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Ashana DC, Johnson KS, Cox CE. Improving Equity in Shared Decision-Making-Reply. JAMA Intern Med 2024; 184:1131. [PMID: 39008319 DOI: 10.1001/jamainternmed.2024.2996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Affiliation(s)
- Deepshikha C Ashana
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Kimberly S Johnson
- Department of Medicine, Duke University, Durham, North Carolina
- Geriatrics Research Education and Clinical Center (GRECC), Durham VA Healthcare System, Durham, North Carolina
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Vadlakonda A, Curry J, Gao Z, Chervu N, Ali K, Lee H, Thompson CK, Benharash P. Current Status of Contralateral Prophylactic Mastectomy: Investigating Structural Racial Disparity. J Am Coll Surg 2024; 239:253-262. [PMID: 38602342 DOI: 10.1097/xcs.0000000000001089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Contralateral prophylactic mastectomy (CPM) remains a personal decision, influenced by psychosocial factors, including cosmesis and peace of mind. Although use of CPM is disproportionately low among Black patients, the degree to which these disparities are driven by patient- vs hospital-level factors remains unknown. STUDY DESIGN Patients undergoing mastectomy for nonmetastatic ductal or lobular breast cancer were tabulated using the National Cancer Database from 2004 to 2020. The primary endpoint was receipt of CPM. Multivariable logistic regression models were constructed with interaction terms between Black-serving hospital (BSH) status and patient race to evaluate associations with CPM. Cox proportional hazard models were used to evaluate long-term survival. RESULTS Of 597,845 women studied, 70,911 (11.9%) were Black. After multivariable adjustment, Black race (adjusted odds ratio 0.65, 95% CI 0.64 to 0.67) and treatment at BSH (adjusted odds ratio 0.84, 95% CI 0.83 to 0.85) were independently linked to lower odds of CPM. Although predicted probability of CPM was universally lower at higher BSH, Black patients faced a steeper reduction compared with White patients. Receipt of CPM was linked to improved survival (hazard ratio [HR] 0.84, 95% CI 0.83 to 0.86), whereas Black race was associated with a greater HR of 10-year mortality (HR 1.14, 95% CI 1.12 to 1.17). CONCLUSIONS Hospitals serving a greater proportion of Black patients are less likely to use CPM, suggestive of disparities in access to CPM at the institutional level. Further research and education are needed to characterize surgeon-specific and institutional practices in patient counseling and shared decision-making that shape disparities in access to CPM.
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Affiliation(s)
- Amulya Vadlakonda
- From the Department of Surgery (Vadlakonda, Curry, Gao, Chervu, Ali, Benharash)
| | - Joanna Curry
- From the Department of Surgery (Vadlakonda, Curry, Gao, Chervu, Ali, Benharash)
| | - Zihan Gao
- From the Department of Surgery (Vadlakonda, Curry, Gao, Chervu, Ali, Benharash)
| | - Nikhil Chervu
- From the Department of Surgery (Vadlakonda, Curry, Gao, Chervu, Ali, Benharash)
| | - Konmal Ali
- From the Department of Surgery (Vadlakonda, Curry, Gao, Chervu, Ali, Benharash)
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA (Lee)
| | - Carlie K Thompson
- Division of General Surgery, Department of Surgery (Thompson), University of California, Los Angeles, CA
| | - Peyman Benharash
- From the Department of Surgery (Vadlakonda, Curry, Gao, Chervu, Ali, Benharash)
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Naar S, Pettus C, Anderson N, Pooler-Burgess M, Ralston P, Flynn H, Combs T, Baquet C, Schatschneider C, Luke D. Study protocol for transforming health equity research in integrated primary care: Antiracism as a disruptive innovation. PLoS One 2024; 19:e0306185. [PMID: 38935743 PMCID: PMC11210870 DOI: 10.1371/journal.pone.0306185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 06/11/2024] [Indexed: 06/29/2024] Open
Abstract
Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups.
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Affiliation(s)
- Sylvie Naar
- Center for Translational Behavioral Science, Florida State University, Tallahassee, FL, United States of America
| | - Carrie Pettus
- Wellbeing & Equity Innovations, Tallahassee, FL, United States of America
| | - Norman Anderson
- Office of Vice President for Research and College of Social Work, Florida State University, Tallahassee, FL, United States of America
| | - Meardith Pooler-Burgess
- Center for Translational Behavioral Science, Florida State University, Tallahassee, FL, United States of America
| | - Penny Ralston
- Center on Better Health and Life for Underserved Populations, Florida State University, Tallahassee, FL, United States of America
| | - Heather Flynn
- Department of Behavioral Sciences and Social Medicine, Florida State University, Tallahassee, FL, United States of America
| | - Todd Combs
- Center for Public Health Systems Science, Brown School, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Claudia Baquet
- Hope Institute, LLC and UM School of Pharmacy, Baltimore, Maryland, United States of America
| | | | - Douglas Luke
- Center for Public Health Systems Science, Brown School, Washington University in St. Louis, St. Louis, Missouri, United States of America
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Carroll L, Cook A, Sebastian A. Do no harm: A call to action by nurses to dismantle structural violence against LGBTQ+ youth. Nurs Outlook 2024; 72:102201. [PMID: 38870554 DOI: 10.1016/j.outlook.2024.102201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 06/15/2024]
Abstract
This commentary addresses structural violence - an overlooked and unrecognized harm within nursing. Structural violence within nursing practice refers to the violent impacts of racism, classism, homophobia, and transphobia as well as other biases on vulnerable and underprivileged groups. As one of the largest and most trusted health professions, collectively nursing has the power to leverage their influence to mitigate the harmful effects of structural violence when caring for LGBTQ+ youth.
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Affiliation(s)
- Lacretia Carroll
- University of Tennessee Health Science Center, College of Nursing, Memphis, TN.
| | - Alex Cook
- University of Tennessee Health Science Center, College of Nursing, Memphis, TN
| | - Andrea Sebastian
- University of Tennessee Health Science Center, College of Nursing, Memphis, TN
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Clark RRS, Klaiman T, Sliwinski K, Hamm RF, Flores E. Using incident reports to diagnose communication challenges for precision intervention in learning health systems: A methods paper. Learn Health Syst 2024; 8:e10425. [PMID: 38883872 PMCID: PMC11176586 DOI: 10.1002/lrh2.10425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/10/2024] [Accepted: 04/15/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself. Methods We abstracted incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes. Results The use of incident reports to conduct research on communication was new for the health system. Conversations with health system-level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis-requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work. Conclusions Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation.
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Affiliation(s)
- Rebecca R S Clark
- Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Philadelphia Pennsylvania USA
- University of Pennsylvania Health System Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics Philadelphia Pennsylvania USA
| | - Tamar Klaiman
- University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Kathy Sliwinski
- Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics Philadelphia Pennsylvania USA
| | - Rebecca F Hamm
- University of Pennsylvania Health System Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics Philadelphia Pennsylvania USA
- Division of Maternal-Fetal Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Emilia Flores
- Center for Evidence-Based Practice University of Pennsylvania Health System Philadelphia Pennsylvania USA
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Brown CE, Jackson SY, Marshall AR, Pytel CC, Cueva KL, Doll KM, Young BA. Discriminatory Healthcare Experiences and Medical Mistrust in Patients With Serious Illness. J Pain Symptom Manage 2024; 67:317-326.e3. [PMID: 38218413 PMCID: PMC11000579 DOI: 10.1016/j.jpainsymman.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/03/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
CONTEXT Though discrimination in healthcare settings is increasingly recognized, the discriminatory experiences of patients with serious illness has not been well studied. OBJECTIVES Describe racial differences in patient-reported experiences with discrimination in the healthcare setting and examine its association with mistrust. METHODS We used surveys containing patient-reported frequency of discrimination using the Discrimination in Medical Setting (DMS) and Microaggressions in Health Care Settings (MHCS) scales, mistrust using the Group Based Medical Mistrust (GBMM) scale, and patient characteristics including patient-reported race, income, wealth, insurance status, and educational attainment. Univariable and multivariable linear regression models as well as risk ratios were used to examine associations between patient characteristics including self-reported race, and DMS, MHCS, and GBMM scores. RESULTS In 174 participants with serious illness, racially minoritized patients were more likely to report experiencing discrimination and microaggressions. In adjusted analyses, DMS scores were associated with elements of class and not with race. Black, Native American/Alaskan Native (NA/AN), and multiracial participants had higher MHCS scores compared to White participants with similar levels of income and education. Higher income was associated with lower GBMM scores in participants with similar DMS or MHCS scores, but Black and NA/AN participants still reported higher levels of mistrust. CONCLUSION In this cross-sectional study of patients with serious illness, discriminatory experiences were associated with worse mistrust in the medical system, particularly for Black and NA/AN participants. These findings suggest that race-conscious approaches are needed to address discrimination and mistrust in marginalized patients with serious illness and their families.
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Affiliation(s)
- Crystal E Brown
- Cambia Palliative Care Center of Excellence at UW Medicine (C.E.B., A.R.M.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine (C.E.B.), Department of Medicine, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities (C.E.B.), School of Medicine, University of Washington, Seattle, Washington, USA.
| | - Sandra Y Jackson
- United States Army (S.Y.J.), Center for Army Analysis, Fort Belvoir, Virginia, USA
| | - Arisa R Marshall
- Cambia Palliative Care Center of Excellence at UW Medicine (C.E.B., A.R.M.), Seattle, Washington, USA
| | - Christina C Pytel
- Department of Anesthesiology and Pain Medicine (C.C.P.), University of Washington, Seattle, Washington, USA
| | - Kristine L Cueva
- Department of Medicine (K.L.C.), University of Washington, Seattle, Washington, USA
| | - Kemi M Doll
- Division of Gynecologic Oncology (K.M.D.), Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Bessie A Young
- Division of Nephrology (B.A.Y.), Department of Medicine, University of Washington, Seattle, Washington, USA; Justice, Equity, Diversity, and Inclusion Center for Transformational Research (B.A.Y.), Office of Healthcare Equity, University of Washington, Seattle, Washington, USA
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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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Juarez PD. Economic Determinants of Health Disparities and the Role of the Primary Care Provider. Prim Care 2023; 50:561-577. [PMID: 37866831 DOI: 10.1016/j.pop.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
The economic determinants of adverse personal health outcomes and population level disparities pose a daunting challenge for primary care providers in promoting health for persons experiencing poverty and neighborhood deprivation. Until they are addressed, however, the health and economic well-being of persons experiencing neighborhood deprivation is not likely to be improved. There is growing evidence of effective interventions that primary care providers can adopt to address social and economic determinants of health. Primary care providers can participate in clinic and community-based approaches that target individual, neighborhood and social level drives of health and disparities.
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Affiliation(s)
- Paul D Juarez
- Department of Family & Community Medicine, Meharry Medical College, 1005 Dr. DB Todd Jr. Boulevard, Nashville, TN 37208, USA.
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Salahshurian E, Moore TA. Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period. West J Nurs Res 2023; 45:1063-1071. [PMID: 37772363 DOI: 10.1177/01939459231202493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.
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Affiliation(s)
- Erin Salahshurian
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Tiffany A Moore
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
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Heaton B, Bond JC, Bae J, Cozier Y. Perceived experiences of racism linked to dental fear and anxiety among Black women. Community Dent Oral Epidemiol 2023; 51:896-907. [PMID: 35964228 PMCID: PMC9925613 DOI: 10.1111/cdoe.12782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Dental fear and anxiety are known determinants of delaying or avoiding dental care and vary considerably based on factors such as age and gender. However, little is known about dental fear and anxiety in racial/ethnic minority populations, which bear a disproportionate burden of poor oral health outcomes. Structural and social pathways responsible for producing these disparities are also understudied. Experiences of racism over the lifecourse may contribute to poor oral health outcomes through a pathway of dental fear and anxiety. This paper aimed to evaluate perceived experiences with racism, dental fear and anxiety, and the utilization of dental services, in the Black Women's Health Study (BWHS), a United States-based prospective cohort. METHODS Analysis of prospective data obtained from a geographic subset of participants in the BWHS was conducted. In 2014, BWHS participants residing in Massachusetts responded to a mailed oral health questionnaire that included the Index of Dental Anxiety and Fear (IDAF-4C+) instrument (N = 484; 69% response rate). Previously collected demographic and health information, along with reported experiences of everyday and lifetime racism, obtained from national BWHS questionnaires between 1995 and 2009, were merged with the Massachusetts-based sub-sample. Associations between high dental anxiety (HDA) (mean IDAF-4C+ score ≥2.5 on the dental fear and anxiety module) and oral health outcomes and perceived racism and HDA were explored via prevalence ratios (PR) calculated using log-binomial regression models, including adjustment for potential confounders. RESULTS Reported exposures to everyday racism occurred weekly on average for the top 25% of the sample, while 13% of participants reported exposure to multiple (n = 3) experiences of unfair treatment due to their race over their lifetime. HDA was prevalent among 17.8% of the sample and was significantly associated with indicators of poor oral health status. High exposures to everyday and lifetime experiences of racism were positively associated with HDA (PR = 1.08; 95% CI: 0.90, 1.58 and PR = 1.72; 95% CI: 1.03, 2.88, respectively). CONCLUSIONS Significant associations between racism and HDA, and between HDA and poor oral health and reduced utilization of dental care were observed. Dental anxiety may be a pathway through which perceived experiences with racism may impact oral health outcomes.
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Affiliation(s)
- Brenda Heaton
- Department of Health Policy & Health, Services Research, Boston University, Henry M. Goldman School of Dental, Medicine, Boston, Massachusetts, USA
- Department of Epidemiology, Boston, University School of Public Health, Boston, Massachusetts, USA
| | - Julia C. Bond
- Department of Health Policy & Health, Services Research, Boston University, Henry M. Goldman School of Dental, Medicine, Boston, Massachusetts, USA
- Department of Epidemiology, Boston, University School of Public Health, Boston, Massachusetts, USA
| | - Jaeyoung Bae
- Department of Health Policy & Health, Services Research, Boston University, Henry M. Goldman School of Dental, Medicine, Boston, Massachusetts, USA
| | - Yvette Cozier
- Department of Epidemiology, Boston, University School of Public Health, Boston, Massachusetts, USA
- Slone Epidemiology Center, Boston, University, Boston, Massachusetts, USA
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Wallace J, Beidler E, Covassin T, Hibbler T, Schatz P. Understanding racial differences in computerized neurocognitive test performance and symptom-reporting to deliver culturally competent patient-centered care for sport-related concussion. APPLIED NEUROPSYCHOLOGY. ADULT 2023; 30:91-100. [PMID: 33980084 DOI: 10.1080/23279095.2021.1912047] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This study examined neurocognitive performance and symptoms between concussed Black and White collegiate athletes at baseline, post-injury, and change from baseline to post-injury. METHOD The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance and four concussion symptom clusters for 235 concussed collegiate athletes. Between-groups differences were documented at baseline and post-injury, along with change in scores for sex/race, and sport/race groups, using ANOVAs. Baseline scores, and days-to-post-test were covariates in post-injury comparisons. Symptom endorsement by race was evaluated using chi-square analyses. RESULTS At baseline, group comparisons by race and sex showed that Black male/female athletes scored lower on reaction time (RT; p = .008), White females scored higher on verbal memory (VerbMem; p = .001), Black females scored lower on visual motor processing speed (VMS; p = .001), and Black football athletes scored slower/poorer on RT (p = .001) and VMS (p = .006). Post-injury, Black males scored lower on visual memory (VisMem; p = .005) and VMS (p = .002), and Black football athletes scored slower on VMS (p = .005), whereas White non-football athletes scored higher on VerbMem (p = .002) and reported fewer symptoms. Significant time-by-sport/race interactions were found for VerbMem (p < .001), VisMem (p < .001) and reported symptoms. With respect to post-injury symptom scores/endorsement, Black athletes scored significantly higher for physical (p = .01) and sleep (p = .01) symptoms. CONCLUSION These findings drive the conversation of how subjective measures of symptoms, and objective clinical concussion measures, may relate to the concussion recovery process and providing a culturally competent clinical management approach for diverse patients.
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Affiliation(s)
- Jessica Wallace
- Department of Health Science, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Erica Beidler
- Department of Athletic Training, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
| | - Tamaria Hibbler
- Department of Athletics, Michigan State University, East Lansing, Michigan, USA
| | - Philip Schatz
- Department of Psychology, Saint Joseph's University, Philadelphia, Pennsylvania, USA
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Chin MH, Orlov NM, Callender BC, Dolan JA, Miller DC, Peek ME, Rusiecki JM, Vela MB. Improvisational and Standup Comedy, Graphic Medicine, and Theatre of the Oppressed to Teach Advancing Health Equity. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1732-1737. [PMID: 35947462 DOI: 10.1097/acm.0000000000004905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ninety-minute virtual workshops that used improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed were implemented in 2020 within a required health equity course at the University of Chicago Pritzker School of Medicine to train 90 first-year medical students in advancing health equity. Learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive students and how students perceive them to gain insight into one's identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White and other social privileges, and systemic factors that lead to health inequities. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of respondents thought workshops were very good or excellent, and 83% agreed or strongly agreed they would recommend workshops to others. Key recommendations are to (1) incorporate experiential storytelling and discussion; (2) define clear learning goals for each workshop, map exercises to these goals, and explain their relevance to students; and (3) create a safe, courageous, brave space for exploration and discussion. For health equity, transformation happens as students share their perspectives of curriculum content from their intersectional identities, experiences, and varied privileges; are challenged by others' perspectives; and attempt to understand how others can experience the same content differently. The arts create a powerful form of sharing beyond routine conversations or discussions, which is critical for honest dialogue on difficult topics, such as racism, homophobia, and White privilege and other social privileges. Educators should enable students to have the space, time, and courage to share their true perspectives and engage in authentic discussions that may be uncomfortable but transformative.
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Affiliation(s)
- Marshall H Chin
- M.H. Chin is the Richard Parrillo Family Distinguished Service Professor of Healthcare Ethics, Department of Medicine, and senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as codirector, Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation National Program Office, and codirector, Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-1924-5641
| | - Nicola M Orlov
- N.M. Orlov is assistant professor of pediatrics, Department of Pediatrics, associate program director, Pediatric Residency Training Program, and junior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as clerkship director for pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Brian C Callender
- B.C. Callender is associate professor of medicine, Department of Medicine, associate junior faculty scholar, Bucksbaum Institute for Clinical Excellence, and core faculty, Institute on the Formation of Knowledge, University of Chicago, as well as career adviser, University of Chicago Pritzker School of Medicine, and senior medical director, University of Chicago Medicine, Chicago, Illinois
| | - James A Dolan
- J.A. Dolan is a research fellow in science communication, King's College, and assistant teaching professor, Engineering and Physical Sciences Research Council Centre for Doctoral Training in Nanoscience and Nanotechnology, Department of Physics, University of Cambridge, Cambridge, United Kingdom; ORCID: https://orcid.org/0000-0001-5019-1544
| | - Doriane C Miller
- D.C. Miller is professor of medicine, Department of Medicine, and senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as director, Center for Community Health and Vitality, Urban Health Initiative, University of Chicago Medicine, and director, Health Equity Integration, Institute for Translational Medicine, University of Chicago and Rush University, Chicago, Illinois
| | - Monica E Peek
- M.E. Peek is the Ellen H. Block Professor for Health Justice, and senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as codirector, Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, Chicago, Illinois
| | - Jennifer M Rusiecki
- J.M. Rusiecki is assistant professor of medicine, Department of Medicine, and women's health track director, Internal Medicine Residency, University of Chicago, Chicago, Illinois
| | - Monica B Vela
- M.B. Vela is professor of medicine, Department of Medicine, and director, Hispanic Center of Excellence, University of Illinois College of Medicine at Chicago, Chicago, Illinois
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Brown‐Johnson C, Cox J, Shankar M, Baratta J, De Leon G, Garcia R, Hollis T, Verano M, Henderson K, Upchurch M, Safaeinili N, Shaw JG, Fortuna RJ, Beverly C, Walsh M, Somerville CS, Haverfield M, Israni ST, Verghese A, Zulman DM. The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients. Health Serv Res 2022; 57 Suppl 2:263-278. [PMID: 35765147 PMCID: PMC9660409 DOI: 10.1111/1475-6773.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care. DATA SOURCES Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY. STUDY DESIGN This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care. DATA COLLECTION METHODS Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation. PRINCIPAL FINDINGS The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions. CONCLUSION P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.
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Affiliation(s)
- Cati Brown‐Johnson
- Evaluation Sciences Unit, Division of Primary Care and Population HealthStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Joy Cox
- Meta Platforms, Inc.One Hacker WayMenlo ParkCaliforniaUSA
| | - Megha Shankar
- Division of General Internal Medicine, Department of MedicineUC San DiegoSan DiegoCaliforniaUSA
| | | | - Gisselle De Leon
- Division of Primary Care and Population HealthStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Raquel Garcia
- Division of Primary Care and Population HealthStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Taylor Hollis
- UAB Marnix E. Heersink School of MedicineBirminghamAlabamaUSA
| | - Mae Verano
- Division of Primary Care and Population HealthStanford University School of MedicinePalo AltoCaliforniaUSA
| | | | | | - Nadia Safaeinili
- Health Policy and ManagementUC Berkeley School of Public HealthBerkeleyCaliforniaUSA
| | - Jonathan Glazer Shaw
- Division of Primary Care and Population HealthStanford University School of MedicinePalo AltoCaliforniaUSA
| | | | - Clyde Beverly
- Presence 5 for Racial Justice Community Advisory BoardStanford University School of MedicinePalo AltoCaliforniaUSA
| | | | | | - Marie Haverfield
- Communication StudiesCollege of Social Studies, San Jose State UniversitySan JoseCaliforniaUSA
| | | | - Abraham Verghese
- Presence CenterStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Donna M. Zulman
- Division of Primary Care and Population HealthStanford University School of MedicinePalo AltoCaliforniaUSA
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14
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Abu-Saad K, Daoud N, Kaplan G, Ziv A, Cohen AD, Olmer L, Pollack D, Kalter-Leibovici O. Comparing Patient Perspectives on Diabetes Management to the Deficit-Based Literature in an Ethnic Minority Population: A Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14769. [PMID: 36429486 PMCID: PMC9691122 DOI: 10.3390/ijerph192214769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
Marginalized racial/ethnic minorities have disproportionately high rates of type 2 diabetes prevalence, complications and mortality. Researchers and policymakers have typically addressed these disparities using a deficit-based discourse focused on individual/cultural deficiencies or failure. A mixed-methods study was used to compare the deficit discourse to the perspectives of adults with diabetes in the Arab minority in Israel, using data from 10 focus groups (5 men's, 5 women's) and 296 quantitative in-person surveys. Both qualitative and quantitative data were triangulated. In addition, multivariable regression models tested associations between diabetes management perspectives and participant characteristics. Contrary to the deficit-based characterizations of patients as fatalistic and unknowledgeable, participants viewed diabetes as a chronic disease with serious complications. They expressed more support for patient responsibility in diabetes management than for passive fatalism, and were less fatalistic as educational level and adequacy of diabetes self-care training increased. The impact of social/environmental barriers and changing cultural norms on lifestyle behaviors was highlighted. Over 95% used prescription medications for diabetes management, although 35% reported economic barriers. The deficit discourse is not well-aligned with Arab patients' evolving perceptions and needs, and has deflected attention from the socioeconomic/structural determinants of health, and the healthcare system's responsibility to provide effective, culturally-relevant diabetes services.
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Affiliation(s)
- Kathleen Abu-Saad
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Nihaya Daoud
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84015, Israel
| | - Giora Kaplan
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Arnona Ziv
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Arnon D. Cohen
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84015, Israel
| | - Liraz Olmer
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Daphna Pollack
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Ofra Kalter-Leibovici
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
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15
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Hall WJ, McCree DH, Beer L, Luo Q, Carter B. Sociodemographic, behavioral, and clinical characteristics associated with perceived discrimination in healthcare settings among Black persons with diagnosed HIV in the United States. AIDS Care 2022; 35:325-333. [PMID: 36328983 DOI: 10.1080/09540121.2022.2141183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Research that explores the intra-racial socio-demographic and clinical characteristics associated with perceived discrimination in healthcare settings in the US is lacking. We examined the prevalence of self-reported discrimination in HIV care settings during the past 12 months among Black persons from a nationally representative sample of US adults with diagnosed HIV collected 6/2018-5/2019. We assessed the prevalence of self-reported discrimination in HIV care settings during the past 12 months, perceived reasons for discrimination, and factors associated with discrimination among Black persons with diagnosed HIV (n = 1,631). Overall, 22% reported experiencing discrimination in a healthcare setting; discrimination was most often attributed to HIV status. Those reporting discrimination were younger, MSM, and living at or below the federal poverty level. They also experienced homelessness, incarceration and illicit substance use in the past 12 months, and anxiety and depression symptoms in the past 2 weeks. They were less likely to use ART or report 100% ART dose adherence in the past 30 days. No associations were found with viral suppression. Systems are needed to monitor, evaluate reports of, and address discrimination in healthcare settings. Incorporating anti-discrimination policies and continuing education opportunities for providers and staff may reduce experiences of discrimination among persons with HIV.
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Affiliation(s)
- Wendasha Jenkins Hall
- Department of Health Promotion and Physical Education, Kennesaw State University, Kennesaw, GA, USA
| | - Donna Hubbard McCree
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Brittani Carter
- Department of Health Promotion and Physical Education, Kennesaw State University, Kennesaw, GA, USA
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Room for all: Inclusive diversity, equity, and access in acupuncture practice, education, and research. Explore (NY) 2022; 18:627-629. [DOI: 10.1016/j.explore.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Zahedi-Spung L, Polnaszek B, Duckham H, Zhang F, Stout MJ, Herrick CJ, Paul R, Carter EB. The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy. J Womens Health (Larchmt) 2022; 31:1156-1164. [PMID: 35245092 PMCID: PMC9419981 DOI: 10.1089/jwh.2021.0273] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The impact of neighborhood level factors on glycemic control and pregnancy outcomes is understudied. The primary objective was to determine whether there is an association between glycemic control during pregnancy and level of neighborhood deprivation, defined by area deprivation index (ADI). Materials and Methods: We conducted a retrospective cohort study of women with type 2 diabetes who received care at a tertiary referral center from 2007 to 2017. Patients living in more deprived neighborhoods (ADI >85th national percentile) were compared to those living in less deprived neighborhoods (ADI ≤85th percentile). The primary outcome was change in hemoglobin A1c (HbA1c) over time. Demographic characteristics were compared between groups, and trends in mean A1c through each trimester were tested with repeated measures analysis. Results: Of 237 women meeting study criteria, 93 (39.2%) lived in less deprived (low ADI) and 144 (60.8%) lived in more deprived neighborhoods (high ADI). Women living in more deprived neighborhoods were more likely to be Black (86.8% vs. 53.8%, p < 0.01), less likely to be married (11.3% vs. 31.2%, p < 0.01), and had more severe diabetes (p = 0.05). Both groups achieved significant improvement in HbA1c across each trimester using repeated measures analysis. Those living in more deprived neighborhoods had significantly more improvement in HbA1c from their initial visit to the third trimester compared to those in less deprived neighborhoods, (p = 0.01) such that there was no longer a statistically significant disparity in HbA1c by the third trimester (6.69 ± 0.97 Less deprived vs. 6.95 ± 1.22 more deprived, p = 0.19). Conclusions: Low-income women living in more deprived neighborhoods enter pregnancy with significantly worse glycemic control than those living in less deprived neighborhoods, but the gap in glycemic control largely closes by the end of pregnancy with similar maternal and neonatal outcomes.
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Affiliation(s)
- Leilah Zahedi-Spung
- Regional Obstetrical Consultants, University of Tennesse-Chattanooga, Division of Maternal Fetal Medicine, Chattanooga, TN.,Address correspondence to: Leilah Zahedi-Spung, MD, Regional Obstetrical Consultants, Chattanooga, TN 37405, USA
| | - Brock Polnaszek
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Hillary Duckham
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Fan Zhang
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Molly J. Stout
- Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Cynthia J. Herrick
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Rachel Paul
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ebony B. Carter
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
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18
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Hamed S, Bradby H, Ahlberg BM, Thapar-Björkert S. Racism in healthcare: a scoping review. BMC Public Health 2022; 22:988. [PMID: 35578322 PMCID: PMC9112453 DOI: 10.1186/s12889-022-13122-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts. METHOD The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim. RESULTS The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace. CONCLUSIONS The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.
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Affiliation(s)
- Sarah Hamed
- Department of Sociology, Uppsala University, Uppsala, Sweden.
| | - Hannah Bradby
- Department of Sociology, Uppsala University, Uppsala, Sweden
| | - Beth Maina Ahlberg
- Department of Sociology, Uppsala University, Uppsala, Sweden.,Skaraborg Institute for Research and Development, Skövde, Sweden
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19
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Chin MH, Aburmishan MM, Zhu M. Standup comedy principles and the personal monologue to explore interpersonal bias: experiential learning in a health disparities course. BMC MEDICAL EDUCATION 2022; 22:80. [PMID: 35123451 PMCID: PMC8817666 DOI: 10.1186/s12909-022-03139-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Interpersonal biases between clinicians and patients contribute to disparities in health care and outcomes by race, ethnicity, and socioeconomic status. We used standup comedy principles and exercises to help medical students recognize how others perceive them and how they perceive others, and engage in difficult discussions around implicit biases and interpersonal racism. METHODS 90 min Zoom workshop with 40 first-year medical students in urban medical school. Intervention consisted of three exercises: Naming icebreaker, Rant and Rave (communicate strong perspective clearly), and Personal Monologue about how others perceive you and how you perceive yourself. Discussion debriefed the personal monologue exercise. Likert scale questions on post-session survey evaluated workshop overall, whether workshop increased skills, and safety of learning environment. Open-ended questions included what trainees liked about the module, what could be improved, and what impact the module had on them? RESULTS Seventeen (42.5%) students responded to survey. Six respondents identified as white, 4 as Asian, 1 as Black, 1 as multiracial, and 5 did not identify. Seventy-six percent rated the module as "very good" or "excellent", and 94% would recommend the module to others. Most respondents reported the workshop helped them become better listeners (75%) and more observant (82%). Eighty-three percent reported the training could help them take better care of patients with lived experiences different than their own. All respondents believed the learning environment was safe, and 94% reported that instructors created an atmosphere in which they could take risks. Thirty-six percent felt stressed. Students reported the workshop helped them recognize their own identities, others' perceptions, and bidirectional biases, and inspired them to strive for more accurate, authentic interactions with patients. CONCLUSIONS Standup comedy principles show promise for engaging students in meaningful, safe discussions about perceptions and interpersonal biases rooted in their own personal experiences and those of their classmates.
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Affiliation(s)
- Marshall H Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC2007, Chicago, IL, 60637, USA.
- MacLean Center for Clinical Medical Ethics, Chicago, IL, USA.
- Bucksbaum Institute for Clinical Excellence, University of Chicago, Chicago, IL, USA.
| | - Mona M Aburmishan
- Mona Comedy Inc., Chicago, IL, USA
- Northeastern Illinois University, Chicago, IL, USA
| | - Mengqi Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC2007, Chicago, IL, 60637, USA
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20
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Sun M, Oliwa T, Peek ME, Tung EL. Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record. Health Aff (Millwood) 2022; 41:203-211. [PMID: 35044842 PMCID: PMC8973827 DOI: 10.1377/hlthaff.2021.01423] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Little is known about how racism and bias may be communicated in the medical record. This study used machine learning to analyze electronic health records (EHRs) from an urban academic medical center and to investigate whether providers' use of negative patient descriptors varied by patient race or ethnicity. We analyzed a sample of 40,113 history and physical notes (January 2019-October 2020) from 18,459 patients for sentences containing a negative descriptor (for example, resistant or noncompliant) of the patient or the patient's behavior. We used mixed effects logistic regression to determine the odds of finding at least one negative descriptor as a function of the patient's race or ethnicity, controlling for sociodemographic and health characteristics. Compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes. Our findings raise concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities.
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21
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Chin MH. New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care. J Clin Endocrinol Metab 2021; 106:e4887-e4902. [PMID: 33837415 PMCID: PMC8083316 DOI: 10.1210/clinem/dgab229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 02/06/2023]
Abstract
Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.
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Affiliation(s)
- Marshall H Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago
- Corresponding author contact information: Marshall H. Chin, MD, MPH, University of Chicago, Section of General Internal Medicine, 5841 South Maryland Avenue, MC2007, Chicago, Illinois 60637 USA, (773) 702-4769 (telephone), (773) 834-2238 (fax), (e-mail)
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22
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Sinisterra M, Wang CH, Marks BE, Barber J, Tully C, Monaghan M, Hilliard ME, Streisand R. Patterns of Continuous Glucose Monitor Use in Young Children Throughout the First 18 Months Following Type 1 Diabetes Diagnosis. Diabetes Technol Ther 2021; 23:777-781. [PMID: 34252292 PMCID: PMC9009587 DOI: 10.1089/dia.2021.0183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective: To describe sociodemographic and parent psychosocial characteristics associated with patterns of continuous glucose monitor (CGM) use across the first 18 months post-type 1 diabetes (T1D) diagnosis among young children. Methods: One hundred fifty-seven parent-child dyads enrolled in a behavioral intervention for parents of young children (1-6 years) newly diagnosed with T1D. Parents reported on baseline sociodemographic characteristics and psychosocial functioning; child CGM use was assessed at five time points during the first 18 months post-diagnosis. Results: Most participants (81.8%) used CGM at least once. Four CGM trajectories emerged (always, later/stable, inconsistent, and never). Participants with private insurance were more likely to be in the always, later/stable, or inconsistent groups versus the never group. Youth in the always and later/stable groups had lower mean HbA1c at 18 months than those in the never group. Conclusions: Given the health benefits of CGM, further exploration of barriers to CGM use in families with public health insurance is needed. ClinicalTrials.gov identifier: NCT02527525.
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Affiliation(s)
| | | | - Brynn E. Marks
- Children's National Hospital, Washington, District of Columbia, USA
| | - John Barber
- Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Carrie Tully
- Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Maureen Monaghan
- Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Marisa E. Hilliard
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Randi Streisand
- Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
- Address correspondence to: Randi Streisand, PhD, Children's National Hospital, 6th Floor Main, CRI/CTS, 111 Michigan Avenue NW, Washington, DC 20010, USA.
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23
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Vargas N, Mora GC, Gleeson S. Race and Ideology in a Pandemic: White Privilege and Patterns of Risk Perception during COVID-19. SOCIAL PROBLEMS 2021; 70:spab037. [PMCID: PMC8499969 DOI: 10.1093/socpro/spab037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Drawing on a unique survey dataset of Californians collected during the early stages of the COVID-19 pandemic, this article examines how race and ideology shape perceptions of risk. Specifically, we position the pandemic as an “unsettled time” (Swidler 1986) and examine how different racialized groups made sense of the economic and health risks posed during this unprecedented period. We find that even when accounting for economic precarity and potential exposure to COVID-19, as well as for various other measures of social status, racialized minorities felt significantly more threatened by COVID-19 than did whites. Religion and political ideology mediated this relationship to some degree, but the racialized differences were substantial. Indeed, we find that even the most liberal whites reported being significantly less concerned about some COVID-19 risks than the most politically conservative of our Latinx and Black respondents. By linking the literature on race and racial stratification with research on risk and culture, we argue that whiteness facilitates a cognitive insulating effect vis-à-vis COVID-19 risks. We discuss the theoretical implications of our findings and conclude by highlighting the enduring importance of racialization, including various manifestations of white privilege, when assessing the social and cultural realities of crises on the ground.
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Clark BA, Virani A, Marshall SK, Saewyc EM. Conditions for shared decision making in the care of transgender youth in Canada. Health Promot Int 2021; 36:570-580. [PMID: 32596730 DOI: 10.1093/heapro/daaa043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Information is lacking on the role shared decision making plays in the care of transgender (trans) youth. This qualitative, descriptive study explored how trans youth, parents and health care providers engaged or did not engage in shared decision-making practices around hormone therapy initiation and what conditions supported shared decision-making approaches in clinical practice. Semi-structured interviews were conducted with 47 participants in British Columbia, Canada, and analyzed using a constructivist grounded theory approach. While formal shared decision-making models were not used in practice, many participants described elements of such approaches when asked about their health care decision-making processes. Others described health care interactions that were not conducive to a shared decision-making approach. The key finding that emerged through this analysis was a set of five conditions for supporting shared decision making when making decisions surrounding initiation of hormone therapy with trans youth. Both supportive relationships and open communication were necessary among participants to support shared decision making. All parties needed to agree regarding what decisions were to be made and what role each person would play in the process. Finally, adequate time was needed for decision-making processes to unfold. When stakeholders meet these five conditions, a gender-affirming and culturally safer shared decision-making approach may be used to support decision making about gender-affirming care. Implications for clinical practice and future research are discussed.
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Affiliation(s)
- Beth A Clark
- School of Nursing, The University of British Columbia, T222-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
| | - Alice Virani
- Ethics Service, Provincial Health Services Authority, Department of Medical Genetics, 4480 Oak Street, Vancouver, BC V6H 3N1, Canada
| | - Sheila K Marshall
- School of Social Work, The University of British Columbia, 2080 West Mall, Room 336, Vancouver, BC V6T 1Z2, Canada
| | - Elizabeth M Saewyc
- School of Nursing, The University of British Columbia, T222-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
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Tan NQP, Volk RJ. Addressing disparities in patients' opportunities for and competencies in shared decision making. BMJ Qual Saf 2021; 31:75-78. [PMID: 34162755 DOI: 10.1136/bmjqs-2021-013533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Naomi Q P Tan
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Peek ME, Vela MB, Chin MH. Practical Lessons for Teaching About Race and Racism: Successfully Leading Free, Frank, and Fearless Discussions. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:S139-S144. [PMID: 32889939 DOI: 10.1097/acm.0000000000003710] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Successfully teaching about race and racism requires a careful balance of emotional safety and honest truth-telling. Creating such environments where all learners can thrive and grow together is a challenge, but a consistently doable one. This article describes 12 lessons learned within 4 main themes: ground rules; language and communication; concepts of social constructs, intersectionality, and bidirectional biases; and structural racism, solutions, and advocacy. The authors' recommendations for how to successfully teach health professions students about race and racism come from their collective experience of over 60 years of instruction, research, and practice. Proficiency in discussing race and addressing racism will become increasingly relevant as health care institutions strive to address the social needs of patients (e.g., food insecurity, housing instability) that contribute to poor health and are largely driven by structural inequities. Having interprofessional team-based care, with teams better able to understand and counteract their own biases, will be critical to addressing the social and structural determinants of health for marginalized patients. Recognizing that implicit biases about race impact both patients and health professions students from underrepresented racial/ethnic backgrounds is a critical step toward building robust curricula about race and health equity that will improve the learning environment for trainees and reduce health disparities.
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Affiliation(s)
- Monica E Peek
- M.E. Peek is associate professor of medicine, Section of General Internal Medicine, member, Center for the Study of Race, Politics and Culture, and associate director, Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, Illinois
| | - Monica B Vela
- M.B. Vela is professor of medicine, Section of General Internal Medicine, member, Center for the Study of Race, Politics and Culture, and associate dean, Multicultural Affairs, The University of Chicago, Chicago, Illinois
| | - Marshall H Chin
- M.H. Chin is Richard Parrillo Family Professor of Healthcare Ethics, Department of Medicine, and director, Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, Illinois
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Iheduru-Anderson K, Shingles RR, Akanegbu C. Discourse of race and racism in nursing: An integrative review of literature. Public Health Nurs 2020; 38:115-130. [PMID: 33155328 DOI: 10.1111/phn.12828] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Race is a barrier and source of inequality affecting ethnic minorities in nursing practice and education. PURPOSE This integrative review study aimed to determine whether racism and institutionalized racism are explicitly named in the titles and abstracts of peer-reviewed publications on nursing education, leadership, and the nursing profession, and to explore the depth of discussion of racialized concepts in peer-reviewed nursing literature. METHOD Whittemore and Knafl's integrative review approach was used to review 23 studies published in nursing journals published from 2008 to 2020. FINDINGS Four themes were extracted: the context of racism discussions in the literature; consequences of experiences of racism; emotional and physical effects of racism on nurses and students of color; and scholars' recommendations. DISCUSSION Nursing must start to openly acknowledge the issue of racism within the profession, and to address it by providing safe spaces for authentic dialogue in academic and practice settings.
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Affiliation(s)
- Kechi Iheduru-Anderson
- School of Rehabilitation and Medical Sciences, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mount Pleasant, MI, USA
| | - René Revis Shingles
- Representative Chair School of Rehabilitation and Medical Sciences, College of Health professions Central Michigan University, Mount Pleasant, MI, USA
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Bi S, Gunter KE, Lopez FY, Anam S, Tan JY, Polin DJ, Jia JL, Xu LJ, Laiteerapong N, Pho MT, Kim KE, Chin MH. Improving Shared Decision Making For Asian American Pacific Islander Sexual and Gender Minorities. Med Care 2019; 57:937-944. [PMID: 31567862 PMCID: PMC7135924 DOI: 10.1097/mlr.0000000000001212] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Asian American Pacific Islander (AAPI) sexual and gender minorities (SGM) face unique challenges in mental health and accessing high-quality health care. OBJECTIVE The objective of this study was to identify barriers and facilitators for shared decision making (SDM) between AAPI SGM and providers, especially surrounding mental health. RESEARCH DESIGN Interviews, focus groups, and surveys. SUBJECTS AAPI SGM interviewees in Chicago (n=20) and San Francisco (n=20). Two focus groups (n=10) in San Francisco. MEASURES Participants were asked open-ended questions about their health care experiences and how their identities impacted these encounters. Follow-up probes explored SDM and mental health. Participants were also surveyed about attitudes towards SGM disclosure and preferences about providers. Transcripts were analyzed for themes and a conceptual model was developed. RESULTS Our conceptual model elucidates the patient, provider, and encounter-centered factors that feed into SDM for AAPI SGM. Some participants shared the stigma of SGM identities and mental health in their AAPI families. Their AAPI and SGM identities were intertwined in affecting mental health. Some providers inappropriately controlled the visibility of the patient's identities, ignoring or overemphasizing them. Participants varied on whether they preferred a provider of the same race, and how prominently their AAPI and/or SGM identities affected SDM. CONCLUSIONS Providers should understand identity-specific challenges for AAPI SGM to engage in SDM. Providers should self-educate about AAPI and SGM history and intracommunity heterogeneity before the encounter, create a safe environment conducive to patient disclosure of SGM identity, and ask questions about patient priorities for the visit, pronouns, and mental health.
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Affiliation(s)
- Stephanie Bi
- Pritzker School of Medicine, University of Chicago, Chicago, IL
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Kathryn E. Gunter
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | | | - Seeba Anam
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL
| | - Judy Y. Tan
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Danielle J. Polin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Justin L. Jia
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Lucy J. Xu
- Pritzker School of Medicine, University of Chicago, Chicago, IL
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Mai T. Pho
- Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
| | - Karen E. Kim
- Section of Gastroenterology, Hepatology, Nutrition and Center for Asian Health Equity, University of Chicago, Chicago, IL
| | - Marshall H. Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
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Vazir S, Newman K, Kispal L, Morin AE, Mu YY, Smith M, Nixon S. Perspectives of Racialized Physiotherapists in Canada on Their Experiences with Racism in the Physiotherapy Profession. Physiother Can 2019; 71:335-345. [PMID: 31762544 DOI: 10.3138/ptc-2018-39] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: We explored the perspectives of racialized physiotherapists in Canada on their experiences of racism in their roles as physiotherapists. Method: This qualitative descriptive cross-sectional study used semi-structured, one-on-one interviews. Data were organized using NVivo qualitative analysis software and analyzed using inductive and deductive coding following the six-step DEPICT method. Results: Twelve Canadian licenced physiotherapists (four men and eight women, three rural and nine urban, from multiple racialized groups) described the experiences of racism they faced in their roles as physiotherapists at the institutionalized, personally mediated, and internalized levels. These experiences were shaped by their personal characteristics, including accent, geographical location, and country of physiotherapy (PT) education. Participants described their responses to these incidents and provided insight into how the profession can mitigate racism and promote diversity and inclusion. Conclusions: Participants described interpersonal racism often mediated by location and accent and experiences of internalized racism causing self-doubt, but they most commonly detailed institutionalized racism. PT was experienced as being infused with Whiteness, which participants typically responded to by downplaying or ignoring. The findings from this study can be used to stimulate conversations in the Canadian PT community, especially among those in leadership positions, about not only acknowledging racism as an issue but also taking action against it with further research, advocacy, and training.
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Affiliation(s)
- Shrey Vazir
- Department of Physical Therapy, University of Toronto, Toronto
| | - Kaela Newman
- Department of Physical Therapy, University of Toronto, Toronto
| | - Lara Kispal
- Department of Physical Therapy, University of Toronto, Toronto
| | - Amanda E Morin
- Department of Physical Therapy, University of Toronto, Toronto
| | - Yang Yusuf Mu
- Department of Physical Therapy, University of Toronto, Toronto
| | - Meredith Smith
- Department of Physical Therapy, University of Toronto, Toronto
| | - Stephanie Nixon
- Department of Physical Therapy, University of Toronto, Toronto
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Loggins Clay S, Griffin M, Averhart W. Black/White disparities in pregnant women in the United States: An examination of risk factors associated with Black/White racial identity. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:654-663. [PMID: 29488271 DOI: 10.1111/hsc.12565] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 06/08/2023]
Abstract
This paper explores racial disparities and risk factors of adverse pregnancy outcomes in Black and White pregnant women in the US. The study uses a cross-sectional approach to explore Black and White disparities using data from the 2012 National Survey on Drug Use and Health (NSDUH), which collects interview data from approximately 70,000 randomly selected participants. We included several self-reported conditions that we categorised as individual and social stressors (e.g. measures of institutionalised racism, individual health behaviours, access to quality care and social context factors). We used descriptive statistics, univariate and multivariate analyses in risk factors of adverse pregnancy outcomes between Black and White women. Black women who were pregnant had a lower socioeconomic status and experienced more measures of institutionalised racism compared to White women who were pregnant. More white women who were pregnant were married, had higher levels of educational attainment, higher income levels, and greater employment opportunities. White pregnant women also had higher levels of private health insurance and less dependency on government programmes for access to healthcare. Results from the regressions indicated that Black pregnant women were less likely to be married (OR = 0.01), less likely to have higher income levels (OR = 0.31) and less likely to be employed (OR = 0.52). However, Black pregnant women were more likely to be younger (OR = 1.82). For the health-eroding behaviours, Black pregnant women were less likely to smoke (OR = 0.53) and use alcohol (0.52). After assessing the SES Household-level stressors (access to healthcare), Black pregnant women were more likely to have Medicaid/CHIP (OR = 3.21) and health coverage through government assistant programmes (OR = 3.80); however, less likely to have private health insurance (OR = 0.38). There are differences in risk factors of adverse pregnancy outcomes between White and Black pregnant women based on measures of individual level/social stressors, institutionalised racism, health behaviours and access to care.
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Affiliation(s)
- Shondra Loggins Clay
- Counseling Center, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Marquianna Griffin
- Chapin Hall Center for Children, Data and Research Technology Liason, Oak Park, IL, USA
| | - Wanda Averhart
- Department of Pediatrics' General Pediatrics Division, University of Florida, Gainesville, FL, USA
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Bakshi N, Sinha CB, Ross D, Khemani K, Loewenstein G, Krishnamurti L. Proponent or collaborative: Physician perspectives and approaches to disease modifying therapies in sickle cell disease. PLoS One 2017; 12:e0178413. [PMID: 28727801 PMCID: PMC5518995 DOI: 10.1371/journal.pone.0178413] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/13/2017] [Indexed: 11/18/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder that primarily affects African-American and other ethnic minority populations. There are three available disease-modifying therapies for sickle cell disease: hydroxyurea (HU), bone marrow transplantation (BMT), and chronic blood transfusion (CBT). Since these treatments vary in their therapeutic intent, efficacy in preventing progression of the disease, short and long-term adverse effects, costs and patient burden, the decision-making process regarding these therapies is complicated for both the patient and healthcare provider. While previous research has focused on the patient perspective of treatment-related decision making, there is a paucity of research investigating the physician perspective of treatment-related decision making. We conducted a qualitative study with physicians who were experts in the field of SCD. Interviews focused on physician perceptions of patient decisional needs as well as physicians' approach to decision making regarding disease-modifying therapies in SCD. Thirty-six physician interviews were analyzed, with a focus on their perspectives regarding available treatment options and on how they approach decision making with patients. We identified two narrative approaches. The Collaborative approach (CA) was characterized by emphasizing the need to discuss all possible treatment options to ensure that the patient and/or family was equipped to make an informed decision. The Proponent approach (PA) was characterized by strongly advocating a pre-determined treatment plan and providing patients/families with information, with the objective of convincing them to accept the treatment. An interplay of patient-related and disease-related factors, decision type and physician-related factors, as well as institutional frameworks, influenced physician perspectives on treatment options and decision making regarding these therapies. These findings point to the potential value of developing systems to foster patient engagement as a way of facilitating shared decision making.
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Affiliation(s)
- Nitya Bakshi
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America.,Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - Cynthia B Sinha
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - Diana Ross
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - Kirshma Khemani
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
| | - George Loewenstein
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Lakshmanan Krishnamurti
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America.,Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University, Atlanta, Georgia, United States of America
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Acosta D, Ackerman-Barger K. Breaking the Silence: Time to Talk About Race and Racism. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:285-288. [PMID: 27655050 DOI: 10.1097/acm.0000000000001416] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Recent events in the United States have catalyzed the need for all educators to begin paying attention to and discovering ways to dialogue about race. No longer can health professions (HP) educators ignore or avoid these difficult conversations. HP students are now demanding them. Cultural sensitivity and unconscious bias training are not enough. Good will and good intentions are not enough. Current faculty development paradigms are no longer sufficient to meet the educational challenges of delving into issues of race, power, privilege, identity, and social justice.Engaging in such conversations, however, can be overwhelmingly stressful for untrained faculty. The authors argue that before any curriculum on race and racism can be developed for HP students, and before faculty members can begin facilitating conversations about race and racism, faculty must receive proper training through intense and introspective faculty development. Training should cover how best to engage in, sustain, and deepen interracial dialogue on difficult topics such as race and racism within academic health centers (AHCs). If such faculty development training-in how to conduct interracial dialogues on race, racism, oppression, and the invisibility of privilege-is made standard at all AHCs, HP educators might be poised to actualize the real benefits of open dialogue and change.
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Affiliation(s)
- David Acosta
- D. Acosta is associate vice chancellor, Diversity and Inclusion, University of California Davis Health System, senior associate dean, Equity, Diversity and Inclusion, and health sciences clinical professor, Department of Family and Community Medicine, University of California Davis School of Medicine, Sacramento, California. K. Ackerman-Barger is assistant adjunct professor, assistant director, Master's Entry Program for Nurses, and codirector, Interprofessional Teaching Scholars Program, University of California Davis Betty Irene Moore School of Nursing, Sacramento, California
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Plaisime MV, Malebranche DJ, Davis AL, Taylor JA. Healthcare Providers' Formative Experiences with Race and Black Male Patients in Urban Hospital Environments. J Racial Ethn Health Disparities 2016; 4:1120-1127. [PMID: 27928771 DOI: 10.1007/s40615-016-0317-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/15/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We explored health providers' formative personal and professional experiences with race and Black men as a way to assess their potential influence on interactions with Black male patients. METHODS Utilizing convenience sampling with snowballing techniques, we identified healthcare providers in two urban university hospitals. We compared Black and White providers' experiences based on race and level of training. We used the Gardener's Tale to conceptualize how racism may lead to racial health disparities. A semi-structured interview guide was used to conduct in-person interviews (n = 16). Using the grounded theory approach, we conducted three types of coding to examine data patterns. RESULTS We found two themes reflective of personally mediated racism: (1) perception of Black males accompanied by two subthemes (a) biased care and (b) fear and discomfort and (2) cognitive dissonance. While this latter theme is more reflective of Jones's internalized racism level, we present its results because its novelty is compelling. CONCLUSIONS Perception of Black males and cognitive dissonance appear to influence providers' approaches with Black male patients. This study suggests the need to develop initiatives and curricula in health professional schools that address provider racial bias. Understanding the dynamics operating in the patient-provider encounter enhances the ability to address and reduce health disparities.
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Affiliation(s)
- Marie V Plaisime
- Department of Sociology and Criminology, Howard University, 2400 Sixth Street, NW, Washington, DC, 20059, USA
| | | | - Andrea L Davis
- Department of Environmental and Occupational Health, Drexel University Dornsife School of Public Health, Nesbitt Hall, 6th Fl., Rm. 656, 3215 Market Street, Philadelphia, PA, 19104, USA
| | - Jennifer A Taylor
- Department of Environmental & Occupational Health, Drexel University Dornsife School of Public Health, Nesbitt Hall, Room 655, 3215 Market Street, Philadelphia, PA, 19104, USA.
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Castaneda-Guarderas A, Glassberg J, Grudzen CR, Ngai KM, Samuels-Kalow ME, Shelton E, Wall SP, Richardson LD. Shared Decision Making With Vulnerable Populations in the Emergency Department. Acad Emerg Med 2016; 23:1410-1416. [PMID: 27860022 DOI: 10.1111/acem.13134] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/02/2016] [Indexed: 01/19/2023]
Abstract
The emergency department (ED) occupies a unique position within the healthcare system, serving as a safety net for vulnerable patients, regardless of their race, ethnicity, religion, country of origin, sexual orientation, socioeconomic status, or medical diagnosis. Shared decision making (SDM) presents special challenges when used with vulnerable population groups. The differing circumstances, needs, and perspectives of vulnerable groups invoke issues of provider bias, disrespect, judgmental attitudes, and lack of cultural competence, as well as patient mistrust and the consequences of their social and economic disenfranchisement. A research agenda that includes community-engaged approaches, mixed-methods studies, and cost-effectiveness analyses is proposed to address the following questions: 1) What are the best processes/formats for SDM among racial, ethnic, cultural, religious, linguistic, social, or otherwise vulnerable groups who experience disadvantage in the healthcare system? 2) What organizational or systemic changes are needed to support SDM in the ED whenever appropriate? 3) What competencies are needed to enable emergency providers to consider patients' situation/context in an unbiased way? 4) How do we teach these competencies to students and residents? 5) How do we cultivate these competencies in practicing emergency physicians, nurses, and other clinical providers who lack them? The authors also identify the importance of using accurate, group-specific data to inform risk estimates for SDM decision aids for vulnerable populations and the need for increased ED-based care coordination and transitional care management capabilities to create additional care options that align with the needs and preferences of vulnerable populations.
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Affiliation(s)
- Ana Castaneda-Guarderas
- Department of Emergency Medicine Aventura Hospital and Medical Center; Miami FL
- Department of Emergency Medicine and Knowledge & Evaluation Research Unit; Mayo Clinic; Rochester MN
| | - Jeffrey Glassberg
- Department of Emergency Medicine; The Icahn School of Medicine at Mount Sinai; New York NY
- Center for Health Equity and Community Engaged Research; Department of Population Health Science & Policy; The Icahn School of Medicine at Mount Sinai; New York NY
- Department of Medicine; Division Hematology & Medical Oncology; The Icahn School of Medicine at Mount Sinai; New York NY
| | - Corita R. Grudzen
- Department of Emergency Medicine and the Department of Population Health; New York University; New York NY
| | - Ka Ming Ngai
- Department of Emergency Medicine; The Icahn School of Medicine at Mount Sinai; New York NY
| | | | - Erica Shelton
- Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Stephen P. Wall
- Department of Emergency Medicine and the Department of Population Health; New York University; New York NY
- Bellevue Hospital Center; New York NY
| | - Lynne D. Richardson
- Department of Emergency Medicine; The Icahn School of Medicine at Mount Sinai; New York NY
- Center for Health Equity and Community Engaged Research; Department of Population Health Science & Policy; The Icahn School of Medicine at Mount Sinai; New York NY
- Department of Population Health Science & Policy; The Icahn School of Medicine at Mount Sinai; New York NY
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Dillon PJ, Basu A. African Americans and Hospice Care: A Culture-Centered Exploration of Enrollment Disparities. HEALTH COMMUNICATION 2016; 31:1385-1394. [PMID: 27007165 DOI: 10.1080/10410236.2015.1072886] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Over the past decade, scholars and practitioners have called for efforts to reduce disparities in the cost and quality of end-of-life care; a key contributor to these disparities is the underuse of hospice care by African American patients. While previous studies have often relied on interviewing minority individuals who may or may not have been terminally ill and of whom few were using hospice care services, this essay draws upon the culture-centered approach to report the findings of a grounded theory analysis of 39 interviews with 26 African American hospice patients (n = 10) and lay caregivers (n = 16). Participants identified several barriers to hospice enrollment and reported how they were able to overcome these barriers by reframing/prioritizing cultural values and practices, creating alternative goals for hospice care, and relying on information obtained outside the formal health system. These findings have implications for understanding hospice experiences, promoting hospice access, and improving end-of-life care.
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Affiliation(s)
| | - Ambar Basu
- b Department of Communication , University of South Florida
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Peek ME, Lopez FY, Williams HS, Xu LJ, McNulty MC, Acree ME, Schneider JA. Development of a Conceptual Framework for Understanding Shared Decision making Among African-American LGBT Patients and their Clinicians. J Gen Intern Med 2016; 31:677-87. [PMID: 27008649 PMCID: PMC4870421 DOI: 10.1007/s11606-016-3616-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Enhancing patient-centered care and shared decision making (SDM) has become a national priority as a means of engaging patients in their care, improving treatment adherence, and enhancing health outcomes. Relatively little is known about the healthcare experiences or shared decision making among racial/ethnic minorities who also identify as being LGBT. The purpose of this paper is to understand how race, sexual orientation and gender identity can simultaneously influence SDM among African-American LGBT persons, and to propose a model of SDM between such patients and their healthcare providers. METHODS We reviewed key constructs necessary for understanding SDM among African-American LGBT persons, which guided our systematic literature review. Eligible studies for the review included English-language studies of adults (≥ 19 y/o) in North America, with a focus on LGBT persons who were African-American/black (i.e., > 50 % of the study population) or included sub-analyses by sexual orientation/gender identity and race. We searched PubMed, CINAHL, ProQuest Dissertations & Theses, PsycINFO, and Scopus databases using MESH terms and keywords related to shared decision making, communication quality (e.g., trust, bias), African-Americans, and LGBT persons. Additional references were identified by manual reviews of peer-reviewed journals' tables of contents and key papers' references. RESULTS We identified 2298 abstracts, three of which met the inclusion criteria. Of the included studies, one was cross-sectional and two were qualitative; one study involved transgender women (91 % minorities, 65 % of whom were African-Americans), and two involved African-American men who have sex with men (MSM). All of the studies focused on HIV infection. Sexual orientation and gender identity were patient-reported factors that negatively impacted patient/provider relationships and SDM. Engaging in SDM helped some patients overcome normative beliefs about clinical encounters. In this paper, we present a conceptual model for understanding SDM in African-American LGBT persons, wherein multiple systems of social stratification (e.g., race, gender, sexual orientation) influence patient and provider perceptions, behaviors, and shared decision making. DISCUSSION Few studies exist that explore SDM among African-American LGBT persons, and no interventions were identified in our systematic review. Thus, we are unable to draw conclusions about the effect size of SDM among this population on health outcomes. Qualitative work suggests that race, sexual orientation and gender work collectively to enhance perceptions of discrimination and decrease SDM among African-American LGBT persons. More research is needed to obtain a comprehensive understanding of shared decision making and subsequent health outcomes among African-Americans along the entire spectrum of gender and sexual orientation.
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Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, , The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
- Chicago Center for Diabetes Translation Research, , The University of Chicago, Chicago, IL, USA.
- MacLean Center for Clinical Medical Ethics, , The University of Chicago, Chicago, IL, USA.
| | - Fanny Y Lopez
- Section of General Internal Medicine, , The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
- Chicago Center for Diabetes Translation Research, , The University of Chicago, Chicago, IL, USA
| | - H Sharif Williams
- Center for Culture, Sexuality and Spirituality, , Goddard College, Plainfield, VT, USA
- Undergraduate Programs, , Goddard College, Plainfield, VT, USA
| | - Lucy J Xu
- Section of General Internal Medicine, , The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Moira C McNulty
- Section of Infectious Diseases, , The University of Chicago, Chicago, IL, USA
| | - M Ellen Acree
- Section of Infectious Diseases, , The University of Chicago, Chicago, IL, USA
| | - John A Schneider
- Section of Infectious Diseases, , The University of Chicago, Chicago, IL, USA
- Department of Public Health Sciences, , University of Chicago, Chicago, IL, USA
- Chicago Center for HIV Elimination, , University of Chicago, Chicago, IL, USA
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DeMeester RH, Lopez FY, Moore JE, Cook SC, Chin MH. A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients. J Gen Intern Med 2016; 31:651-62. [PMID: 26988980 PMCID: PMC4870417 DOI: 10.1007/s11606-016-3608-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dual-minority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender ("LGBT") racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.
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Affiliation(s)
- Rachel H. DeMeester
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
- Robert Wood Johnson Foundation Reducing Health Care Disparities Through Payment and Delivery System Reform Program Office, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
| | - Fanny Y. Lopez
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
| | - Jennifer E. Moore
- Institute for Medicaid Innovation, Washington, DC USA
- Department of Obstetrics & Gynecology, Medical School, University of Michigan, Ann Arbor, MI USA
| | - Scott C. Cook
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
- Robert Wood Johnson Foundation Reducing Health Care Disparities Through Payment and Delivery System Reform Program Office, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
| | - Marshall H. Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
- Robert Wood Johnson Foundation Reducing Health Care Disparities Through Payment and Delivery System Reform Program Office, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637 USA
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Tan JY, Xu LJ, Lopez FY, Jia JL, Pho MT, Kim KE, Chin MH. Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap. LGBT Health 2016; 3:327-34. [PMID: 27158858 DOI: 10.1089/lgbt.2015.0143] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered.
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Affiliation(s)
- Judy Y Tan
- 1 Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Lucy J Xu
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,3 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
| | - Fanny Y Lopez
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois
| | - Justin L Jia
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,4 The College, University of Chicago , Chicago, Illinois
| | - Mai T Pho
- 5 Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago , Chicago, Illinois
| | - Karen E Kim
- 6 Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago , Chicago, Illinois.,7 Center for Asian Health Equity, University of Chicago , Chicago, Illinois
| | - Marshall H Chin
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,8 Robert Wood Johnson Foundation Finding Answers: Solving Disparities through Payment and Delivery System Reform Program Office, University of Chicago , Chicago, Illinois
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Valenzuela JM, Smith L. Topical Review: Provider-Patient Interactions: An Important Consideration for Racial/Ethnic Health Disparities in Youth. J Pediatr Psychol 2015; 41:473-80. [PMID: 26403332 DOI: 10.1093/jpepsy/jsv086] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 08/18/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To summarize literature on the role of provider-patient interactions (PPI) in racial/ethnic health disparities and consider the relevance of PPI for understanding health disparities in pediatric psychology. METHODS Topical review of literature focusing on health disparities and PPI in adult and pediatric populations. RESULTS For adults, evidence is clear that racial/ethnic minorities experience poorer quality PPI, which may be associated with poorer health outcomes. In pediatric populations, the emerging literature indicates similar associations, and potential promising targets for intervention including information exchange, shared decision-making and patient-centered communication. PPI research in pediatric populations poses a number of methodological challenges including culturally and developmentally sensitive measurement of triadic (caregiver, patient, provider) interactions. CONCLUSIONS Health disparities in PPI exist for racial/ethnic minority youth and may contribute to poorer health outcomes. Pediatric psychologists can make valuable contributions, given their expertise and role within medical settings. Research, clinical, and policy recommendations are discussed.
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Affiliation(s)
| | - Laura Smith
- USF Diabetes Center and the Health Informatics Institute, and Department of Pediatrics, Morsani College of Medicine, University of South Florida
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Goddu AP, Raffel KE, Peek ME. A story of change: The influence of narrative on African-Americans with diabetes. PATIENT EDUCATION AND COUNSELING 2015; 98:1017-24. [PMID: 25986500 PMCID: PMC4492448 DOI: 10.1016/j.pec.2015.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 03/24/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To understand if narratives can be effective tools for diabetes empowerment, from the perspective of African-American participants in a program that improved diabetes self-efficacy and self-management. METHODS In-depth interviews and focus groups were conducted with program graduates. Participants were asked to comment on the program's film, storytelling, and role-play, and whether those narratives had contributed to their diabetes behavior change. An iterative process of coding, analyzing, and summarizing transcripts was completed using the framework approach. RESULTS African-American adults (n=36) with diabetes reported that narratives positively influenced the diabetes behavior change they had experienced by improving their attitudes/beliefs while increasing their knowledge/skills. The social proliferation of narrative - discussing stories, rehearsing their messages with role-play, and building social support through storytelling - was reported as especially influential. CONCLUSION Utilizing narratives in group settings may facilitate health behavior change, particularly in minority communities with traditions of storytelling. Theoretical models explaining narrative's effect on behavior change should consider the social context of narratives. PRACTICE IMPLICATIONS Narratives may be promising tools to promote diabetes empowerment. Interventions using narratives may be more effective if they include group time to discuss and rehearse the stories presented, and if they foster an environment conducive to social support among participants.
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Affiliation(s)
- Anna P Goddu
- Department of Medicine, University of Chicago, Chicago, USA; Center for Health and the Social Sciences, University of Chicago, Chicago, USA; Chicago Center for Diabetes Translation Research, Chicago, USA
| | - Katie E Raffel
- Pritzker School of Medicine, University of Chicago, Chicago, USA
| | - Monica E Peek
- Department of Medicine, University of Chicago, Chicago, USA; Center for Health and the Social Sciences, University of Chicago, Chicago, USA; Chicago Center for Diabetes Translation Research, Chicago, USA; Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, USA.
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Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med 2013; 173:1195-205. [PMID: 23712712 PMCID: PMC4390034 DOI: 10.1001/jamainternmed.2013.6048] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care. OBJECTIVE To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients. DESIGN AND SETTING Survey study in an academic research setting. PARTICIPANTS A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21,754 (69.6%) of admitted patients. MAIN OUTCOMES AND MEASURES The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs. RESULTS The mean length of stay was 5.34 days, and the mean hospitalization costs were $14,576. While 96.3% of patients expressed a desire to receive information about their illnesses and treatment options, 71.1% of patients preferred to leave medical decision making to their physician. Preference to participate in decision making increased with educational level and with private health insurance. Compared with patients who had a strong desire to delegate decisions to their physician, patients who preferred to participate in decision making concerning their care had a 0.26-day (95% CI, 0.06-0.47 day) longer length of stay (P = .01) and $865 (95% CI, $155-$1575) higher total hospitalization costs (P = .02). CONCLUSIONS AND RELEVANCE Patient preference to participate in decision making concerning their care may be associated with increased resource utilization among hospitalized patients. Variation in patient preference to participate in medical decision making and its effects on costs and outcomes in the presence of varying physician incentives deserve further examination.
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Affiliation(s)
- Hyo Jung Tak
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Peek ME, Gorawara-Bhat R, Quinn MT, Odoms-Young A, Wilson SC, Chin MH. Patient trust in physicians and shared decision-making among African-Americans with diabetes. HEALTH COMMUNICATION 2013; 28:616-23. [PMID: 23050731 PMCID: PMC3766485 DOI: 10.1080/10410236.2012.710873] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
This study explores patient trust in physicians and its relationship to shared decision-making (SDM) among African-Americans with diabetes (types 1 and 2). We conducted a series of focus groups (n = 27) and in-depth interviews (n = 24). Topic guides were developed utilizing theoretical constructs. Each interview was audiotaped and transcribed verbatim. Each transcript was independently coded by two randomly assigned members of the research team; codes and themes were identified in an iterative fashion utilizing Atlas.ti software. The mean age of study participants was 62 years and 85% were female. We found that (1) race as a social construct has the potential to influence key domains of patient trust (interpersonal/relationship aspects and medical skills/technical competence), (2) the relationship between patient trust and shared decision-making is bidirectional in nature, and (3) enhancing patient trust may potentially increase or decrease SDM among African-Americans with diabetes. Mistrust of physicians among African-Americans with diabetes may partially be addressed through (1) patient education efforts, (2) physician training in interpersonal skills and cultural competence, and (3) physician efforts to engage patients in SDM. To help enhance patient outcomes among African-Americans with diabetes, physicians might consider incorporating strategies to simultaneously engender their patients' trust and encourage shared decision-making.
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Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, Diabetes Research and Training Center, Center for Health and the Social Sciences & Center for the Study of Race, Politics, and Culture, University of Chicago, Chicago, IL 60637, USA
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Peek ME, Harmon SA, Scott SJ, Eder M, Roberson TS, Tang H, Chin MH. Culturally tailoring patient education and communication skills training to empower African-Americans with diabetes. Transl Behav Med 2012; 2:296-308. [PMID: 24073128 PMCID: PMC3717912 DOI: 10.1007/s13142-012-0125-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
New translational strategies are needed to improve diabetes outcomes among low-income African-Americans. Our goal was to develop/pilot test a patient intervention combining culturally tailored diabetes education with shared decision-making training. This was an observational cohort study. Surveys and clinical data were collected at baseline, program completion, and 3 and 6 months. There were 21 participants; the mean age was 61 years. Eighty-six percent of participants attended >70 % of classes. There were improvements in diabetes self-efficacy, self-care behaviors (i.e., following a "healthful eating plan" (mean score at baseline 3.4 vs. 5.2 at program's end; p = 0.002), self glucose monitoring (mean score at baseline 4.3 vs. 6.2 at program's end; p = 0.04), and foot care (mean score at baseline 4.1 vs. 6.0 at program's end; p = 0.001)), hemoglobin A1c (8.24 at baseline vs. 7.33 at 3-month follow-up, p = 0.02), and HDL cholesterol (51.2 at baseline vs. 61.8 at 6-month follow-up, p = 0.01). Combining tailored education with shared decision-making may be a promising strategy for empowering low-income African-Americans and improving health outcomes.
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Affiliation(s)
- Monica E Peek
- />Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2007, Room B 228, Chicago, IL 60637 USA
- />Diabetes Research and Training Center, University of Chicago, Chicago, IL USA
- />Center for Health and the Social Sciences, University of Chicago, Chicago, IL USA
- />Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, IL USA
| | | | | | - Milton Eder
- />Access Community Health Network (ACCESS), Chicago, IL USA
| | - Tonya S Roberson
- />Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2007, Room B 228, Chicago, IL 60637 USA
- />Diabetes Research and Training Center, University of Chicago, Chicago, IL USA
| | - Hui Tang
- />Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2007, Room B 228, Chicago, IL 60637 USA
- />Diabetes Research and Training Center, University of Chicago, Chicago, IL USA
| | - Marshall H Chin
- />Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2007, Room B 228, Chicago, IL 60637 USA
- />Diabetes Research and Training Center, University of Chicago, Chicago, IL USA
- />Center for Health and the Social Sciences, University of Chicago, Chicago, IL USA
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Abstract
Approximately half of adults with diabetes have at least one comorbid condition. However, diabetes care guidelines focus on diabetes-specific care, and their recommendations may not be appropriate for many patients with diabetes and comorbidity. We describe Piette and Kerr's typology of comorbid conditions, which categorizes conditions based on if they are clinically dominant (eclipse diabetes management), symptomatic versus asymptomatic, and concordant (similar pathophysiologic processes as diabetes) versus discordant. We integrate this typology with clinical evidence and shared decision-making methods to create an algorithmic approach to prioritizing care in patients with diabetes and comorbidity. Initial steps are determining the patient's goals of care and preferences for treatment, whether there is a clinically dominant condition or inadequately treated symptomatic condition, and the risk of cardiovascular disease. With these data in hand, the clinician and patient prioritize diabetes treatments during a shared decision-making process. These steps should be repeated, especially when the patient's clinical status changes. This patient-centered process emphasizes overall quality of life and functioning rather than a narrow focus on diabetes.
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Affiliation(s)
- Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois 60637, USA.
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