACTICE IMPLICATIONS

Strategies improving language access and cultural sensitivity may be important for Asian immigrant patients. These could include interpretation services, bilingual community-based providers, and cultural sensitivity training.

Therapeutic Alliance Between Bereaved Parents and Physicians in the PICU

OBJECTIVES

Therapeutic alliance is the collaborative bond that develops between patients/families and healthcare providers. Our objective is to determine the extent of therapeutic alliance bereaved parents perceive to have occurred with their child's physicians during their child's PICU stay, and associated factors.

DESIGN

Multicenter observational study.

SETTING

Eight children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network.

PATIENTS

Parents greater than or equal to 18 years old whose child died in a PICU (including cardiac ICU).

INTERVENTIONS

Bereaved parents completed the Human Connection Scale, a 16-item measure of therapeutic alliance, 6 months after their child's death. Human Connection Scale scores range from 16 to 64 with higher scores indicating greater alliance. Parents provided sociodemographic data, and medical records were reviewed for the child's clinical characteristics.

MEASUREMENTS AND MAIN RESULTS

Two-hundred and thirty-three parents of 157 deceased children responded to the Human Connection Scale with greater than or equal to 80% item completion. Among parents, 146 (62.7%) were female, 155 (66.5%) were White and 46 (19.7%) were Black, 175 (75.1%) were married, and 209 (89.7%) had at least a high-school education. Among children, median age at the time of death was 5.9 years (interquartile range, 0.64-13.9 yr) and 114 (72.6%) died after limitation or withdrawal of life support. Mean Human Connection Scale score was 51.4 ± 11.1 for all parents, 52.6 ± 9.0 for White parents, and 47.0 ± 13.7 for Black parents. In multivariable modeling predicting Human Connection Scale scores, race was the only parent or child characteristic in the final model. Human Connection Scale scores were significantly different (-4.56; 95% CI, -8.53 to -0.6; p = 0.025) between the Black and White parents with items about trust, care, and honest communication showing the greatest mean difference.

CONCLUSIONS

Among parents bereaved in the PICU, therapeutic alliance with physicians is moderately high. Future research should identify strategies to strengthen therapeutic alliance with Black parents and examine the role of alliance on bereaved parents' health outcomes.

Justice and unintentional discrimination in health care: A qualitative content analysis

BACKGROUND:

Discrimination in health care is a common phenomenon whose complete understanding has always been a major concern of health-care systems to control and reduce it. This study aimed to explore the experiences of unintentional discrimination and related factors in health-care providers.

MATERIALS AND METHODS:

This qualitative study was conducted with a content analysis approach in 2019. Data were collected through semi-structured interviews with 13 health-care providers including two physicians, three nursing supervisors, two head nurses, four staff nurses, and two nurse aides in two general hospitals in Tehran, Iran. Participants were selected through purposeful sampling. The obtained data were analyzed by Graneheim and Lundman method.

RESULTS:

Three main categories and eight subcategories were obtained from the data analysis: (1) forced discrimination (superiors' pressures and executive orders, occupational concerns, and fear of the superiors); (2) guided discrimination (professional challenges, managers' policymaking, and lack of medical ethics knowledge); and (3) lack of resources (workforce shortage and lack of medical equipment).

CONCLUSION:

The results of this study suggest that health-care providers such as doctors and nurses are unintentionally forced to provide discriminatory care on some occasions. Knowing and managing these unwanted factors can partly counteract unintentional discrimination. Thus, preventing the factors that lead to superiors' pressures and occupational forces and improving the medical ethics knowledge should be considered by health-care managers.

Depression Mediates Association Between Perceived Ethnic Discrimination and Elevated Blood Glucose Levels Among Sub-Saharan African Migrants in Australia

Depression and perceived ethnic discrimination (PED) are both implicated in type 2 diabetes mellitus (T2DM) risk in some migrant populations. The role of these factors remains understudied in sub-Saharan African migrants, who comprise a significant at-risk group for T2DM in Australia. To assess interactions between PED, depression scores and elevated blood glucose levels among sub-Sahara African immigrants in North-Eastern Australia. Face to face surveys were used to assess PED and depressive tendencies in a purposive sample of 170 adults (aged ≥18 year). Fasting blood glucose levels (FBGL) were measured at the time of interviews. Prevalence of elevated FBGL (≥6.1 mmol/L), PED and severe depression (SD) were: 17.6% (n = 30), 14.7% (n = 25) and 18.8% (n = 32), respectively. Prevalence of elevated FBGL, PED and SD were all higher in males than females. The highest prevalence of elevated BGL, PED and SD each occurred in the 40-50 year age group. Strong positive correlations of both high level PED and SD with elevated FBGL were observed. There was also a strong positive association between PED and SD. Depression score was found to mediate partially the strong association between PED and elevated FBGL (β-value for PED dropped from β = 0.452 to β = 0.246, p < 0.01 and the associated between FBGL and SD remained strong β = 0.554, p < 0.01). The strong association between elevated FBGL and PED seems to be moderated by SD, indicating that interventions to attenuate depression and PED may be a useful adjunct to diabetes prevention programs in this population. Interventions targeted to specific age groups may also be warranted.

Patient-Reported Experiences of Discrimination in the US Health Care System

Importance

Although considerable evidence exists on the association between negative health outcomes and daily experiences of discrimination, less is known about such experiences in the health care system at the national level. It is critically necessary to measure and address discrimination in the health care system to mitigate harm to patients and as part of the larger ongoing project of responding to health inequities.

Objectives

To (1) identify the national prevalence of patient-reported experiences of discrimination in the health care system, the frequency with which they occur, and the main types of discrimination experienced and (2) examine differences in the prevalence of discrimination across demographic groups.

Design, Setting, and Participants

This cross-sectional national survey fielded online in May 2019 used a general population sample from the National Opinion Research Center's AmeriSpeak Panel. Surveys were sent to 3253 US adults aged 21 years or older, including oversamples of African American respondents, Hispanic respondents, and respondents with annual household incomes below 200% of the federal poverty level.

Main Outcomes and Measures

Analyses drew on 3 survey items measuring patient-reported experiences of discrimination, the primary types of discrimination experienced, the frequency with which they occurred, and the demographic and health-related characteristics of the respondents. Weighted bivariable and multivariable logistic regressions were conducted to assess associations between experiences of discrimination and several demographic and health-related characteristics.

Results

Of 2137 US adult respondents who completed the survey (66.3% response rate; unweighted 51.0% female; mean [SD] age, 49.6 [16.3] years), 458 (21.4%) reported that they had experienced discrimination in the health care system. After applying weights to generate population-level estimates, most of those who had experienced discrimination (330 [72.0%]) reported experiencing it more than once. Of 458 reporting experiences of discrimination, racial/ethnic discrimination was the most common type (79 [17.3%]), followed by discrimination based on educational or income level (59 [12.9%]), weight (53 [11.6%]), sex (52 [11.4%]), and age (44 [9.6%]). In multivariable analysis, the odds of experiencing discrimination were higher for respondents who identified as female (odds ratio [OR], 1.88; 95% CI, 1.50-2.36) and lower for older respondents (OR, 0.98; 95% CI, 0.98-0.99), respondents earning at least $50 000 in annual household income (OR, 0.76; 95% CI, 0.60-0.95), and those reporting good (OR, 0.59; 95% CI, 0.46-0.75) or excellent (OR, 0.41; 95% CI, 0.31-0.56) health compared with poor or fair health.

Conclusions and Relevance

The results of this study suggest that experiences of discrimination in the health care system appear more common than previously recognized and deserve considerable attention. These findings contribute to understanding of the scale at which interpersonal discrimination occurs in the US health care system and provide crucial evidence for next steps in assessing the risks and consequences of such discrimination. The findings also point to a need for further analysis of how interpersonal discrimination interacts with structural inequities and social determinants of health to build effective responses.

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.

Co-Occurring Youth Profiles of Adverse Childhood Experiences and Protective Factors: Associations with Health, Resilience, and Racial Disparities

It is important to understand racial/ethnic differences in adverse childhood experiences (ACEs), given their relationship to long-term physical and mental health, and the public health cost of the significant disparities that exist. Moreover, in order to inform interventions and promote resilience, it is critical to examine protective factors that mitigate the relationship between adversity and poor health. The current study utilized latent transition analyses (LTA) to examine co-occurring profiles of ACEs and protective factors (from school, family, and community contexts) and links to health outcomes among 30,668 Black (10.4%), Latinx (12.3%), and White youth (77.3%) ages 12-17 (52.5% male) who participated in the 2011-12 National Survey of Children's Health (NSCH). Results suggested that greater adversity was associated with worse health, while more access to protective factors was associated with better health. White youth had consistently lower endorsement of ACEs, greater access to protective factors, and better health compared to their Black and Latinx counterparts. Efforts to improve child health and racial/ethnic disparities in research and practice must consider adversity, protective factors, and the systemic inequities faced by racial/ethnic minority youth in the United States.

Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals

Perceived discrimination based on criminal record is associated with social determinants of health such as housing and employment. However, there is limited data on discrimination based on criminal record within health care settings. We examined how perceived discrimination based on criminal record within health care settings, among individuals with a history of incarceration, was associated with self-reported general health status. We used data from individuals recruited from 11 sites within the Transitions Clinic Network (TCN) who were released from prison within the prior 6 months, had a chronic health condition and/or were age 50 or older, and had complete information on demographics, medical history, self-reported general health status, and self-reported perceived discrimination (n = 743).Study participants were mostly of minority racial and ethnic background (76%), and had a high prevalence of self-reported chronic health conditions with half reporting mental health conditions and substance use disorders (52% and 50%, respectively), and 85% reporting one or more chronic medical conditions. Over a quarter (27%, n = 203) reported perceived discrimination by health care providers due to criminal record with a higher proportion of individuals with fair or poor health reporting discrimination compared to those in good or excellent health (33% vs. 23%; p = .002). After adjusting for age and reported chronic conditions, participants reporting discrimination due to criminal record had 43% increased odds of reporting fair/poor health (AOR 1.43, 95% CI 1.01-2.03). Race and ethnicity did not modify this relationship.Participants reporting discrimination due to criminal record had increased odds of reporting fair/poor health. The association between perceived discrimination by health care providers due to criminal record and health should be explored in future longitudinal studies among individuals at high risk of incarceration.Clinical Trial Registration: NCT01863290.

The role of feature-based discrimination in driving health disparities among Black Americans

Objective: A growing body of research finds that darker skin tone is often associated with poorer physical and mental health in Blacks. However, the psychosocial mechanisms underlying the skin tone-health link remain elusive. The present study seeks to address this knowledge gap by investigating the direct and indirect (through perceived discrimination, socioeconomic status, and self-esteem) effects of skin tone on self-reported physical and mental health.Design: An urban sample of 130 Blacks aged 35 and above completed a self-administered computerized survey as a part of larger cross-sectional study.Results: Self-esteem played a particularly important role in mediating the associations between skin tone and self-reported physical and mental health. This suggests that self-esteem could be a point of intervention to help Blacks with darker skin tone achieve better health.Conclusion: The present study highlights the important role feature-based discrimination plays in determining mental and physical health outcomes among Blacks.

Percepção de Preconceito num Quilombo Urbano do Sul do Brasil

Resumo O negro, e por consequência as populações quilombolas, em uma sociedade racista e preconceituosa, participa de um processo de (re)construção identitária que passa, necessariamente, por questões culturais, históricas, de território e de parentesco. Nesse sentido, o objetivo deste estudo foi conhecer a percepção de moradores de um quilombo sobre o preconceito racial vivenciado por eles. Para isso, realizou-se uma pesquisa qualitativa, descritiva e exploratória, tendo como participantes seis residentes em posições de liderança num quilombo urbano: duas adolescentes, dois adultos e duas idosas. Foram feitas entrevistas com perguntas semiestruturadas, abordando história de vida e percepção sobre discriminação racial. Os dados foram gravados e filmados, para, posteriormente, serem transcritos. Para a análise, utilizou-se a Análise de Conteúdo Temática. Os principais resultados apontaram diferenças significativas entre a percepção de adolescentes, por um lado, e adultos e idosos, por outro. Os adultos e as idosas indicaram não se sentirem discriminados por serem negros e moradores de quilombo, ao contrário das adolescentes, que referiram sofrer bullying por esses motivos na escola e em ambientes públicos como shoppings e comércios em geral. As idosas relataram sentir-se discriminadas em função da idade, mas nunca pela sua negritude ou pelo local onde moram. Entende-se que esta percepção tão diferente entre jovens, adultos e idosos deva-se, principalmente, ao nível de escolaridade mais elevado das adolescentes e, consequentemente, à sua maior capacidade reflexiva. Esta lhes permite perceber por si mesmas aquilo que não lhes foi dito no grupo familiar e que lhes foi ocultado nos debates escolares.

End-of-Life Concerns and Experiences of Living With Advanced Breast Cancer Among Medically Underserved Women

CONTEXT

Breast cancer morbidity and mortality disproportionately affect medically underserved women. Most studies of the experience of living with advanced breast cancer do not focus on this population. A deeper understanding of racial/ethnic minorities' and low-income patients' experiences is needed to reduce breast cancer health and health care disparities.

OBJECTIVES

This qualitative, community-based participatory research study explores the lived experiences of medically underserved women with advanced breast cancer.

METHODS

We conducted in-depth, semistructured interviews with low-income patients from a community clinic and safety-net hospital, focusing on issues related to advanced breast cancer and end of life. Six team members independently coded transcripts, jointly reconciled coding differences, and identified key themes.

RESULTS

All 63 participants (83% response rate) had an income ≤200% of the federal poverty level; 68% identified as a racial/ethnic minority. Four predominant themes emerged: compounding of pre-existing financial distress, perceived bias/lack of confidence in medical care received, balancing personal needs with the needs of others, and enhanced engagement with sources of life meaning.

CONCLUSION

Participants resiliently maintained engaged lives yet described extreme financial duress and perceived provider bias, which are known contributors to worse quality of life and health outcomes. Participants downplayed their desire to discuss dying to accommodate pressure to "stay positive" and to mitigate others' discomfort. Improving care for underserved women with advanced cancer will require addressing disparities from screening through hospice, developing personalized opportunities to discuss death and dying, and enhancing access to and affordability of medical and social support.

A Health Profile and Overview of Healthcare Experiences of Cambodian American Refugees and Immigrants Residing in Southern California

Asian Americans are understudied in health research and often aggregated into one homogenous group, thereby disguising disparities across subgroups. Cambodian Americans, one of the largest refugee communities in the United States, may be at high risk for adverse health outcomes. This study compares the health status and healthcare experiences of Cambodian American refugees and immigrants. Data were collected via questionnaires and medical records from two community clinics in Southern California (n = 308). Chi square and t-tests examined the socio-demographic differences between immigrants and refugees, and ANCOVA models compared the mean differences in responses for each outcome, adjusting for age at immigration, education level, and clinic site. Cambodian American refugees reported overall lower levels of health-related quality of life (all p's < 0.05 in unadjusted models) and self-rated health [unadjusted means (SD) = 18.2 (16.8) vs. 21.7 (13.7), p < 0.05], but either similar or more positive healthcare experiences than Cambodian American immigrants. In adjusted analyses, refugees had higher rates of diabetes and cardiovascular disease risk (e.g. heart condition and hypertension; p's < 0.05) compared to Cambodian American immigrants. There were minimal differences in self-reported health behaviors between the two groups. There is a need for more health promotion efforts among Cambodian American refugees and immigrants to improve their health outcomes and perceived wellbeing.

Changes in Perceptions of Discrimination in Health Care in California, 2003 to 2017

IMPORTANCE

Research in the early 2000s in California demonstrated that racial and ethnic minorities, immigrants, and those with limited English proficiency (LEP) experienced high rates of discrimination in health care. Less is known about how patients' perceptions of discrimination in health care have changed since then.

OBJECTIVE

To determine whether perceptions of discrimination in health care have changed overall and for specific vulnerable populations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the California Health Interview Survey for state residents aged 18 years and older for 2 periods, 2003 to 2005 and 2015 to 2017. χ2 analyses and multivariate logistic regression were performed to compare recent discrimination in health care in late vs early periods controlling for race/ethnicity, poverty level, education, insurance status, usual source of care, self-reported health, and LEP. Additional subanalyses were performed by race/ethnicity, immigrant status, and LEP status. Jackknife replicate weights were provided by the California Health Interview Survey.

EXPOSURE

Survey year was dichotomized as combined 2003 to 2005 and combined 2015 to 2017.

MAIN OUTCOMES AND MEASURES

Survey respondents were identified as having experienced recent discrimination in health care if they responded "yes" to the question, "Was there ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?" and reported that this occurred within the last 5 years.

RESULTS

There were 84 088 participants in 2003 to 2005 (51.0% female; 14.7% aged ≥65 years) and 63 242 participants in 2015 to 2017 (51.1% female; 18.0% aged ≥65 years). Rates of recent discrimination in health care decreased from 6.0% to 4.0% (difference, 2.0%; 95% CI, 1.5%-2.5%; P < .001). In adjusted analyses, perceptions of discrimination in health care decreased in 2015 to 2017 compared with 2003 to 2005 (odds ratio [OR], 0.60; 95% CI, 0.53-0.68; P < .001). There was a significant race × period interaction for Latino individuals (OR, 0.58; 95% CI, 0.40-0.83; P = .003) but not for Asian individuals (OR, 0.76; 95% CI, 0.50-1.16; P = .20) or African American individuals (OR, 1.24; 95% CI, 0.76-2.02; P = .40). There was a significant immigrant status × period interaction (OR, 0.55; 95% CI, 0.44-0.69; P < .001) and LEP status × period interaction (OR, 0.67; 95% CI, 0.51-0.89; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that perceptions of discrimination in health care in California decreased between 2003 to 2005 and 2015 to 2017 among Latino individuals, immigrants, and those with LEP. African American participants reported consistently high rates of discrimination, indicating that interventions targeting health care discrimination are still necessary.

Perceived discrimination in medical settings and perceived quality of care: A population-based study in Chicago

Perceived discrimination in medical settings remains prevalent within the U.S. health care system. However, the details of these experiences and their associations with perceived quality of care are not well understood. Our study assessed multiple measures of perceived racial/ethnic discrimination in medical settings and investigated the locations and purported perpetrators of the discriminatory experiences within a population-based sample of 1,543 Black, White, Mexican, Puerto Rican, and Other adults. We used logistic regression to estimate associations between perceived discrimination in the medical setting and three quality of care indicators. Overall, 40% of the sample reported one or more types of perceived discrimination in a medical setting, with significant differences by race/ethnicity. Discrimination was perceived across health settings and from a variety of providers and staff. In adjusted logistic regression models, individuals reporting discrimination had more than twice the odds of reporting fair or poor quality of care (OR = 2.4 [95% CI: 1.4-4.3]). In addition, perceived discrimination in medical settings was significantly associated with report of not having enough time with the physician and not being as involved in decision-making as desired. These findings expand our understanding of perceived discriminatory experiences in health care and the consequences of it for patients, providers, and health care systems. This information is essential for identifying future provider interventions and improving the training of health care professionals.

Medical Mistrust, Racism, and Delays in Preventive Health Screening Among African-American Men

The contribution of medical mistrust to healthcare utilization delays has gained increased public health attention. However, few studies examine these associations among African-American men, who delay preventive healthcare more often and report higher levels of medical mistrust than non-Hispanic White men. Additionally, studies rarely account for other factors reportedly working in tandem with medical mistrust to increase African-American men's preventive health screening delays (i.e., everyday racism and perceived racism in healthcare). We examined associations between medical mistrust, perceived racism in healthcare, everyday racism, and preventive health screening delays. Analyses were conducted using cross-sectional data from 610 African-American men aged 20 years and older recruited primarily from barbershops in four US regions (2003-2009). Independent variables were medical mistrust (MM), everyday racism (ER), and perceived racism in healthcare (PRH). Dependent variables were self-reported routine checkup, blood pressure screening, and cholesterol screening delays. Using multiple logistic regression and tests for mediation, we calculated odds ratios and 95% confidence intervals to assess associations between the independent and dependent variables. After final adjustment, African-American men with higher MM were significantly more likely to delay blood pressure screenings. Men with more frequent ER exposure were significantly more likely to delay routine checkups and blood pressure screenings. Higher levels of PRH were associated with a significant increased likelihood of delaying cholesterol screening. MM did not mediate associations between ER and screening delays. Increasing preventive health screening among African-American men requires addressing medical mistrust and racism in and outside healthcare institutions.

Racial Discrimination in Health Care and Utilization of Health Care: a Cross-sectional Study of California Adults

BACKGROUND

Racial and ethnic discrimination in health care have been associated with suboptimal use of health care. However, limited research has examined how facets of health care utilization influence, and are influenced by, discrimination.

OBJECTIVE

This study aimed to determine if type of insurance coverage and location of usual source of care used were associated with perceptions of racial or ethnic discrimination in health care. Additionally, this study examined if perceived racial or ethnic discrimination influenced delaying or forgoing prescriptions or medical care.

DESIGN

Data from the 2015-2016 California Health Interview Survey were used. Logistic regression models estimated odds of perceiving racial or ethnic discrimination from insurance type and location of usual source of care. Logistic regression models estimated odds of delaying or forgoing medical care or prescriptions.

PARTICIPANTS

Responses for 39,171 adults aged 18 and over were used.

MAIN MEASURES

Key health care utilization variables were as follows: current insurance coverage, location of usual source of care, delaying or forgoing medical care, and delaying or forgoing prescriptions. We examined if these effects differed by race. Ever experiencing racial or ethnic discrimination in the health care setting functioned as a dependent and independent variable in analyses.

KEY RESULTS

When insurance type and location of care were included in the same model, only the former was associated with perceived discrimination. Specifically, those with Medicaid had 66% higher odds of perceiving discrimination, relative to those with employer-sponsored coverage (AOR = 1.66; 95% CI 1.11, 2.47). Race did not moderate the impact of discrimination. Perceived discrimination was associated with higher odds of delaying or forgoing both prescriptions (AOR = 1.97; 95% CI 1.26, 3.09) and medical care (AOR = 1.84; 95% CI 1.31, 2.59).

CONCLUSIONS

Health care providers have an opportunity to improve the experiences of their patients, particularly those with publicly sponsored coverage.

Equitable health: let's stick together as we address global discrimination, prejudice and stigma

Tackling discrimination permanently in healthcare is not insurmountable. It is achievable. Discrimination is costly in lives, in healthcare delivery and waste, in human capital, in financial resource and even in healthcare improvement initiatives that do not adequately account for its impact. Healthcare must understand the underlying inequalities each faces from the start and tailor care toward equal health outcomes. Solutions have been offered and should be funded and evaluated. Additionally, a global plan to address discrimination and bias in healthcare must be consistent, accountable and be shaped around standardized tools and measures. The idea that an individual is better or more important than another has no place in today’s world, particularly in health. Therefore, it is critical that each is provided his or her individual needs to achieve best outcomes. It is critical for healthcare to advance health equity. Global healthcare must do its part to be a team leader on this issue.

Racial and cultural minority experiences and perceptions of health care provision in a mid-western region

Background

Disparities across a number of health indicators between the general population and particular racial and cultural minority groups including African Americans, Native Americans and Latino/a Americans have been well documented. Some evidence suggests that particular groups may receive poorer standards of care due to biased beliefs or attitudes held by health professionals. Less research has been conducted in specifically non-urban areas with smaller minority populations.

Methods

This study explored the self-reported health care experiences for 117 racial and cultural minority Americans residing in a Mid-Western jurisdiction. Prior health care experiences (including perceived discrimination), attitudes towards cultural competence and satisfaction with health care interactions were ascertained and compared across for four sub-groups (African-American, Native American, Latino/a American, Asian American). A series of multiple regression models then explored relationships between a concert of independent variables (cultural strength, prior experiences of discrimination, education level) and health care service preferences and outcomes.

Results

Overall, racial/cultural minority groups (African Americans, Native Americans, Latino/a Americans, and Asian Americans) reported general satisfaction with current healthcare providers, low levels of both health care provider racism and poor treatment, high levels of cultural strength and good access to health care services. Native American participants however, reported more frequent episodes of poor treatment compared to other groups. Incidentally, poor treatment predicted lower levels of treatment satisfaction and racist experiences predicted being afraid of attending conventional health care services. Cultural strength predicted a preference for consulting a health care professional from the same cultural background.

Conclusions

This study provided a rare insight into minority health care expectations and experiences in a region with comparatively lower proportions of racial and cultural minorities. Additionally, the study explored the impact of cultural strength on health care interactions and outcomes. While the bulk of the sample reported satisfaction with treatment, the notable minority of participants reporting poor treatment is still of some concern. Cultural strength did not appear to impact health care behaviours although it predicted a desire for cultural matching. Implications for culturally competent health care provision are discussed within.

Differential reporting of discriminatory experiences in Brazil and the United States

There has been little cross-national comparison of perceived discrimination, and few studies have considered how intersectional identities shape perception of discriminatory treatment in different societies. Using data from the ELSA-Brasil, a study of Brazilian civil servants, and the Americans' Changing Lives Study, a nationally-representative sample of U.S. adults, we compare reports of lifetime discrimination among race-by-gender groups in each society. We also consider whether educational attainment explains any group differences, or if differences across groups vary by level of education. Results reveal higher lifetime discrimination experiences among Black respondents in both countries, especially Black men, than among Whites, and lower reports among White women than White men. Brown men and women also reported higher levels than White men in Brazil. For all race-by-gender groups in both countries, except Brazilian White men, reports of discrimination were higher among the more educated, though adjusting for educational differences across groups did not explain group differences. In Brazil, we found the greatest racial disparities among the college educated, while U.S. Black men were more likely to report discrimination than White men at all levels of education. Results reveal broad similarities across countries, despite important differences in their histories, and an intersectional approach contributed to identification of these similarities and some differences in discrimination experiences. These findings have implications for social and public health surveillance and intervention to address the harmful consequences of discrimination.

Determining the spatial heterogeneity underlying racial and ethnic differences in timely mammography screening

BACKGROUND

The leading cause of cancer death for women worldwide continues to be breast cancer. Early detection through timely mammography has been recognized to increase the probability of survival. While mammography rates have risen for many women in recent years, disparities in screening along racial/ethnic lines persist across nations. In this paper, we argue that the role of local context, as identified through spatial heterogeneity, is an unexplored dynamic which explains some of the gaps in mammography utilization by race/ethnicity.

METHODS

We apply geographically weighted regression methods to responses from the 2008 Public Health Corporations' Southeastern Household Health Survey, to examine the spatial heterogeneity in mammograms in the Philadelphia metropolitan area.

RESULTS

We find first aspatially that minority identity, in fact, increases the odds of a timely mammogram: 74% for non-Hispanic Blacks and 80% for Hispanic/Latinas. However, the geographically weighted regression confirms the relation of race/ethnicity to mammograms varies by space. Notably, the coefficients for Hispanic/Latinas are only significant in portions of the region. In other words, the increased odds of a timely mammography we found are not constant spatially. Other key variables that are known to influence timely screening, such as the source of healthcare and social capital, measured as community connection, also vary by space.

CONCLUSIONS

These results have ramifications globally, demonstrating that the influence of individual characteristics which motivate, or inhibit, cancer screening may not be constant across space. This inconsistency calls for healthcare practitioners and outreach services to be mindful of the local context in their planning and resource allocation efforts.

Hispanics' Satisfaction with Free Clinic Providers: An Analysis of Patient-Centered Medical Home Characteristics

Hispanic Americans are less likely to be insured and they experience cultural and linguistic barriers that may prevent them from obtaining necessary and preventive healthcare. Adoption of Patient Centered Medical Home (PCMH) concepts in healthcare settings utilized by Hispanics could improve Hispanic patients' satisfaction with their healthcare providers. This study examined the association between Spanish-speaking and non-Spanish-speaking patients' perceptions of PCMH characteristics and satisfaction with the provider. Data were collected using a self-administered survey from two unaffiliated free clinics. Logistic regression modeled the associations between patients' perceptions of PCMH and their satisfaction with their provider, and their desire to see the same provider in the future. The sample consisted of 367 adults; 44 % were Spanish-speaking. Spanish-speaking patients were younger, less educated, and had fewer chronic conditions than non-Spanish-speaking patients. In adjusted analyses for each population, better ratings of the provider's communication skills were associated with increased satisfaction with the provider (Spanish-speaking: OR = 8.33, 95 % CI = 2.19-31.76; non-Spanish-speaking: OR = 31.39, 95 % CI = 6.91-142.62), and willingness to see the provider again (Spanish-speaking: OR = 12.54, 95 % CI = 2.80-56.24; non-Spanish-speaking: OR = 8.77, 95 % CI = 2.40-31.96). Among Spanish-speakers, lower perceived discrimination was associated with 137 % increased odds and higher perceived staff helpfulness had 212 % increased odds of seeing the provider again. Relative to other PCMH components, interpersonal skills were the most important factors in patient satisfaction with free clinics. Increased training for clinicians on cultural competence and clinician-patient communication may lead to improved patient satisfaction for both Spanish and non-Spanish speakers seen at free clinics, particularly clinics in states without Medicaid expansion.