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Gillani B, Prince DM, Ray-Novak M, Feerasta G, Jones D, Mintz LJ, Moore SE. Mapping the Dynamic Complexity of Sexual and Gender Minority Healthcare Disparities: A Systems Thinking Approach. Healthcare (Basel) 2024; 12:424. [PMID: 38391800 PMCID: PMC10888405 DOI: 10.3390/healthcare12040424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/10/2023] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
Sexual and gender minority (SGM) populations experience extensive health disparities compared to their straight and cisgender counterparts. The importance of addressing these disparities is paramount, as SGM groups often encounter significant barriers to accessing comprehensive healthcare, including societal stigma, provider bias, and financial constraints. This study utilizes a community-based system dynamics approach to understand and visualize the barriers to and facilitators of healthcare engagement for SGM groups across their life course. It aims to identify core constructs, relationships, and dynamic feedback mechanisms related to the experiences of connection/disconnection with physical, mental, and dental healthcare of SGM individuals. Barriers to access, such as discriminatory practices and the limited availability of SGM-informed healthcare professionals, exacerbate these disparities, underscoring the urgency of developing targeted interventions. System dynamics, a complex systems science (CSS) methodology, was used for this research. Group model building sessions were conducted with diverse SGM groups, including youth, older adults, and trans and gender-expansive community members. Causal loop diagrams were developed according to an iterative process, and a meta-model of their collective experiences was created. The study revealed extensive, dynamic, and shifting structural barriers for SGM community members accessing healthcare. Societal and structural stigma, provider bias, and pathologization were identified as significant barriers throughout their life course. Community-led interventions and SGM-focused holistic healthcare were identified as critical facilitators of SGM healthcare connection. The findings highlight the need for SGM-affirming and culturally responsive healthcare settings. This paper calls for a concerted effort from SGM health researchers to use CSS in developing interventions to reduce SGM health disparities.
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Affiliation(s)
- Braveheart Gillani
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH 44106, USA; (B.G.); (M.R.-N.)
| | - Dana M. Prince
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH 44106, USA; (B.G.); (M.R.-N.)
| | - Meagan Ray-Novak
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH 44106, USA; (B.G.); (M.R.-N.)
| | - Gulnar Feerasta
- LGBT Center of Greater Cleveland, Cleveland, OH 44102, USA; (G.F.); (D.J.)
| | - Devinity Jones
- LGBT Center of Greater Cleveland, Cleveland, OH 44102, USA; (G.F.); (D.J.)
| | - Laura J. Mintz
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Scott Emory Moore
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, USA;
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Hilgeman MM, Lange TM, Bishop T, Cramer RJ. Spreading pride in all who served: A health education program to improve access and mental health outcomes for sexual and gender minority veterans. Psychol Serv 2023; 20:596-608. [PMID: 35113622 PMCID: PMC10189955 DOI: 10.1037/ser0000604] [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] [Indexed: 11/08/2022]
Abstract
Access to effective, replicable services is critical to reduce known mental health disparities for sexual and gender minority or LGBTQ+ veterans (lesbian, gay, bisexual, transgender, queer, questioning, and related identities). This paper examines the impact of a manualized 10-week health education group, called PRIDE in All Who Served on veteran patient experience, protective factors (e.g., identity acceptance), and mental health outcomes (e.g., suicide risk) at 10 Department of Veterans Affairs (VA) facilities. Implementation facilitation strategies (e.g., consultation, staff training) supported adoption at new sites and initial facilitators and barriers are described. Forty-four veterans (M = 47.21 years old) completed outcome surveys before and after the group. Significant improvement in acceptance concerns, identity uncertainty, community involvement, and likelihood of future suicide attempts were observed; other changes in mental health symptoms were not replicated in this sample (e.g., depression, anxiety). Open-ended veteran feedback reflected improved social support and engagement and increased self-understanding as the most frequent themes. At the facility level, Healthcare Equality Index scores (a Human Rights Campaign measure of affirmative care climate) improved from 30% to 90% achieving top-performer/leader status from pre- to postimplementation. Manualized approaches, like PRIDE in All Who Served, that are based on established minority stress models and can be spread for use with diverse LGBTQ+ veterans (e.g., age, race, gender identity, sexual orientation, rurality, housing) are needed. The PRIDE in All Who Served program is an increasingly available resource to VA clinicians advocating for greater health equity within a national healthcare setting. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Michelle M. Hilgeman
- Research & Development Service (151), Tuscaloosa VA Medical Center, 3701 Loop Rd., Tuscaloosa, AL 35404
- Psychology Department & Alabama Research Institute on Aging, University of Alabama, Tuscaloosa, AL 35487
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294
| | | | - Teddy Bishop
- Research & Development Service (151), Tuscaloosa VA Medical Center, 3701 Loop Rd., Tuscaloosa, AL 35404
| | - Robert J. Cramer
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223
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Ngaruiya C. When women win, we all win-Call for a gendered global NCD agenda. FASEB Bioadv 2022; 4:741-757. [PMID: 36479209 PMCID: PMC9721093 DOI: 10.1096/fba.2021-00140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 08/24/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022] Open
Abstract
Gender is a social determinant of health, interacting with other factors such as income, education, and housing and affects health care access and health care outcomes. This paper reviews key literature and policies on health disparities and gender disparities within health. It examines noncommunicable disease (NCD) health outcomes through a gender lens and challenges existing prevailing measures of success for NCD outcomes that focus primarily on mortality. Chronic respiratory disease, one of the four leading contributors to NCD mortality, is highlighted as a case study to demonstrate the gender gap. Women have different risk factors and higher morbidity for chronic respiratory disease compared to men but morbidity is shadowed by a penultimate research focus on mortality, which results in less attention to the gap in women's NCD outcomes. This, in turn, affects how resources, programs, and interventions are implemented. It will likely slow progress in reducing overall NCD burden if we do not address risk factors in an equitable fashion. The article closes with recommendations to address these gender gaps in NCD outcomes. At the policy level, increasing representation and inclusion in global public health leadership, prioritizing NCDs among marginalized populations by global health societies and political organizations, aligning the gendered global NCD agenda with other well-established movements will each catalyze change for gender-based disparities in global NCDs specifically. Lastly, incorporating gender-based indicators and targets in major NCD-related goals and advancing gender-based NCD research will strengthen the evidence base for women's unique NCD risks and health outcomes.
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Affiliation(s)
- Christine Ngaruiya
- Section of Global Health and International Emergency Medicine, Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Yale Network for Global Noncommunicable Diseases (NGN)Yale School of MedicineNew HavenConnecticutUSA
- Women Lift Health Women Leaders in Global Health (2020)https://www.womenlifthealth.org/profile/christine‐ngaruiya/
- Kenyan Doctors USAhttps://www.kedusa.org
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Fish JN, King-Marshall EC, Williams ND, Aparicio EM, Tralka HM, Boekeloo BO. What motivates community mental and behavioral health organizations to participate in LGBTQ+ cultural competency trainings? THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2022; 92:647-656. [PMID: 35939617 PMCID: PMC10152511 DOI: 10.1037/ort0000641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The constantly evolving language, understanding, and cultural context regarding the mental health of lesbian, gay, bisexual, transgender, queer, and other sexual and gender diverse individuals (LGBTQ+) require mental health providers to obtain LGBTQ+ cultural competency training to be affirmative and effective with this population. Unfortunately, many providers are not obtaining this ongoing training and mental health disparities continue to plague LGBTQ+ populations. Guided by the Consolidation Framework for Implementation Research (CFIR), we conducted eight focus groups with community mental and behavioral health organization (MBHO) administrators (e.g., directors, clinical supervisors) and therapists to explore what factors facilitated or inhibited their adoption and implementation of a multicomponent LGBTQ+ cultural competency training program that required administrator and therapist participation in multiple learning sessions over several months (i.e., workshop, clinical consultation, and organizational technical assistance). Results from template analysis supported CFIR-aligned themes, including characteristics of individuals, inner setting, outer setting, and process, and two additional codes-marketing and other/previous training opportunities-emerged from the focus group data. Findings suggest that therapists are motivated to engage in such a program because they want to feel more efficacious, and administrators see the benefits of LGBTQ+ training programs for their clientele and marketing. Barriers to adoption and implementation include cost and personnel resistance, although participants believed these barriers were surmountable. Emphasizing therapist efficacy, clientele need, and benefits for marketing mental and behavioral health services could motivate MBHOs' and therapists' adoption and implementation of LGBTQ+ cultural competency training. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Jessica N. Fish
- Department of Family Science, School of Public Health, University of Maryland
- University of Maryland Prevention Research Center
| | - Evelyn C. King-Marshall
- Department of Family Science, School of Public Health, University of Maryland
- University of Maryland Prevention Research Center
| | - Natasha D. Williams
- Department of Family Science, School of Public Health, University of Maryland
- University of Maryland Prevention Research Center
| | - Elizabeth M. Aparicio
- University of Maryland Prevention Research Center
- Department of Behavioral and Community Health, School of Public Health, University of Maryland
| | - Hannah M. Tralka
- University of Maryland Prevention Research Center
- Department of Behavioral and Community Health, School of Public Health, University of Maryland
| | - Bradley O. Boekeloo
- University of Maryland Prevention Research Center
- Department of Behavioral and Community Health, School of Public Health, University of Maryland
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Thompson HM, Clement AM, Ortiz R, Preston TM, Quantrell ALW, Enfield M, King AJ, Klosinski L, Reback CJ, Hamilton A, Milburn N. Community engagement to improve access to healthcare: a comparative case study to advance implementation science for transgender health equity. Int J Equity Health 2022; 21:104. [PMID: 35907962 PMCID: PMC9339189 DOI: 10.1186/s12939-022-01702-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent calls to action have been made for Implementation Science to attend to health inequities at the intersections of race, gender, and social injustice in the United States. Transgender people, particularly Black and Latina transgender women, experience a range of health inequities and social injustices. In this study, we compared two processes of transgender community engagement in Los Angeles and in Chicago as an implementation strategy to address inequitable access to care; we adapted and extended the Exploration Planning Implementation and Sustainment (EPIS) framework for transgender health equity. METHODS A comparative case method and the EPIS framework were used to examine parallel implementation strategies of transgender community engagement to expand access to care. To foster conceptual development and adaptation of EPIS for trans health equity, the comparative case method required detailed description, exploration, and analyses of the community-engagement processes that led to different interventions to expand access. In both cities, the unit of analysis was a steering committee made up of local transgender and cisgender stakeholders. RESULTS Both steering committees initiated their exploration processes with World Café-style, transgender community-engaged events in order to assess community needs and structural barriers to healthcare. The steering committees curated activities that amplified the voices of transgender community members among stakeholders, encouraging more effective and collaborative ways to advance transgender health equity. Based on analysis and findings from the Los Angeles town hall, the steering committee worked with a local medical school, extending the transgender medicine curriculum, and incorporating elements of transgender community-engagement. The Chicago steering committee determined from their findings that the most impactful intervention on structural racism and barriers to healthcare access would be to design and pilot an employment program for Black and Latina transgender women. CONCLUSION In Los Angeles and Chicago, transgender community engagement guided implementation processes and led to critical insights regarding specific, local barriers to healthcare. The steering committee itself represented an important vehicle for individual-, organizational-, and community-level relationship and capacity building. This comparative case study highlights key adaptations of EPIS toward the formation of an implementation science framework for transgender health equity.
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Affiliation(s)
- Hale M Thompson
- Rush University Medical Center, 1645 W. Jackson Blvd., Suite 302, Chicago, IL, 60612, USA.
| | - Allison M Clement
- University of California-Los Angeles, 760 Westwood Plaza A8-159A, Los Angeles, CA, 90095, USA
| | - Reyna Ortiz
- TaskForce Prevention & Community Services, 9 N. Cicero, Chicago, IL, 60644, USA
| | - Toni Marie Preston
- Howard Brown Health Center, 4025 N. Sheridan Road, Chicago, IL, 60613, USA
| | | | - Michelle Enfield
- AIDS Project Los Angeles, 5901 W. Olympic Blvd., Suite 310, Los Angeles, CA, 90036, USA
| | - A J King
- Center for AIDS Research, University of California-Los Angeles, 11075 Santa Monica Blvd, Suite 100, Los Angeles, CA, 90025, USA
| | - Lee Klosinski
- University of California-Los Angeles, 760 Westwood PlazaA8-159A, Los Angeles, CA, 90095, USA
| | - Cathy J Reback
- Friends Research Institute, 6910 Santa Monica Boulevard, Los Angeles, CA, 90038, USA
| | - Alison Hamilton
- University of California-Los Angeles, 760 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Norweeta Milburn
- University of California-Los Angeles, 760 Westwood Plaza A8-159A, Los Angeles, CA, 90095, USA
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McDowell A, Myong C, Tevis D, Fung V. Sexual Orientation and Gender Identity Data Reporting Among U.S. Health Centers. Am J Prev Med 2022; 62:e325-e332. [PMID: 35232619 PMCID: PMC9843854 DOI: 10.1016/j.amepre.2021.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Sexual orientation and gender identity data collection is necessary to address health inequities. This study examines sexual orientation and gender identity data reporting among community health centers. METHODS Using the 2016-2019 Uniform Data System for 1,381 community health centers, trends in reporting of sexual orientation and gender identity data were examined. Multivariable logistic regression was used to assess associations between community health center characteristics and whether sexual orientation and gender identity data were available for ≥75% of a community health center's patients in 2019. Data were analyzed in 2021. RESULTS In 2016-2019, the percentage of community health centers with sexual orientation and gender identity data for ≥75% of patients increased from 14.9% to 53.0%. In 2019, community health centers were more likely to have this data for ≥75% of patients if they were in nonmetro counties (OR=1.48, 95% CI=1.04, 2.10 versus metro), were in the South (OR=2.27, 95% CI=1.57, 3.31) or West (OR=1.91, 95% CI=1.27, 2.88 versus the Northeast), and had more patients aged between 18 and 39 years (OR=1.04, 95% CI=1.02, 1.07), between 40 and 64 years (OR=1.04, 95% CI=1.02, 1.06 vs <18 years), or veterans (OR=1.10, 95% CI=1.01, 1.20). This was less likely among community health centers serving 10,000-20,000 patients (OR=0.70, 95% CI=0.52, 0.95) and >20,000 patients (OR=0.44, 95% CI=0.32, 0.61 vs <10,000) and community health centers with more patients of American Indian/Alaskan Native (OR=0.98, 95% CI=0.97, 0.99) or unknown race (OR=0.92, 95% CI=0.86, 0.97 versus White). CONCLUSIONS Collection of sexual orientation and gender identity data by community health centers has increased substantially since 2016, although gaps remain.
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Affiliation(s)
- Alex McDowell
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
| | - Catherine Myong
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts; Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Delaney Tevis
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts; School of Medicine, University of California San Francisco, San Francisco, California
| | - Vicki Fung
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Restriction of Access to Healthcare and Discrimination of Individuals of Sexual and Gender Minority: An Analysis of Judgments of the European Court of Human Rights from an Ethical Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052650. [PMID: 35270340 PMCID: PMC8909593 DOI: 10.3390/ijerph19052650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 01/27/2023]
Abstract
Individuals of sexual and gender minority (SGM) form a vulnerable group with specific healthcare needs that might be prone to experience discrimination and restrictions regarding their access to healthcare. As the judgments of the European Court of Human Rights (ECtHR) offer a normative perspective on these issues, we analyzed them systematically (1) to identify whether and in what manner ECtHR's judgments concern restriction of access to healthcare for SGM individuals and (2) to identify and categorize the ways of discrimination to which SGM individuals are exposed. We conducted a systematic search of the database of the ECtHR's judgments with the use of specified search terms. Descriptive statistics were performed on the identified judgments. Subsequently, we analyzed the judgments with the use of a qualitative method of thematic analysis. We identified n = 73 cases relevant for our study. In n = 7 (9.59%) of judgments, we found limitations of access to healthcare for SGM individuals, e.g., in cases of restrictions for transsexual individuals to receive hormone or surgical therapy. We regard this as a specific form of discrimination. Furthermore, we identified five other categories of discrimination: restriction of parental rights, failure to respect one's gender identity/sexual orientation, discrimination by jurisdiction, prohibition of promotion, and verbal/physical attacks. The ECtHR proves to have a balanced view on the sensitive topic of sexual self-determination condemning any form of discrimination or restriction of access to healthcare. However, there is a need for further research on discriminatory acts by other individuals, e.g., healthcare providers, rather than by public authorities.
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Poteat TC, Logie CH, van der Merwe LLA. Advancing LGBTQI health research. Lancet 2021; 397:2031-2033. [PMID: 33992129 DOI: 10.1016/s0140-6736(21)01057-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Tonia C Poteat
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - L Leigh Ann van der Merwe
- Social Health Empowerment, Feminist Collective of Transgender Women of Africa, East London, South Africa
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