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Tran J, Byerly S, Nelson J, Lenart EK, Kerwin AJ, Filiberto DM. Race and Socio-Economic Status Impact Withdrawal of Treatment in Young Traumatic Brain Injury. J Pain Symptom Manage 2024:S0885-3924(24)00913-8. [PMID: 39097244 DOI: 10.1016/j.jpainsymman.2024.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/17/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024]
Abstract
CONTEXT Withdrawal of life-sustaining therapies (WDLST) in young individuals with traumatic brain injury (TBI) is an overwhelming situation often made more stressful by socioeconomic factors that shape health outcomes. Identifying these factors is crucial to developing equitable and goal-concordant care for patients and families. OBJECTIVES We aimed to identify predictors of WDLST in young patients with 1-TBI. We hypothesized uninsured payment method, race, and co-morbid status are associated with WDLST. METHODS We queried the 2021 Trauma Quality Improvement Program database for patients <45 years with TBI. Patients with WDLST were compared to patients without WDLST. Multivariable logistic regression (MLR) was performed. RESULTS 61,115 patients were included, of whom 2,487 (4.1%) underwent WDLST. Patients in the WDLST cohort were older (29 vs 27, P<0.001), more likely to suffer from a penetrating mechanism (29% vs 11%, P<.0001), and have uninsured (22% vs 18%) or other payment method (5% vs 3%) when compared to the non-WDLST cohort. MLR identified age (AOR:1.019, 95% CI 1.014-1.024, P<.0001), non-Hispanic ethnicity (AOR:1.590, 95% CI 1.373-1.841, P<.0001), penetrating mechanism (AOR:3.075, 95% CI 2.727-3.467, P<.0001), systolic blood pressure (AOR: 0.992, 95% CI 0.990-0.993, P<0.0001), advanced directive (AOR:4.987, 95% CI 2.823-8.812, P<.0001), cirrhosis (AOR:3.854, 95% CI 2.641-5.625, P<.0001), disseminated cancer (AOR:6.595, 95% CI 2.370-18.357, P=0.0003), and interfacility transfer (AOR:1.457, 95% CI 1.295-1.640, P<0.0001) as factors associated with WDLST. Black patients were less likely to undergo WDLST when compared to white patients (AOR:0.687, 95% CI 0.603-0.782, P<.0001). CONCLUSION The decision for WDLST in young patients with severe TBI may be influenced by cultural and socioeconomic factors in addition to clinical considerations.
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Affiliation(s)
- Jessica Tran
- College of Medicine (T.J), University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, Tennessee, USA.
| | - Saskya Byerly
- Division of Trauma and Surgical Critical Care (B.S., L.E.K., K.A.J., F.D.M.), Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, Tennessee, USA
| | - Jeffrey Nelson
- Division of General Internal Medicine (N.J.), Department of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, Tennessee, USA
| | - Emily K Lenart
- Division of Trauma and Surgical Critical Care (B.S., L.E.K., K.A.J., F.D.M.), Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, Tennessee, USA
| | - Andrew J Kerwin
- Division of Trauma and Surgical Critical Care (B.S., L.E.K., K.A.J., F.D.M.), Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, Tennessee, USA
| | - Dina M Filiberto
- Division of Trauma and Surgical Critical Care (B.S., L.E.K., K.A.J., F.D.M.), Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, Tennessee, USA
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Kissi A, Vorensky M, Sturgeon JA, Vervoort T, van Alboom I, Guck A, Perera RA, Rao S, Trost Z. Racial Differences in Movement-Related Appraisals and Pain Behaviors Among Adults With Chronic Low Back Pain. THE JOURNAL OF PAIN 2024; 25:104438. [PMID: 38065466 PMCID: PMC11058036 DOI: 10.1016/j.jpain.2023.11.021] [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] [Received: 05/15/2023] [Revised: 11/10/2023] [Accepted: 11/27/2023] [Indexed: 01/12/2024]
Abstract
Research documents racial disparities in chronic low back pain (CLBP). Few studies have examined racial disparities in movement-related appraisals and no studies have examined anticipatory appraisals prior to or pain behaviors during functional activities among individuals with CLBP. This cross-sectional study examined racial differences in anticipatory appraisals of pain, concerns about harm, and anxiety, appraisals of pain and anxiety during movement, and observed pain behaviors during 3 activities of daily living (supine-to-standing bed task, sitting-to-standing chair task, floor-to-waist lifting task) in a sample (N = 126) of non-Hispanic Black (31.0%), Hispanic (30.2%), and non-Hispanic White (38.9%) individuals with CLBP. Hispanic participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed and chair tasks compared to non-Hispanic White participants. Hispanic participants reported more pain during the bed task and more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed task and more pre-movement anxiety prior to the chair task compared to non-Hispanic White participants. Non-Hispanic Black participants reported more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants were observed to have significantly more verbalizations of pain during the bed task compared to non-Hispanic White participants. Current findings identify racial disparities in important cognitive-behavioral and fear-avoidance mechanisms of pain. Results indicate a need to revisit traditional theoretical and treatment models in CLBP, ensuring racial disparities in pain cognitions are considered. PERSPECTIVE: This study examined racial disparities in anticipatory and movement-related appraisals, and pain behaviors during activities of daily living among Non-Hispanic Black, Non-Hispanic White, and Hispanic individuals with CLBP. Racial disparities identified in the current study have potentially important theoretical implications surrounding cognitive-behavioral and fear-avoidance mechanisms of pain.
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Affiliation(s)
- Ama Kissi
- Department of Experimental-Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium
| | - Mark Vorensky
- Rusk Rehabilitation, NYU Langone Health, 333 East 38 Street, New York, NY 10016, United States of America
- Department of Physical Therapy, New York University, 380 2 Ave, New York, NY 10010, United States of America
- Department of Physical Therapy, Touro University, 3 Times Square, New York, NY 10036, United States of America
| | - John A. Sturgeon
- Department of Anesthesiology, University of Michigan, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, United States of America
| | - Tine Vervoort
- Department of Experimental-Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium
| | - Ischa van Alboom
- Department of Experimental-Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium
| | - Adam Guck
- Department of Family Medicine, John Peter Smith Health Network, Fort Worth, TX 76104, United States of America
| | - Robert A. Perera
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 1223 E Marshall St, Richmond, VA 23298, United States of America
| | - Smita Rao
- Department of Physical Therapy, New York University, 380 2 Ave, New York, NY 10010, United States of America
| | - Zina Trost
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 1223 E Marshall St, Richmond, VA 23298, United States of America
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Flores MW, Mullin B, Sharp A, Kumar A, Moyer M, Cook BL. Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014. J Racial Ethn Health Disparities 2024; 11:755-763. [PMID: 37326794 DOI: 10.1007/s40615-023-01558-w] [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: 10/19/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 06/17/2023]
Abstract
In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.
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Affiliation(s)
- Michael William Flores
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge St., Suite 26, Cambridge, MA, 02141, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Brian Mullin
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge St., Suite 26, Cambridge, MA, 02141, USA
| | - Amanda Sharp
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge St., Suite 26, Cambridge, MA, 02141, USA
- Center for Mindfulness & Compassion, Cambridge Health Alliance, Cambridge, MA, USA
| | - Anika Kumar
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge St., Suite 26, Cambridge, MA, 02141, USA
- Heller School of Social Policy, Brandies University, Waltham, MA, USA
| | - Margo Moyer
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge St., Suite 26, Cambridge, MA, 02141, USA
| | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge St., Suite 26, Cambridge, MA, 02141, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Ragunanthan NW, Lamb J, Hauspurg A, Beck S. Assessment of Racial Disparities in Aspirin Prophylaxis for Preeclampsia Prevention. Am J Perinatol 2024; 41:635-640. [PMID: 35189651 PMCID: PMC9900494 DOI: 10.1055/s-0042-1743142] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Low-dose aspirin is recommended for preeclampsia prevention among women with high-risk conditions, including chronic hypertension. Black women have higher rates of hypertensive disorders of pregnancy, and whether this is related to disparities in aspirin prophylaxis is unknown. We investigated the relationship between race and counseling/prescription and uptake of aspirin among a cohort of women with chronic hypertension. STUDY DESIGN This is a single-institution, retrospective cohort study of women with chronic hypertension who delivered between 2016 and 2018. Medical record review was performed to assess counseling/prescription of aspirin prophylaxis and self-reported uptake. Self-reported uptake was determined by mention in the provider's notes or by inclusion in the medication reconciliation system. Demographic and obstetric outcome data were compared by self-reported race (Black vs. all other races) in univariate analysis. Multivariable logistic regression analysis was performed to evaluate the association between race and aspirin adherence. RESULTS We included 872 women: 361 (41.4%) Black women and 511 (58.6%) white or other race women. Overall, 567 (65.0%) women were counseled and/or given a prescription for aspirin, and 411 (72.4%) of those women reported uptake. Black women were equally likely to be counseled and/or prescribed aspirin compared with all other races (67.3 vs. 63.4%; p = 0.7). However, Black women were less likely to report uptake of aspirin (63.8 vs. 79.0%; p < 0.001). After adjustment for total prenatal visits and tobacco use, Black race was associated with an adjusted odds ratio of 0.53 (95% confidence interval: 0.36-0.78) for uptake of aspirin. CONCLUSION In our cohort, recommendation for aspirin prophylaxis was suboptimal in all groups, reaching only 65% of eligible women. Black women were equally likely as women of other races to receive counseling about aspirin, but rates of uptake were lower. Our findings suggest that counseling and prescription of aspirin alone in high-risk Black women are not sufficient for utilization of this intervention. KEY POINTS · Rates of counseling about aspirin prophylaxis for preeclampsia did not vary by race.. · Black women had lower rates of uptake of aspirin compared with women of other races.. · Counseling about aspirin was inadequate in general, reaching only 65% of eligible women..
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Affiliation(s)
- Nina W. Ragunanthan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jordan Lamb
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stacy Beck
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Hansen MA, Hirth J, Zoorob R, Langabeer J. Demographics and clinical features associated with rates of electronic message utilization in the primary care setting. Int J Med Inform 2024; 183:105339. [PMID: 38219417 DOI: 10.1016/j.ijmedinf.2024.105339] [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] [Received: 08/22/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Electronic messages are growing as an important form of patient-provider communication, particularly in the primary care setting. However, adoption of healthcare technology has been under-utilized by underserved patient populations. The purpose of this study was to describe how adoption and utilization of electronic messaging occurred within a large primary care urban-based patient population. METHODS In this retrospective study, the frequency of electronic messages initiated by adult outpatient primary care patients was observed. Patients were classified as either non-portal adopters, non-message utilizers, low message utilizers, and high message utilizers. Logistic regression modeling was used to compare factors associated with message utilization rates to determine disparities in access. RESULTS Among a sample of 27,453 ethnically diverse adult patients from the Houston, Texas Metropolitan area, 33,497 unique messages were sent (1.22 messages/patient). Message burden was predominantly derived by a small number of high utilizers (individuals who sent 3 or more messages), who comprised 15.7 % of the study population (n = 4302) but accounted for 77 % of the message volume (n = 25,776). These high utilizers were typically older, White, English speaking, from middle to upper income zip codes, had higher number of comorbidities, and a higher number of clinical visits. CONCLUSIONS Most inbox messages were generated by a small number of patients. While it was reassuring to see older and sicker individuals utilizing electronic messaging, patients from minority and/or lower income background utilized electronic messaging much less. This may propagate systematic bias and decrease the level of care for traditionally underserved patients.
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Affiliation(s)
- Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, United States; University of Texas, School of Biomedical Informatics, Houston, TX, United States.
| | - Jacqueline Hirth
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, United States; University of Texas Medical Branch, Galveston, TX, United States
| | - Roger Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - James Langabeer
- University of Texas, School of Biomedical Informatics, Houston, TX, United States
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Khaleghzadegan S, Rosen M, Links A, Ahmad A, Kilcullen M, Boss E, Beach MC, Saha S. Validating computer-generated measures of linguistic style matching and accommodation in patient-clinician communication. PATIENT EDUCATION AND COUNSELING 2024; 119:108074. [PMID: 38070297 DOI: 10.1016/j.pec.2023.108074] [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] [Received: 07/06/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE To explore the validity of computer-analyzed linguistic style matching (LSM) in patient-clinician communication. METHODS Using 330 transcribed HIV patient encounters, we quantified word use with Linguistic Inquiry and Word Count (LIWC), a dictionary-based text analysis software. We measured LSM by calculating the degree to which clinicians matched patients in the use of LIWC "function words" (e.g., articles, pronouns). We tested associations of different LSM metrics with patients' perceptions that their clinicians spoke similiarly to them. RESULTS We developed 3 measures of LSM: 1) at the whole-visit level; (2) at the turn-by-turn level; and (3) using a "rolling-window" approach, measuring matching between clusters of 8 turns per conversant. None of these measures was associated with patient-rated speech similarity. However, we found that increasing trajectories of LSM, from beginning to end of the visit, were associated with higher patient-rated speech similarity (β 0.35, CI 0.06, 0.64), compared to unchanging trajectories. CONCLUSIONS Our findings point to the potential value of clinicians' adapting their communication style to match their patients, over the course of the visit. PRACTICE IMPLICATIONS With further validation, computer-based linguistic analyses may prove an efficient tool for generating data on communication patterns and providing feedback to clinicians in real time.
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Affiliation(s)
- Salar Khaleghzadegan
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.
| | - Michael Rosen
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anne Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alya Ahmad
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Molly Kilcullen
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Boss
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Catherine Beach
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Somnath Saha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA; Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, USA
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Tseng TY, Mitchell MM, Chander G, Latkin C, Kennedy C, Knowlton AR. Patient-centered Engagement as a Mediator in the Associations of Healthcare Discrimination, Pain Care Denial, and Later Substance Use Among a Sample of Predominately African Americans Living with HIV. AIDS Behav 2024; 28:429-438. [PMID: 38060111 DOI: 10.1007/s10461-023-04235-5] [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] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
Chronic pain is prevalent and often under-addressed among people with HIV and people who use drugs, likely compounding the stress of discrimination in healthcare, and self-medicating along with its associated overdose risk or other problematic coping. Due to challenges in treating pain and HIV in the context of substance use, collaborative, patient-centered patient-provider engagement (PCE) may be particularly important for mitigating the impact of pain on illicit drug use and promoting sustained recovery. We examined whether PCE with primary care provider (PCE-PCP) mediated the effects of pain, discrimination, and denial of prescription pain medication on later substance use for pain among a sample of 331 predominately African Americans with HIV and a drug use history in Baltimore, Maryland, USA. Baseline pain level was directly associated with a higher chance of substance use for pain at 12 months (Standardized Coefficient = 0.26, p < .01). Indirect paths were observed from baseline healthcare discrimination (Standardized Coefficient = 0.05, 95% CI=[0.01, 0.13]) and pain medication denial (Standardized Coefficient = 0.06, 95% CI=[0.01, 0.14]) to a higher chance of substance use for pain at 12 months. Effects of prior discrimination and pain medication denial on later self-medication were mediated through worse PCE-PCP at 6 months. Results underscore the importance of PCE interpersonal skills and integrative care models in addressing mistreatment in healthcare and substance use in this population. An integrated approach for treating pain and substance use disorders concurrently with HIV and other comorbidities is much needed. Interventions should target individuals at multiple risks of discriminations and healthcare professionals to promote PCE.
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Affiliation(s)
- Tuo-Yen Tseng
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy R Knowlton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Aruma JF, Hearn M, Bernacchi V, Moss JL. Examining the roles of travel distance, medical mistrust, and cancer fatalism in the uptake of clinical cancer prevention among women in rural and urban US communities: A secondary data analysis. Prev Med Rep 2024; 38:102611. [PMID: 38375162 PMCID: PMC10874844 DOI: 10.1016/j.pmedr.2024.102611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/04/2024] [Accepted: 01/12/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction Rural adults are less likely to receive cancer screening than urban adults, likely due to systematic differences in community- and individual-level factors. The purpose of this study was to analyze the relative contributions of rurality, travel time, medical mistrust, and cancer fatalism in explaining uptake of clinical cancer prevention services. Methods We conducted a secondary data analysis of 2019-2020 survey data from women, ages 45-65, in rural and urban counties in central Pennsylvania, examining rurality, travel time to a primary care provider, medical mistrust, and cancer fatalism, as well as uptake of guideline-recommended colorectal cancer screening, cervical cancer screening, and preventive check-up. Final models used multivariable logistic regression to assess the relationships among study variables, controlling for participant demographics. Results Among 474 participants, 48.9 % resided in rural counties. Most participants had received clinical cancer prevention services (colorectal cancer screening: 55.4 %; cervical cancer screening: 82.8 %; preventive check-up in the last year: 75.4 %). Uptake of services was less common among participants with higher medical mistrust (colorectal cancer screening: adjusted odds ratio [aOR] = 0.87, 95 % confidence interval [CI] = 0.76-1.00; cervical cancer screening: aOR = 0.79, 95 % CI = 0.63-1.00; last-year check-up: aOR = 0.74, 95 % CI = 0.63-0.88). Conclusions Patient attitudes, particularly medical mistrust, may contribute to rural/urban disparities in clinical cancer prevention among women. Community- and individual-level interventions are needed to improve cancer outcomes in rural areas.
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Affiliation(s)
- Jane-Frances Aruma
- Penn State College of Medicine, The Pennsylvania State University, State College, PA, USA
| | - Madison Hearn
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Veronica Bernacchi
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Jennifer L. Moss
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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Olinger R, Matejka B, Chakravarty R, Johnston M, Ornelas E, Draves J, Jain N, Hentschel J, Owen W, Ma Y, Marx W, Freitag J, Zhang N, Guage C, Crabtree C. Americans do not select their doctors based on race. FRONTIERS IN SOCIOLOGY 2024; 8:1191080. [PMID: 38328739 PMCID: PMC10847235 DOI: 10.3389/fsoc.2023.1191080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 11/28/2023] [Indexed: 02/09/2024]
Abstract
To what extent do Americans racially discriminate against doctors? While a large literature shows that racial biases pervade the American healthcare system, there has been no systematic examination of these biases in terms of who patients select for medical treatment. We examine this question in the context of the ongoing global COVID-19 pandemic, where a wealth of qualitative evidence suggests that discrimination against some historically marginalized communities, particularly Asians, has increased throughout the United States. Conducting a well-powered conjoint experiment with a national sample of 1,498 Americans, we find that respondents do not, on average, discriminate against Asian or doctors from other systematically minoritized groups. We also find no consistent evidence of treatment effect heterogeneity; Americans of all types appear not to care about the racial identity of their doctor, at least in our study. This finding has important implications for the potential limits of American prejudice.
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Teixeira da Silva D, Valente PK, Lin W, Hightow-Weidman L, Mayer K, Biello K, Bauermeister J. Psychosocial and structural stressors and engagement in medical care among young sexual minority men across racial identities. Behav Med 2023:1-9. [PMID: 38126713 DOI: 10.1080/08964289.2023.2277931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/17/2023] [Indexed: 12/23/2023]
Abstract
Psychosocial and structural stressors and low engagement in medical care likely contribute to the disproportionate burden of chronic disease among sexual minority men (SMM) across the life course. However, how these stressors impact engagement in medical care among young SMM (YSMM) across racial identities remains understudied. The association of psychosocial and structural stressors with forgoing care among YSMM across racial identities was examined using race-stratified adjusted logistic regression of cross-sectional data. Among 737 HIV-negative SMM aged 16-24 years, nearly all (93%) experienced discrimination in their daily lives. Non-Hispanic/Latinx Black participants reported significantly higher levels of discrimination, exposure to community violence, and food insecurity. Medical mistrust and mental health were not significantly different across racial groups. In the full sample model, education, food insecurity, and discrimination were associated with forgoing care. Among the non-Hispanic/Latinx White sample, medical mistrust and discrimination were associated with forgoing care. Among the non-Hispanic/Latinx Black sample, discrimination was associated with forgoing care. Among the Hispanic/Latinx sample, food insecurity was associated with forgoing care. Psychosocial and structural stressors were common in this YSMM cohort, and significantly different across racial/ethnic identities. Race-stratified analysis revealed differences in the association of stressors with forgoing care among YSMM across racial identities, not appreciated in the analysis limited to the total study population. Our findings may support efforts to address health inequity and improve engagement in medical care among SMM.
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Affiliation(s)
| | - Pablo K Valente
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Willey Lin
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kenneth Mayer
- The Fenway Institute at Fenway Health, Boston, MA, USA
| | - Katie Biello
- The Fenway Institute at Fenway Health, Boston, MA, USA
- School of Public Health, Brown University, Providence, RI, USA
| | - José Bauermeister
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Ramsoondar N, Anawati A, Cameron E. Racism as a determinant of health and health care: Rapid evidence narrative from the SAFE for Health Institutions project. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:594-598. [PMID: 37704247 PMCID: PMC10498908 DOI: 10.46747/cfp.6909594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Nusha Ramsoondar
- Medical student at the Northern Ontario School of Medicine (NOSM) University in Thunder Bay, Ont
| | - Alex Anawati
- Associate Professor, co-lead of the SAFE (Social Accountability as the Framework for Engagement) for Health Institutions project, and Physician Clinical Lead for Leadership, Advocacy, and Policy in the Centre for Social Accountability at NOSM University and Health Sciences North in Sudbury, Ont; and has been a member of the College of Family Physicians of Canada's Social Accountability Working Group
| | - Erin Cameron
- Associate Professor, co-lead of the SAFE for Health Institutions project, and Director of the Centre for Social Accountability at NOSM University
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Ramsoondar N, Anawati A, Cameron E. Le racisme comme déterminant de la santé et des soins de santé. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:601-605. [PMID: 37704242 PMCID: PMC10498905 DOI: 10.46747/cfp.6909601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Nusha Ramsoondar
- Étudiante en médecine à l'École de médecine du Nord de l'Ontario (NOSM), à Thunder Bay (Ontario)
| | - Alex Anawati
- Professeur agrégé, codirecteur du projet SAFE (Responsabilité sociale comme référentiel pour la mobilisation) à l'intention des établissements de santé, médecin clinicien responsable du Leadership, de la défense des intérêts et des politiques au Centre pour la responsabilité sociale de l'Université NOSM et de Health Sciences North à Sudbury (Ontario), et il était membre du Groupe de travail sur la responsabilité sociale du Collège des médecins de famille du Canada
| | - Erin Cameron
- Professeure agrégée et codirectrice du projet SAFE à l'intention des établissements de santé et directrice du Centre pour la responsabilité sociale de l'Université NOSM
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Wang N, Chen J. Decreasing Racial Disparities in Preventable Emergency Department Visits Through Hospital Health Information Technology Patient Engagement Functionalities. Telemed J E Health 2023; 29:841-850. [PMID: 36374942 PMCID: PMC10277978 DOI: 10.1089/tmj.2022.0199] [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: 05/06/2022] [Revised: 09/17/2022] [Accepted: 10/04/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: Hospitals are a major source of care for underserved populations in the United States. However, little is known about how hospital-based health information technology (HIT) can improve the efficiency of care and reduce disparities. Objective: We examined the variation of preventable emergency department (ED) visits and associated racial disparities by hospital adoption of HIT patient engagement (HIT-PE) functionalities. Methods: This was an observational study of 6,543,514 non-Hispanic Black (Black) and non-Hispanic White (White) adult patients using 2019 datasets of seven states (Arizona, Florida, Kentucky, Maryland, North Carolina, Vermont, Wisconsin) from the State Emergency Department Databases, American Hospital Association Annual Survey & Information Technology Supplement, and Area Health Resources File. Results: High HIT-PE adoption was associated with lower rates of preventable ED (odds ratio [OR] = 0.992, p < 0.001). Specific HIT-PE functions such as importing medical records from other organizations into the patient portal (OR = 0.977, p < 0.001), electronically sending medical information to a third party (OR = 0.970, p < 0.001), and scheduling appointments online (OR = 0.987, p < 0.001) were also associated with reduced preventable ED rates. Black patients had higher rates of preventable ED compared with Whites (OR = 1.386, p < 0.001); however, the interaction of Black patients and high HIT-PE adoption was associated with lower rates of preventable ED (OR = 0.977, p < 0.001). Our results also showed that higher HIT-PE adoption was associated with a reduction in preventable ED visits among Black patients with comorbidities and Black patients living in low-income areas. Conclusions: The results of our study suggest that there is potential to reduce preventable ED rates and racial disparities through hospital-based HIT-PE functionalities.
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Affiliation(s)
- Nianyang Wang
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Maryland, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Maryland, USA
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Parente VM, Nagy G, Pollak KI. Patient- and Family-Centered Hospital Care-The Need for Structural Humility. JAMA Pediatr 2023; 177:553-554. [PMID: 37010842 PMCID: PMC10947776 DOI: 10.1001/jamapediatrics.2023.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
This Viewpoint discusses communication between clinicians and caregivers of racial and ethnic minoritized groups.
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Affiliation(s)
- Victoria M Parente
- Division of Hospital Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Gabriela Nagy
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Cancer Prevention and Control, Duke Cancer Institute, Durham, North Carolina
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Syed G, Sims J, House SH, Bruno B, Boulware A, Tang K, Curenton SM. Innovations and Opportunities in Care for Black Mothers and Birthing People. FAMILY & COMMUNITY HEALTH 2023; 46:87-94. [PMID: 36799941 DOI: 10.1097/fch.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
In recent years, there has been increased attention given to how racism fuels health inequities, including the inadequacy of prenatal care (PNC) that Black women and Black birthing people receive. This increase of attention has brought notable advancements in research, practice, and policy that intend to better understand and address these systemic inequities within the health care system. This review aims to provide an overview of promising developments in the study of Black mothers' and birthing people's experiences in PNC and delivery, to detail current research surrounding interventions to improve quality and mitigate bias in obstetric care, and to offer ways in which legislation can support such strategies targeting the root causes of inequities in care.
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Affiliation(s)
- Gullnar Syed
- SRI International, Arlington, Virginia (Ms Syed); Wheelock College of Education & Human Development, Boston University, Boston, Massachusetts (Mss Syed, Bruno, and Tang and Drs Sims and Curenton); Center for Youth, Family, and Community Partnerships, Durham County Cooperative Extension, North Carolina State University (Dr House); and Comparative Human Development, University of Chicago, Chicago, Illinois (Dr Boulware)
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Washington A, Randall J. "We're Not Taken Seriously": Describing the Experiences of Perceived Discrimination in Medical Settings for Black Women. J Racial Ethn Health Disparities 2023; 10:883-891. [PMID: 35239178 PMCID: PMC8893054 DOI: 10.1007/s40615-022-01276-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cervical cancer disparities persist for Black women despite targeted efforts. Reasons for this vary; one potential factor affecting screening and prevention is perceived discrimination in medical settings. The purpose of this study was to describe experiences of perceived discrimination in medical settings for Black women and to explore the impact on cervical cancer screening and prevention. METHODS This paper presents mixed methods results using the Discrimination in Medical Settings (DMS) scale and qualitative interviews to understand the medical experiences of Black women. We administered the DMS scale to 48 Black women and interviewed five about their experiences engaging in the healthcare system. RESULTS High levels of perceived discrimination were experienced by our sample, with the majority of women having experienced discrimination in the medical setting. Qualitative data contextualized these results, including the impact on the patient-provider relationship and on the development of medical mistrust. Most women reported they had been screened within the last 3 years (75%) and had seen a doctor within the past year (89.6%). CONCLUSIONS Black women are engaging in healthcare while experiencing perceived discrimination in medical settings. Future interventions should address the poor quality of medical encounters that Black women experience.
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Wang C, Malaktaris A, McLean CL, Kelsven S, Chu GM, Ross KS, Endsley M, Minassian A, Liu L, Hong S, Lang AJ. Mitigating the health effects of systemic racism: Evaluation of the Race-Based Stress and Trauma Empowerment intervention. Contemp Clin Trials 2023; 127:107118. [PMID: 36796623 PMCID: PMC10389054 DOI: 10.1016/j.cct.2023.107118] [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: 10/27/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Disparities in physical and mental health among Black, Indigenous, and People of Color (BIPOC) are well-documented and mirrored in the Veteran population. Chronic stress due to racism and discrimination is one possible mechanism driving these negative health outcomes. The Race-Based Stress and Trauma Empowerment (RBSTE) group is a novel, manualized, health promotion intervention designed to address the direct and indirect impacts of racism among Veterans of Color. This paper describes the protocol of the first pilot randomized controlled trial (RCT) of RBSTE. This study will examine the feasibility, acceptability, and appropriateness of RBSTE compared to an active control (an adaptation of Present-Centered Therapy; PCT) in a Veterans Affairs (VA) healthcare setting. A secondary aim is to identify and optimize strategies for holistic evaluation. METHODS Veterans of Color (N = 48) endorsing perceived discrimination and stress will be randomized to RBSTE or PCT; both groups will be delivered in 8 weekly, 90-min virtual group sessions. Outcomes will include measures of psychological distress, discrimination and ethnoracial identity, holistic wellness, and allostatic load. Measures will be administered at baseline and post-intervention. CONCLUSION This study will inform future interventions targeting identity-based stressors and represents an important step in advancing equity for BIPOC in medicine and research. CLINICAL TRIAL REGISTRATION NUMBER NCT05422638.
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Affiliation(s)
- Clarice Wang
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Anne Malaktaris
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Caitlin L McLean
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Skylar Kelsven
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Gage M Chu
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Keisha S Ross
- VA St. Louis Health Care System, 915 N. Grand Blvd, St. Louis, MO 63106, USA.
| | - Maurice Endsley
- VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA.
| | - Arpi Minassian
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Lin Liu
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Suzi Hong
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Ariel J Lang
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
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Aguilar GA, Lundsberg LS, Stanwood NL, Gariepy AM. Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care. Contraception 2023; 120:109949. [PMID: 36641096 DOI: 10.1016/j.contraception.2023.109949] [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: 06/01/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care. STUDY DESIGN English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction. RESULTS Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01). CONCLUSION Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures. IMPLICATIONS Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.
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Affiliation(s)
- Gabriela A Aguilar
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States
| | - Nancy L Stanwood
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States
| | - Aileen M Gariepy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States
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Loo S, Brady KJS, Ragavan MI, Griffith KN. Validation of the Clinicians' Cultural Sensitivity Survey for Use in Pedatric Primary Care Settings. J Immigr Minor Health 2023:10.1007/s10903-023-01469-2. [PMID: 36966449 PMCID: PMC10330110 DOI: 10.1007/s10903-023-01469-2] [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] [Accepted: 03/02/2023] [Indexed: 03/27/2023]
Abstract
Incorporating cultural sensitivity into healthcare settings is important to deliver high-quality and equitable care, particularly for marginalized communities who are non-White, non-English speaking, or immigrants. The Clinicians' Cultural Sensitivity Survey (CCSS) was developed as a patient-reported survey assessing clinicians' recognition of cultural factors affecting care quality for older Latino patients; however, this instrument has not been adapted for use in pediatric primary care. Our objective was to examine the validity and reliability of a modified CCSS that was adapted for use with parents of pediatric patients. A convenience sampling approach was used to identify eligible parents during well-child visits at an urban pediatric primary care clinic. Parents were administered the CCSS via electronic tablet in a private location. We first conducted exploratory factor analyses (EFAs) to explore the dimensionality of survey responses in the adapted CCSS, and then conducted a series of confirmatory factor analyses (CFAs) using maximum likelihood estimation based on the results of the EFAs. Exploratory and confirmatory factor analyses (N = 212 parent surveys) supported a three-factor structure assessing racial discrimination ([Formula: see text]=0.96), culturally-affirming practices ([Formula: see text]=0.86), and causal attribution of health problems ([Formula: see text]=0.85). In CFAs, the three-factor model also outperformed other potential factor structures in terms of fit statistics including scaled root mean square error approximation (0.098), Tucker-Lewis Index (0.936), Comparative Fit Index (0.950), and demonstrated adequate fit according to the standardized root mean square residual (0.061). Our findings support the internal consistency, reliability, and construct validity of the adapted CCSS for use in a pediatric population.
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Affiliation(s)
- Stephanie Loo
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Keri J S Brady
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Maya I Ragavan
- Department of Pediatrics, University of Pittsburgh/Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Kevin N Griffith
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA.
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Leung J, Som A, McMorrow L, Zickuhr L, Wolbers J, Bain K, Flood J, Baker EA. Rethinking the Difficult Patient: Formative Qualitative Study Using Participatory Theater to Improve Physician-Patient Communication in Rheumatology. JMIR Form Res 2023; 7:e40573. [PMID: 36877547 PMCID: PMC10028511 DOI: 10.2196/40573] [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: 06/27/2022] [Revised: 12/24/2022] [Accepted: 12/27/2022] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Effective physician-patient communication is crucial for positive health outcomes for patients with chronic diseases. However, current methods of physician education in communication are often insufficient to help physicians understand how patients' actions are influenced by the contexts within which they live. An arts-based participatory theater approach can provide the necessary health equity framing to address this deficiency. OBJECTIVE The aim of this study was to develop, pilot, and conduct a formative evaluation of an interactive arts-based communication skills intervention for graduate-level medical trainees grounded in a narrative representative of the experience of patients with systemic lupus erythematosus. METHODS We hypothesized that the delivery of interactive communication modules through a participatory theater approach would lead to changes in both attitudes and the capacity to act on those attitudes among participants in 4 conceptual categories related to patient communication (understanding social determinants of health, expressing empathy, shared decision-making, and concordance). We developed a participatory, arts-based intervention to pilot this conceptual framework with the intended audience (rheumatology trainees). The intervention was delivered through routine educational conferences at a single institution. We conducted a formative evaluation by collecting qualitative focus group feedback to evaluate the implementation of the modules. RESULTS Our formative data suggest that the participatory theater approach and the design of the modules added value to the participants' learning experience by facilitating interconnection of the 4 communication concepts (eg, participants were able to gain insight into both what physicians and patients were thinking about on the same topic). Participants also provided several suggestions for improving the intervention such as ensuring that the didactic material had more active engagement and considering additional ways to acknowledge real-world constraints (eg, limited time with patients) in implementing communication strategies. CONCLUSIONS Our findings from this formative evaluation of communication modules suggest that participatory theater is an effective method for framing physician education with a health equity lens, although considerations in the realms of functional demands of health care providers and use of structural competency as a framing concept are needed. The integration of social and structural contexts into the delivery of this communication skills intervention may be important for the uptake of these skills by intervention participants. Participatory theater provided an opportunity for dynamic interactivity among participants and facilitated greater engagement with the communication module content.
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Affiliation(s)
- Jerik Leung
- Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Avira Som
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Lily McMorrow
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Lisa Zickuhr
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - John Wolbers
- Metro Theater Company, St. Louis, MO, United States
| | - Karen Bain
- Metro Theater Company, St. Louis, MO, United States
| | - Julia Flood
- Metro Theater Company, St. Louis, MO, United States
| | - Elizabeth A Baker
- Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, United States
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Parker MN, Lavender JM, Schvey NA, Tanofsky-Kraff M. Practical Considerations for Using the Eating Disorder Examination Interview with Adolescents. Adolesc Health Med Ther 2023; 14:63-85. [PMID: 36860931 PMCID: PMC9969870 DOI: 10.2147/ahmt.s220102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
Approximately 35 years after its initial publication, the Eating Disorder Examination (EDE) remains one of the most widely used semi-structured interviews for assessing eating disorder diagnoses and symptomatology. Although the interview provides certain advantages over other common measurement approaches (ie, questionnaires), there are particular considerations regarding the EDE that warrant attention, including in its use with adolescents. The aims of this paper are therefore to: 1) provide a brief overview of the interview itself, as well as a description of its origin and underlying conceptual framework; 2) describe relevant factors for administering the interview with adolescents; 3) review potential limitations regarding use of the EDE with adolescents; 4) address considerations for using the EDE with pertinent subpopulations of adolescents who may experience distinct eating disorder symptoms and/or risk factors; and 5) discuss the integration of self-report questionnaires with the EDE. Advantages of using the EDE include the ability for interviewers to clarify complex concepts and mitigate inattentive responding, enhanced orientation to the interview timeframe to improve recall, increased diagnostic accuracy compared to questionnaires, and accounting for potentially salient external factors (eg, food/eating rules imposed by a parent/guardian). Limitations include more extensive training requirements, greater assessment burden, variable psychometric performance across subgroups, lack of items evaluating muscularity-oriented symptoms and avoidant/restrictive food intake disorder diagnostic criteria, and lack of explicit consideration for salient risk factors other than weight and shape concerns (eg, food insecurity).
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Affiliation(s)
- Megan N Parker
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jason M Lavender
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA,Military Cardiovascular Outcomes Research (MiCOR) Program, Bethesda, MD, USA,The Metis Foundation, San Antonio, TX, USA,Correspondence: Jason M Lavender, Military Cardiovascular Outcomes Research Program, 4301 Jones Bridge Road, Building 17, Suite 2A, Bethesda, MD, 20814, USA, Email
| | - Natasha A Schvey
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Marian Tanofsky-Kraff
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA,Military Cardiovascular Outcomes Research (MiCOR) Program, Bethesda, MD, USA
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22
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Patient Disparities and Provider Diversity in Orthopaedic Surgery: A Complex Relationship. J Am Acad Orthop Surg 2023; 31:132-139. [PMID: 36563332 DOI: 10.5435/jaaos-d-22-00410] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
Disparities in the access to, utilization of, and outcomes after orthopaedic surgery are a notable problem in the field that limits patients' ability to access the highest level of care and achieve optimal outcomes. Disparities exist based on numerous sociodemographic factors, with sex and race/ethnicity being two of the most well-studied factors linked to disparities in orthopaedic care. These disparities cross all subspecialties and tend to negatively affect women and racial/ethnic minorities. The increased recognition of the disparities in orthopaedic care has been paralleled by an increased recognition of the lack of diversity among orthopaedic surgeons. Although efforts are being made to improve the representation of women and underrepresented minorities among orthopaedic surgeons, the numbers, particularly of racial and ethnic minorities, show little improvement. The lack of gender and racial diversity among orthopaedic surgeons may be one of many factors related to the gender and racial disparities seen in orthopaedic care. Patients may prefer a provider that they can better identify with and that may affect care. Orthopaedic surgery as a specialty must continue to work to foster an inclusive environment and make concerted efforts to improve diversity through the recruitment of women and underrepresented minorities, among others, for the benefit of patients, surgeons, and the continued growth of the field as a whole.
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23
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Achstetter K, Köppen J, Hengel P, Blümel M, Busse R. Drivers of patient perceptions of health system responsiveness in Germany. Int J Health Plann Manage 2022; 37 Suppl 1:166-186. [PMID: 36184993 DOI: 10.1002/hpm.3570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Health system responsiveness (HSR)-the ability of a health system to meet the non-medical legitimate expectations of patients-is a key to patient-centred health systems. Although responsiveness is essential to provide equitable and accountable health care, little is known about patient-side drivers of HSR. This study aims to narrow this gap. METHODS A survey among 20,000 Germans with substitutive private health insurance included questions on HSR and patient characteristics such as health literacy (HL), experienced discrimination, and sociodemographic information. Survey data were linked to patient-level claims data. Logistic regression was applied to assess the association between HSR and patient characteristics. RESULTS The sample (age 54.0 ± 16.1; 60.5% male) contains 2951 respondents with outpatient physician care in the past year. Of the nine HSR items, eight are rated as (very) good (74.4%-94.3%), except for coordination between providers (60.2%). Patient characteristics highly influence HSR: patients with high HL, for instance, are more likely to assess responsiveness as (very) good (e.g., clear explanations from physicians: OR 4.17). Poor assessment of responsiveness is seen among users who experienced discrimination. CONCLUSION This study revealed new associations between HSR and patient characteristics. Incorporating this knowledge in practice would help strengthen patient-centred health services by considering patient experiences and expectations. This highlights that HSR can be used as a tool to evaluate and promote patient-centred health services. Future research should investigate additional drivers of HSR, both on the patient and the provider sides.
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Affiliation(s)
- Katharina Achstetter
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany.,Berlin Centre for Health Economics Research, Technische Universität Berlin, Berlin, Germany
| | - Julia Köppen
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany.,Berlin Centre for Health Economics Research, Technische Universität Berlin, Berlin, Germany
| | - Philipp Hengel
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany.,Berlin Centre for Health Economics Research, Technische Universität Berlin, Berlin, Germany
| | - Miriam Blümel
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany.,Berlin Centre for Health Economics Research, Technische Universität Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany.,Berlin Centre for Health Economics Research, Technische Universität Berlin, Berlin, Germany
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24
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Scanzera AC, Thermozier S, Chang AY, Kim SJ, Chan RP. Adherence to Urgent Eye Visits during the COVID-19 Pandemic: A Population Characteristics Study. Ophthalmic Epidemiol 2022; 29:613-620. [PMID: 34895007 PMCID: PMC9189247 DOI: 10.1080/09286586.2021.2015785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To explore individual and community factors associated with adherence to physician recommended urgent eye visits via a tele-triage system during the COVID-19 pandemic. METHOD We retrospectively reviewed acute visit requests and medical exam data between April 6, 2020 and June 6, 2020. Patient demographics and adherence to visit were examined. Census tract level community characteristics from the U.S. Census Bureau and zip code level COVID-19 related death data from the Cook County Medical Examiner's Office were appended to each geocoded patient address. Descriptive statistics, t-tests, and logistic regression analyses were performed to explore the effects of individual and community variables on adherence to visit. RESULTS Of 229 patients recommended an urgent visit, 216 had matching criteria on chart review, and 192 (88.9%) adhered to their visit. No difference in adherence was found based on individual characteristics including: age (p = .24), gender (p = .94), race (p = .56), insurance (p = .28), nor new versus established patient status (p = .20). However, individuals who did not adhere were more likely to reside in neighborhoods with a greater proportion of Blacks (59.4% vs. 33.4%; p = .03), greater unemployment rates (17.5% vs. 10.7%; p < .01), and greater cumulative deaths from COVID-19 (56 vs. 31; p = .01). Unemployment rate continued to be statistically significant after controlling for race and cumulative deaths from COVID-19 (p = .04). CONCLUSION We found that as community unemployment rate increases, adherence to urgent eye visits decreases, after controlling for relevant neighborhood characteristics. Unemployment rates were highest in predominantly Black neighborhoods early in the pandemic, which may have contributed to existing racial disparities in eye care.
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Affiliation(s)
- Angelica C. Scanzera
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, United States
| | - Stephanie Thermozier
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, United States
| | - Arthur Y. Chang
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, United States
| | - Sage J. Kim
- Division of Health Policy & Administration, School of Public Health, University of Illinois at Chicago, Chicago, United States
| | - R.V. Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, United States
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25
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Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:2128-2141. [PMID: 35762196 DOI: 10.1111/hsc.13884] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/10/2022] [Accepted: 05/27/2022] [Indexed: 06/15/2023]
Abstract
Experiencing homelessness is associated with poor health, high levels of chronic disease and high premature mortality. Experiencing homelessness is known to be socially stigmatised and stigma has been suggested as a cause of health inequalities. No previous review has synthesised the evidence about stigma related to homelessness and the impact on the health of people experiencing homelessness. The present mixed-methods review systematically searched four databases and retrieved 21 original articles with relevant data around stigma, homelessness and health. Across all studies, there was broad agreement that some people experiencing homelessness experience significant stigma from providers when accessing health care and this impacts on general health and service access. There is also evidence that perceived stigma related to homelessness correlates with poorer mental and physical health.
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26
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Sheahan KL, Kroll-Desrosiers A, Goldstein KM, Sheahan MM, Oumarou A, Mattocks K. Sufficiency of Health Information During Pregnancy: What's Missing and for Whom? A Cross-Sectional Analysis Among Veterans. J Womens Health (Larchmt) 2022; 31:1557-1566. [PMID: 35404136 DOI: 10.1089/jwh.2021.0462] [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: 11/13/2022] Open
Abstract
Background: Women Veterans often experience trauma and physical and mental health conditions that increase risk of adverse pregnancy outcomes. Information provision during pregnancy may facilitate improved outcomes. However, little evidence exists about information women Veterans receive during pregnancy, and their perceptions of it. Materials and Methods: We recruited pregnant Veterans from 15 Veterans Affairs medical centers. Through telephone surveys, women (N = 851) provided information about sociodemographic characteristics, military service, health, and pregnancy experiences. We asked postpartum women whether, during pregnancy, they received sufficient information about nine health topics. We calculated a composite score (range: 0-9) that reflected sufficiency of information received. Multivariable logistic regression models identified determinants of perceived sufficiency of information. Results: Mean age was 32.1 years. Most reported being White (56.3%), non-Hispanic (80.3%), married/living with a partner (85.1%), and employed (54.4%). Most (54.6%) had been diagnosed with depression (54.6%); one-quarter reported current depressive symptoms. Mean sufficiency of information score was 6.9. Topics that women most reported they did not receive sufficient information on included, what to expect during delivery (32.3%) and how their spouse/partner might support them during labor (40.3%). History of depression (β = -0.35, p = 0.03), current depressive symptoms (β = -0.66, p = 0.001), military sexual trauma (β = 0.37, p = 0.03), and experience of violence (β = 0.66, p = 0.03) were associated with lower sufficiency of information scores. Conclusion: Results indicate need for enhanced and tailored provision of information for Veterans during pregnancy, particularly among those with experience of trauma, past depression diagnoses, and current depressive symptoms. This may include optimizing care coordination and increasing access to childbirth education classes and doula support.
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Affiliation(s)
- Kate L Sheahan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Health Services Research and Development, Durham VA Health Care System, Durham, North Carolina, USA
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Health Services Research and Development, Durham VA Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Annie Oumarou
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Health Services Research and Development, Durham VA Health Care System, Durham, North Carolina, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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27
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Leung T, Burgess DJ, Rollins AL, Patterson S, Damush T, Bair MJ, Salyers MP, Spoont M, Slaven JE, O'Connor C, Walker K, Zou DS, Austin E, Akins J, Miller J, Chinman M, Matthias MS. Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study. JMIR Res Protoc 2022; 11:e37712. [PMID: 36066967 PMCID: PMC9490546 DOI: 10.2196/37712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/19/2022] [Accepted: 07/26/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Mental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making. OBJECTIVE The primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research. METHODS This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings. RESULTS Participants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex. CONCLUSIONS Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals. TRIAL REGISTRATION ClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37712.
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Affiliation(s)
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States.,Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Angela L Rollins
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States.,Regenstrief Institute, Indianapolis, IN, United States.,Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States
| | - Scott Patterson
- Department of Psychiatry, Richard L. Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Teresa Damush
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States.,Regenstrief Institute, Indianapolis, IN, United States.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Matthew J Bair
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States.,Regenstrief Institute, Indianapolis, IN, United States.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States
| | - Michele Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States.,Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - James E Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Caitlin O'Connor
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Kiara Walker
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Denise S Zou
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Emily Austin
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States
| | - John Akins
- Department of Psychiatry, Richard L. Roudebush VA Medical Center, Indianapolis, IN, United States
| | - James Miller
- Department of Psychiatry, Richard L. Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care, Pittsburgh, PA, United States.,RAND Corporation Pittsburgh Office, Pittsburgh, PA, United States
| | - Marianne S Matthias
- Center for Health Information and Communication, Health Services Research & Development, Richard L Roudebush VA Medical Center, Indianapolis, IN, United States.,Regenstrief Institute, Indianapolis, IN, United States.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
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28
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Sun K, Corneli AL, Dombeck C, Swezey T, Rogers JL, Criscione-Schreiber LG, Sadun RE, Eudy AM, Doss J, Bosworth HB, Clowse MEB. Barriers to Taking Medications for Systemic Lupus Erythematosus: A Qualitative Study of Racial Minority Patients, Lupus Providers, and Clinic Staff. Arthritis Care Res (Hoboken) 2022; 74:1459-1467. [PMID: 33662174 PMCID: PMC8417148 DOI: 10.1002/acr.24591] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/18/2021] [Accepted: 03/02/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Underrepresented racial and ethnic minorities are disproportionately affected by systemic lupus erythematosus (SLE). Racial and ethnic minorities also have more severe SLE manifestations that require use of immunosuppressive medications, and often have lower rates of medication adherence. We aimed to explore barriers of adherence to SLE immunosuppressive medications among minority SLE patients. METHODS We conducted a qualitative descriptive study using in-depth interviews with a purposive sample of racial minority SLE patients taking oral immunosuppressants (methotrexate, azathioprine, or mycophenolate), and lupus clinic providers and staff. Interviews were audiorecorded, transcribed, and analyzed using applied thematic analysis. We grouped themes using the Capability, Opportunity, Motivation, Behavior conceptual model. RESULTS We interviewed 12 SLE patients (4 adherent, 8 nonadherent) and 12 providers and staff. We identified capability barriers to include external factors related to acquiring medications, specifically cost-, pharmacy-, and clinic-related issues; opportunity barriers to include external barriers to taking medications, specifically logistic- and medication-related issues; and motivation factors to include intrinsic barriers, encompassing patients' knowledge, beliefs, attitudes, and physical and mental health. The most frequently described barriers were cost, side effects, busyness/forgetting, and lack of understanding, although barriers differed by patient and adherence level, with logistic and intrinsic barriers described predominantly by nonadherent patients and side effects described predominantly by adherent patients. CONCLUSION Our findings suggest that interventions may be most impactful if they are designed to facilitate logistics of taking medications and increase patients' motivation while allowing for personalization to address the individual differences in adherence barriers.
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Affiliation(s)
- Kai Sun
- Duke University Hospital and Duke University School of Medicine, Durham, North Carolina
| | - Amy L Corneli
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina
| | - Carrie Dombeck
- Duke University School of Medicine, Durham, North Carolina
| | - Teresa Swezey
- Duke University School of Medicine, Durham, North Carolina
| | - Jennifer L Rogers
- Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina
| | | | | | - Amanda M Eudy
- Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina
| | - Jayanth Doss
- Duke University School of Medicine, Durham, North Carolina
| | - Hayden B Bosworth
- Duke University School of Medicine and Durham Veterans Administration Medical Center, Durham, North Carolina
| | - Megan E B Clowse
- Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina
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29
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Thorburn S, Lindly OJ. A systematic search and review of the discrimination in health care measure, and its adaptations. PATIENT EDUCATION AND COUNSELING 2022; 105:1703-1713. [PMID: 34688522 PMCID: PMC9576001 DOI: 10.1016/j.pec.2021.10.008] [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] [Received: 10/06/2020] [Revised: 05/25/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Discrimination occurs in health care settings contributing to health inequities. Yet guidance on how best to measure discrimination in health care is still limited. OBJECTIVES We sought to (1) identify and describe the characteristics of published studies that used the Discrimination in Health Care Measure, a scale first published in 2001; (2) review how the measure has been used or adapted and summarize the measure's published psychometric properties and its variations; and (3) summarize associations between the measure and health-related variables. METHODS We performed a systematic search and review of the measure by searching PsycINFO, PubMed, Sociological Abstracts, and Web of Science from January 1, 2001 through January 31, 2017. We screened 260 unique articles, identified 22 eligible articles, and completed a narrative synthesis. RESULTS Most studies measured race or ethnicity-based discrimination. All studies made minor revisions to the measure, and most reported high reliabilities. Discrimination in health care, using this measure, was associated with adverse health outcomes. DISCUSSION AND PRACTICE IMPLICATIONS Study results indicate that the measure is easy to use and adapt. Researchers should consider using the Discrimination in Health Care Measure when designing studies that will examine individuals' discriminatory experiences when receiving health care.
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Affiliation(s)
- Sheryl Thorburn
- School of Social and Behavioral Health Sciences, Oregon State University, United States
| | - Olivia J Lindly
- Department of Health Sciences, Northern Arizona University, United States.
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30
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Nong P, Williamson A, Anthony D, Platt J, Kardia S. Discrimination, trust, and withholding information from providers: Implications for missing data and inequity. SSM Popul Health 2022; 18:101092. [PMID: 35479582 PMCID: PMC9035429 DOI: 10.1016/j.ssmph.2022.101092] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022] Open
Abstract
Quality care requires collaborative communication, information exchange, and decision-making between patients and providers. Complete and accurate data about patients and from patients are especially important as high volumes of data are used to build clinical decision support tools and inform precision medicine initiatives. However, systematically missing data can bias these tools and threaten their effectiveness. Data completeness relies in many ways on patients being comfortable disclosing information to their providers without prohibitive concerns about security or privacy. Patients are likely to withhold information in the context of low trust relationships with providers, but it is unknown how experiences of discrimination in the healthcare system also relate to non-disclosure. In this study, we assess the relationship between withholding information from providers, experiences of discrimination, and multiple types of patient trust. Using a nationally representative sample of US adults (n = 2,029), weighted logistic regression modeling indicated a statistically significant relationship between experiences of discrimination and withholding information from providers (OR 3.7; CI [2.6-5.2], p < .001). Low trust in provider disclosure of conflicts of interest and low trust in providers' responsible use of health information were also positively associated with non-disclosure. We further analyzed the relationship between non-disclosure and the five most common types of discrimination (e.g., discrimination based on race, education/income, weight, gender, and age). We observed that all five types were statistically significantly associated with non-disclosure (p < .05). These results suggest that experiences of discrimination and specific types of low trust have a meaningful association with a patient's willingness to share information with their provider, with important implications for the quality of data available for medical decision-making and care. Because incomplete information can contribute to lower quality care, especially in the context of data-driven decision-making, patients experiencing discrimination may be further disadvantaged and harmed by systematic data missingness in their records.
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Affiliation(s)
- Paige Nong
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Alicia Williamson
- University of Michigan School of Information, 105 S. State St, Ann Arbor, MI 48109, USA
| | - Denise Anthony
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Jodyn Platt
- University of Michigan Department of Learning Health Sciences, 300 N Ingalls St, Ann Arbor, MI, 48109, USA
| | - Sharon Kardia
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
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31
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Starr LT, Ulrich C, Perez GA, Aryal S, Junker P, O’Connor NR, Meghani SH. Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation. Am J Hosp Palliat Care 2022; 39:619-632. [PMID: 34318700 PMCID: PMC8795236 DOI: 10.1177/10499091211034383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities. OBJECTIVE To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs. METHODS This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital. RESULTS In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race. CONCLUSIONS Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Connie Ulrich
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - G. Adriana Perez
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration *
Consultation * Analysis) Lab, University of Pennsylvania School of Nursing,
Philadelphia, Pennsylvania
| | | | - Nina R. O’Connor
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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32
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Fernandez JR, Richmond J, Nápoles AM, Kruglanski AW, Forde AT. Everyday discrimination and cancer metaphor preferences: The mediating effects of needs for personal significance and cognitive closure. SSM Popul Health 2022; 17:100991. [PMID: 35005182 PMCID: PMC8715368 DOI: 10.1016/j.ssmph.2021.100991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022] Open
Abstract
Metaphors are often used to describe cancer experiences (e.g., battle, journey). Few studies explore how social threats (e.g., discrimination) shape metaphor preferences. We examined the relationship between discrimination and preferences for cancer battle metaphors (i.e., concrete, action-based) versus journey metaphors (i.e., open-ended, reflective) and mediating effects of needs for personal significance and cognitive closure. We also stratified the analysis when discrimination was/was not attributed to race and by racial/ethnic group. Four-hundred twenty-seven U.S. participants completed an online survey. Items included everyday discrimination, need for personal significance, need for cognitive closure, and preference for cancer scenarios using battle or journey metaphors. Multigroup structural equation modeling examined: serial mediation (i.e., discrimination predicting metaphor preference via needs for personal significance and cognitive closure) stratified by discrimination attribution; and single mediation (i.e., discrimination predicting need for cognitive closure via need for personal significance) stratified by racial/ethnic group. Discrimination was associated with battle metaphor preferences through serial mediation when discrimination was not attributed to race (β = 0.02, 95% CI [0.01,0.05]). Discrimination was directly associated with journey metaphor preferences (β = -0.20, 95% CI [-0.37,-0.06]) and the serial mediation was nonsignificant when discrimination was attributed to race. The single mediation model varied across racial/ethnic groups and was strongest for Non-Hispanic White participants (β = 0.17, 95% CI [0.07,0.30]). Discrimination may shape cancer metaphor preferences through needs for personal significance and cognitive closure, yet these relationships differ based on whether discrimination is attributed to race and racial/ethnic group. Given that the U.S. health system often focuses on battle metaphors when framing cancer treatment and screenings, individuals who prefer journey metaphors (i.e., those who experienced more frequent racial discrimination in the present study) may experience a systematic disadvantage in cancer communication. A more careful consideration of cultural, racial, and ethnic differences in metaphor use may be a crucial step towards reducing cancer disparities.
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Affiliation(s)
- Jessica R. Fernandez
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer Richmond
- Department of Medicine, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna M. Nápoles
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Arie W. Kruglanski
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Allana T. Forde
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Chilakala A, Camacho-Rivera M, Frye V. Experiences of race- and gender-based discrimination among Black female physicians. J Natl Med Assoc 2022; 114:104-113. [PMID: 35058066 DOI: 10.1016/j.jnma.2021.12.008] [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] [Received: 07/06/2021] [Revised: 09/24/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Recently, in the United States, there has been a strong effort to increase representation of members of social groups underrepresented in medicine (URiM). Experiences of discrimination among URiM group members, including women and people of color, have negative effects on their health and well-being and drive further underrepresentation. Here we report results of a qualitative research study designed to characterize Black female physicians' experiences of discrimination related to their identities both as women and people of color, in medical education and the practice of medicine. METHODS A trained interviewer conducted semi-structured qualitative, in-depth interviews with twenty Black, cis-gender, female physicians working in various fields of medicine. Broadly framed within intersectionality theory and analyzed using a pragmatic analytic approach, all interviews were transcribed, read, coded, and analyzed identifying key emergent themes. RESULTS Two broad and overlapping themes emerged: (1) experiencing and managing micro/macroaggressions and biases in the workplace; and (2) strategies to overcome experiences of intersectional discrimination. Each theme contained several subthemes, such as "presumed incompetence", "isolation and exclusion", "managing burdensome expectations", "building support systems", "speaking up", and "resilience". Participants described both intersectional and independent forms of discrimination and a range of sources of discrimination, including patients, peers, and colleagues, in their careers as trainees and professionals. Most described minimal and largely ineffective efforts to prevent or mitigate the impact of discrimination at any level of their educational and professional contexts. DISCUSSION Black female physicians report experiencing damaging discrimination with few effective intervention efforts in tAheir medical training and workplaces. There is need for more research and evaluation of interventions to reduce discrimination at all levels of education and training.
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Affiliation(s)
- Akhila Chilakala
- Sophie Davis School of Biomedical Education, CUNY School of Medicine, Townsend Harris Hall, Room 313, 160 Convent Avenue, New York, NY 10031, United States; Department of Community Health Sciences, SUNY Downstate Health Sciences University, United States; Department of Community Health and Social Medicine, CUNY School of Medicine, United States
| | - Marlene Camacho-Rivera
- Sophie Davis School of Biomedical Education, CUNY School of Medicine, Townsend Harris Hall, Room 313, 160 Convent Avenue, New York, NY 10031, United States; Department of Community Health Sciences, SUNY Downstate Health Sciences University, United States; Department of Community Health and Social Medicine, CUNY School of Medicine, United States
| | - Victoria Frye
- Sophie Davis School of Biomedical Education, CUNY School of Medicine, Townsend Harris Hall, Room 313, 160 Convent Avenue, New York, NY 10031, United States; Department of Community Health Sciences, SUNY Downstate Health Sciences University, United States; Department of Community Health and Social Medicine, CUNY School of Medicine, United States.
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Diversity and perception of equity and respect in the Society of Skeletal Radiology (SSR). Skeletal Radiol 2022; 51:849-854. [PMID: 34477922 PMCID: PMC8413112 DOI: 10.1007/s00256-021-03901-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the perception of equity and respect in the workplace and within the SSR. We hypothesized that responses would differ by gender and minorities underrepresented in medicine (URiM) status. METHODS An electronic survey was sent to 1,531 SSR members between January 2020 and March 2020 to determine perception of equity and respect. Descriptive statistics were calculated, and analysis of differences in response by gender/minority status was performed using the Fisher's exact test. The study was exempt from IRB approval. RESULTS There were 176 responses (11.5%). Most respondents (61.9%) were between 30 and 50 years. Members identified as male (M) in 74.4%, as female (F) in 25.0%, and as "other" in 0.6%. URiM comprised 9.1% of members. Women worked more commonly in academia (p = 0.005), had the perception of unequal opportunities for leadership positions within the institution (p = 0.006), and emphasized the importance of having a mentor of the same gender (p = 0.001). URiM members were less likely to hold a leadership position (p = 0.1, trend), had a perception of unequal opportunities for leadership positions within the institution (p = 0.06, trend), and reported the importance of having a mentor of the same race (p = 0.06, trend). There were no significant differences between gender or URiM status and perception of the SSR to provide an inclusive environment and leadership opportunities (p ≥ 0.39). CONCLUSION While survey participation was limited and potentially biased, respondents perceived that women and minorities have fewer opportunities and are treated with lower regard in the workplace compared to male, non-minority colleagues.
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Nicholson HL, Wheeler PB, Smith NC, Alawode OA. Examining the Relationship between Discrimination and Prescription Drug Misuse: Findings from a National Survey of Black Americans. Subst Use Misuse 2022; 57:1014-1021. [PMID: 35395923 DOI: 10.1080/10826084.2022.2052096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Research shows that substance use may be a way individuals cope with psychosocial stressors. Less is known about whether discrimination contributes to prescription drug misuse. Methods: Using a national sample of Black Americans, we examined whether two psychosocial stressors (i.e., everyday and lifetime major discrimination) were associated with lifetime prescription drug misuse (i.e., opioids, tranquilizers, sedatives, or stimulants). Results: Our logistic regression models separately examining the influence of everyday and major discrimination controlling for relevant demographic, health, and other drug use variables showed that only everyday discrimination was associated with higher odds of prescription drug misuse. In the model simultaneously considering both types of discrimination, only unit increases in everyday discrimination were associated with higher odds of prescription drug misuse. Conclusions: Encounters with everyday discrimination may be an important psychosocial stressor linked to prescription drug misuse in Black adults and possibly other racial-ethnic minorities. Intervention strategies aiming to reduce prescription drug misuse should consider developing ways to curb the negative health-related consequences of discriminatory experiences. Strategies to combat discrimination-related prescription drug misuse and limitations of this study are discussed.
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Affiliation(s)
- Harvey L Nicholson
- Department of Sociology and Criminology & Law, University of Florida, Gainesville, Florida, USA
| | - Paris B Wheeler
- Department of Educational, School, and Counseling Psychology, University of Kentucky, Lexington, Kentucky, USA
| | - Nicholas C Smith
- Department of Sociology, Indiana University, Bloomington, Indiana, USA
| | - Oluwatobi A Alawode
- Department of Sociology and Criminology & Law, University of Florida, Gainesville, Florida, USA
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Cuevas AG, Boen C. Tip of the iceberg: Measuring racial discrimination in studies of health. Stress Health 2021; 37:1043-1050. [PMID: 33739613 PMCID: PMC8449795 DOI: 10.1002/smi.3047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 11/09/2022]
Abstract
There is compelling evidence that racial discrimination is a risk factor for illness and disease. But what are health scientists measuring-and what do they think they are measuring-when they include measures of racial discrimination in health research? We synthesize theoretical conceptualizations of racial discrimination in health research and critically assess whether and how these concepts correspond (or not) to widely used measures of racial discrimination. In doing so, we show that while researchers often use terms such as 'self-reported discrimination', 'perceptions of discrimination', and 'exposure to discrimination' interchangeably, these concepts are indeed unique, with each holding a distinct epistemological position and theoretical and methodological capacity to uncover the impact of racial discrimination on health and health disparities. Importantly, we argue that commonly used measures of self-reported or perceived racial discrimination are just the 'tip of the iceberg' in terms of revealing the ways in which discrimination shapes health inequities. Scientists and practitioners must be cognizant of and intentional in their measurement choices and language, as the framing of these processes will inform policy and intervention efforts aimed at eliminating discrimination.
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Affiliation(s)
- Adolfo G. Cuevas
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Courtney Boen
- Department of Sociology, Population Studies Center, & Population Aging Research Center, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Bulgarelli AF, Dos Santos CM, Rech RS, Baumgarten A, Goulart BN. Tooth Loss Condition and Social Discrimination in Brazilian Healthcare Services. Int J Public Health 2021; 66:586597. [PMID: 34744559 PMCID: PMC8565290 DOI: 10.3389/ijph.2021.586597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/24/2021] [Indexed: 01/16/2023] Open
Abstract
Objective: To explore factors associated with social discrimination against users of health services regarding dental aesthetic conditions. Methods: Based on a Brazilian National Survey, multivariate Poisson regressions with robust variance were used to explore the association of outcome discrimination related to different motivations in health services and exposure to sociodemographic and dental variables. Effect modification by complete prosthesis wearing was assessed. Results: Among the 60,200 people interviewed, 11.5% reported being discriminated against in health services. For women, a higher prevalence of discrimination was found among those in the age group of 30–44 years. For both sexes, discrimination was associated with black and brown skin color. Regarding dental characteristics, the higher the tooth loss was, the higher the prevalence of discrimination; however, complete prosthesis wearing presented as a protective factor. Social discrimination was the major motivation for reported discrimination and presented higher prevalence in edentulous individuals who did not wear prosthesis. Conclusion: Dental loss may lead to self-reported discrimination in health care services. The prevalence of discrimination increases when tooth loss increases, and the major reason associated is social discrimination.
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Affiliation(s)
- Alexandre F Bulgarelli
- Graduate Program in Collective Health, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Department of Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Camila M Dos Santos
- Department of Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Rafaela S Rech
- Department of Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandre Baumgarten
- Department of Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Bárbara N Goulart
- Psychology Institute, Department of health and human communication, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Kiker WA, Rutz Voumard R, Andrews LIB, Holloway RG, Brumback LC, Engelberg RA, Curtis JR, Creutzfeldt CJ. Assessment of Discordance Between Physicians and Family Members Regarding Prognosis in Patients With Severe Acute Brain Injury. JAMA Netw Open 2021; 4:e2128991. [PMID: 34673964 PMCID: PMC8531991 DOI: 10.1001/jamanetworkopen.2021.28991] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Shared decision-making requires key stakeholders to align in perceptions of prognosis and likely treatment outcomes. OBJECTIVE For patients with severe acute brain injury, the objective of this study was to better understand prognosis discordance between physicians and families by determining prevalence and associated factors. DESIGN, SETTING, AND PARTICIPANTS This mixed-methods cross-sectional study analyzed a cohort collected from January 4, 2018, to July 22, 2020. This study was conducted in the medical and cardiac intensive care units of a single neuroscience center. Participants included families, physicians, and nurses of patients admitted with severe acute brain injury. EXPOSURES Severe acute brain injury was defined as stroke, traumatic brain injury, or hypoxic ischemic encephalopathy with a Glasgow Coma Scale score less than or equal to 12 points after hospital day 2. MAIN OUTCOMES AND MEASURES Prognosis discordance was defined as a 20% or greater difference between family and physician prognosis predictions; misunderstanding was defined as a 20% or greater difference between physician prediction and the family's estimate of physician prediction; and optimistic belief difference was defined as any difference (>0%) between family prediction and their estimate of physician prediction. Logistic regression was used to identify associations with discordance. Optimistic belief differences were analyzed as a subgroup of prognosis discordance. RESULTS Among 222 enrolled patients, prognostic predictions were available for 193 patients (mean [SD] age, 57 [19] years; 106 men [55%]). Prognosis discordance occurred for 118 patients (61%) and was significantly more common among families who identified with minoritized racial groups compared with White families (odds ratio [OR], 3.14; CI, 1.40-7.07, P = .006); among siblings (OR, 4.93; 95% CI, 1.35-17.93, P = .02) and adult children (OR, 2.43; 95% CI, 1.10-5.37; P = .03) compared with spouses; and when nurses perceived family understanding as poor compared with good (OR, 3.73; 95% CI, 1.88-7.40; P < .001). Misunderstanding was present for 80 of 173 patients (46%) evaluated for this type of prognosis discordance, and optimistic belief difference was present for 94 of 173 patients (54%). In qualitative analysis, faith and uncertainty emerged as themes underlying belief differences. Nurse perception of poor family understanding was significantly associated with misunderstanding (OR, 2.06; 95% CI, 1.07-3.94; P = .03), and physician perception with optimistic belief differences (OR, 2.32; 95% CI, 1.10-4.88; P = .03). CONCLUSIONS AND RELEVANCE Results of this cross-sectional study suggest that for patients with severe acute brain injury, prognosis discordance between physicians and families was common. Efforts to improve communication and decision-making should aim to reduce this discordance and find ways to target both misunderstanding and optimistic belief differences.
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Affiliation(s)
- Whitney A. Kiker
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Rachel Rutz Voumard
- Harborview Medical Center, Department of Neurology, University of Washington, Seattle
- Palliative and Supportive Care Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Leah I. B. Andrews
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - J. Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Claire J. Creutzfeldt
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Harborview Medical Center, Department of Neurology, University of Washington, Seattle
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Smith NC. Black-White disparities in women's physical health: The role of socioeconomic status and racism-related stressors. SOCIAL SCIENCE RESEARCH 2021; 99:102593. [PMID: 34429206 DOI: 10.1016/j.ssresearch.2021.102593] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 05/18/2023]
Abstract
Black women have elevated rates of multiple physical illnesses and conditions when compared to White women - disparities that are only partially explained by socioeconomic status (SES). Consequently, scholars have called for renewed attention to the significance of racism-related stress in explaining Black-White disparities in women's physical health. Drawing on the biopsychosocial model of racism as a stressor and the intersectionality perspective, this study examines the extent to which SES and racism-related stressors - i.e., discrimination, criminalization, and adverse neighborhood conditions - account for disparities in self-rated physical health and chronic health conditions between Black and White women. Results indicate that Black women have lower SES and report greater exposure to racism-related stressors across all domains. Moreover, I find that SES and racism-related stressors jointly account for more than 90% of the Black-White disparity in women's self-rated physical health and almost 50% of the Black-White disparity in chronic health conditions. Theoretical and policy implications of these findings are discussed.
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Affiliation(s)
- Nicholas C Smith
- Indiana University - Bloomington, Department of Sociology Ballantine Hall 744, 1020 East Kirkwood Avenue Bloomington, IN, 47405, USA.
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State- and Provider-Level Racism and Health Care in the U.S. Am J Prev Med 2021; 61:338-347. [PMID: 34419231 DOI: 10.1016/j.amepre.2021.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/24/2021] [Accepted: 03/02/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION This study examines the associations between state-level and provider sources of racism and healthcare access and quality for non-Hispanic Black and White individuals. METHODS Data from 2 sources were integrated: (1) data from the Association of American Medical Colleges' Consumer Survey of Health Care Access (2014-2019), which included measures of self-reported healthcare access, healthcare quality, and provider racial discrimination and (2) administrative data compiled to index state-level racism. State-level racism composite scores were calculated from federal sources (U.S. Census, Department of Labor, Department of Justice). The data set comprised 21,030 adults (n=2,110 Black, n=18,920 White) who needed care within the past year. Participants were recruited from a national panel, and the survey employed age-insurance quotas. Logistic and linear regressions were conducted in 2020, adjusting for demographic, geographic, and health-related covariates. RESULTS Among White individuals, more state-level racism was associated with 5% higher odds of being able to get care and 6% higher odds of sufficient time with provider. Among Black individuals, more state-level racism was associated with 8% lower odds of being able to get care. Provider racial discrimination was also associated with 80% lower odds of provider explaining care, 77% lower odds of provider answering questions, and 68% lower odds of sufficient time with provider. CONCLUSIONS State-level racism may engender benefits to healthcare access and quality for White individuals and may decrease access for Black individuals. Disparities may be driven by both White advantage and Black disadvantage. State-level policies may be the actionable levers of healthcare inequities with implications for preventive medicine.
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Houston AR, Lincoln A, Gillespie S, Da Fonseca T, Issa O, Ellis H, Salhi C. You Have to Pay to Live: Somali Young Adult Experiences With the U.S. Health Care System. QUALITATIVE HEALTH RESEARCH 2021; 31:1875-1889. [PMID: 34024208 DOI: 10.1177/10497323211010159] [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: 06/12/2023]
Abstract
There is increasing documentation that refugees face experiences of interpersonal or structural discrimination in health care and employment. This study examines how Somali refugees understand various forms of discrimination in employment and health care related to their health, utilization of, and engagement with the health care system in the United States. We draw on semistructured qualitative interviews (N = 35) with Somali young adults in three U.S. states-Minnesota, Massachusetts, and Maine. Using modified grounded theory analysis, we explore how experiences of discrimination in employment and health care settings impact health care access, utilization, and perceptions of health among Somali young adults. Discrimination was identified as a major barrier to using health services and securing employment with employer-sponsored insurance coverage. These findings highlight how interpersonal and structural discrimination in employment and health care are mutually reinforcing in their production of barriers to health care utilization among Somali refugees.
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Affiliation(s)
| | | | | | | | - Osob Issa
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Heidi Ellis
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Carmel Salhi
- Northeastern University, Boston, Massachusetts, USA
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Roder‐DeWan S, Baril N, Belanoff CM, Declercq ER, Langer A. Being Known: A Grounded Theory Study of the Meaning of Quality Maternity Care to People of Color in Boston. J Midwifery Womens Health 2021; 66:452-458. [PMID: 34240539 PMCID: PMC8456935 DOI: 10.1111/jmwh.13240] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Experiences of people of color with maternity care are understudied but understanding them is important to improving quality and reducing racial disparities in birth outcomes in the United States. This qualitative study explored experiences with maternity care among people of color to describe the meaning of quality maternity care to the cohort and, ultimately, to inform the design of a freestanding birth center in Boston. METHODS Using a grounded theory design and elements of community-based participatory research, community activists developing Boston's first freestanding birth center and academics collaborated on this study. Semistructured interviews and focus groups with purposefully sampled people of color were conducted and analyzed using a constant comparative method. Interviewees described their maternity care experiences, ideas about perfect maternity care, and how a freestanding birth center might meet their needs. Open coding, axial coding, and selective coding were used to develop a local theory of what quality care means. RESULTS A total of 23 people of color participated in semistructured interviews and focus groups. A core phenomenon arose from the narratives: being known (ie, being seen or heard, or being treated as individuals) during maternity care was an important element of quality care. Contextual factors, including interpersonal and structural racism, power differentials between perinatal care providers and patients, and the bureaucratic nature of hospital-based maternity care, facilitated negative experiences. People of color did extra work to prevent and mitigate negative experiences, which left them feeling traumatized, regretful, or sad about maternity care. This extra work came in many forms, including cognitive work such as worrying about racism and behavioral changes such as dressing differently to get health care needs met. DISCUSSION Being known characterizes quality maternity care among people of color in our sample. Maternity care settings can provide personalized care that helps clients feel known without requiring them to do extra work to achieve this experience.
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Affiliation(s)
| | | | - Candice M. Belanoff
- Department of Community Health SciencesBoston University School of Public HealthBostonMassachusetts
| | - Eugene R. Declercq
- Department of Community Health SciencesBoston University School of Public HealthBostonMassachusetts
| | - Ana Langer
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusetts
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Attanasio LB, Ranchoff BL, Geissler KH. Perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content: Evidence from the Listening to Mothers in California survey. PLoS One 2021; 16:e0253055. [PMID: 34161359 PMCID: PMC8221509 DOI: 10.1371/journal.pone.0253055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/27/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Postpartum visits are an important opportunity to address ongoing maternal health. Experiences of discrimination in healthcare can impact healthcare use, including postpartum visits. However, it is unknown whether discrimination is associated with postpartum visit content. This study aimed to examine the relationship between perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content. RESEARCH DESIGN Data were from Listening to Mothers in California, a population-based survey of people with a singleton hospital birth in California in 2016. Adjusted logistic regression models estimated the association between perceived discrimination during the childbirth hospitalization and 1) postpartum visit attendance, and 2) topics addressed at the postpartum visit (birth control, depression and breastfeeding) for those who attended. RESULTS 90.6% of women attended a postpartum visit, and 8.6% reported discrimination during the childbirth hospitalization. In adjusted models, any discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit, respectively. There was a 7pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%), a 15pp lower predicted probability of being asked about depression (64% vs. 79%), and a 9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%). CONCLUSIONS Amid heightened attention to the importance of postpartum care, there is a need to better understand determinants of postpartum care quality. Our findings highlight the potential consequences of healthcare discrimination in the perinatal period, including lower quality of postpartum care.
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Affiliation(s)
- Laura B. Attanasio
- University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts, United States of America
| | - Brittany L. Ranchoff
- University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts, United States of America
| | - Kimberley H. Geissler
- University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts, United States of America
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Redelmeier DA, Ng K, Thiruchelvam D, Shafir E. Association of socioeconomic status with medical assistance in dying: a case-control analysis. BMJ Open 2021; 11:e043547. [PMID: 34035092 PMCID: PMC8154947 DOI: 10.1136/bmjopen-2020-043547] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints. DESIGN Population-based case-control study of adults who died. SETTING Ontario, Canada, between 1 June 2016 and 1 June 2019. PATIENTS Patients receiving palliative care under universal insurance with no user fees. EXPOSURE Patient's socioeconomic status identified using standardised quintiles. MAIN OUTCOME MEASURE Whether the patient received medical assistance in dying. RESULTS A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design. CONCLUSIONS Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.
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Affiliation(s)
- Donald A Redelmeier
- Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kelvin Ng
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Psychology, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eldar Shafir
- Public Policy, Princeton University, Princeton, New Jersey, USA
- Psychology, Princeton University, Princeton, New Jersey, USA
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Threats M, Bond K. HIV Information Acquisition and Use Among Young Black Men Who Have Sex With Men Who Use the Internet: Mixed Methods Study. J Med Internet Res 2021; 23:e22986. [PMID: 33960953 PMCID: PMC8140385 DOI: 10.2196/22986] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/31/2020] [Accepted: 01/16/2021] [Indexed: 12/31/2022] Open
Abstract
Background HIV disproportionately affects young Black men who have sex with men (YBMSM) in the United States. eHealth holds potential for supporting linkage and engagement in HIV prevention and care and the delivery of HIV information to YBMSM. Objective This study aims to investigate HIV information acquisition and use among YBMSM who use the internet. Methods A web-based self-administered survey and semistructured interviews were conducted. The survey findings informed the development of the interview guide. Descriptive statistics were used to characterize the survey sample, and interview data were analyzed thematically using modified grounded theory methodologies. Results Among the internet sample (N=83), the average age was 29.2 (SD 3.5) years, 41% (n=34) of participants self-reported living with HIV, 43% (n=36) were HIV-negative, and 15% (n=13) were unsure of their HIV status. Most participants (n=79, 95%) acquired HIV information through the internet while using a mobile phone. Web-based HIV information was intentionally sought from consumer health information websites (n=31, 37%), government health information websites (n=25, 30%), and social media (n=14, 17%). Most men incidentally acquired HIV information via advertisements on social media sites and geospatial dating apps (n=54, 65%), posts on social media sites from their web-based social ties (n=44, 53%), and advertisements while browsing the internet (n=40, 48%). Although the internet is the top source of HIV information, health care providers were the most preferred (n=42, 50%) and trusted (n=80, 96%) source of HIV information. HIV information was used to facilitate the use of HIV prevention and care services. The qualitative sample included YBMSM across a range of ages and at different points of engagement in HIV prevention and care. Qualitative findings included the importance of the internet as a primary source of HIV information. The internet was used because of its ease of accessibility, because of its ability to maintain anonymity while searching for sensitive information, and to mitigate intersecting stigmas in health care settings. Participants used HIV information to assess their risk for HIV and AIDS, support their skill building for HIV prevention, inform patient–doctor communication, and learn about HIV prevention and treatment options. Men expressed concerns about their diminishing access to online spaces for HIV information exchange among YBMSM because of censorship policies on social media sites and the stigmatizing framing and tone of mass media HIV-prevention advertisements encountered while using the internet. Conclusions YBMSM in this sample had high utilization of eHealth for HIV information acquisition and use but diminished access to their preferred and most trusted source of HIV information: health care providers. Future eHealth-based HIV interventions culturally tailored for YBMSM should aim to reduce intersectional stigma at the point of care and support patient–provider communication. The findings demonstrate the need for community-informed, culturally tailored HIV messaging and online spaces for informational support exchange among YBMSM.
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Affiliation(s)
- Megan Threats
- School of Communication and Information, Rutgers University, New Brunswick, NJ, United States.,Yale School of Public Health, Center for Interdisciplinary Research on AIDS, New Haven, CT, United States
| | - Keosha Bond
- Yale School of Public Health, Center for Interdisciplinary Research on AIDS, New Haven, CT, United States.,Department of Community Health and Social Medicine, City University of New York School of Medicine, New York, NY, United States
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/05/2021] [Indexed: 12/19/2022] Open
Abstract
Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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Starr LT, O'Connor NR, Meghani SH. Improved Serious Illness Communication May Help Mitigate Racial Disparities in Care Among Black Americans with COVID-19. J Gen Intern Med 2021; 36:1071-1076. [PMID: 33464466 PMCID: PMC7814859 DOI: 10.1007/s11606-020-06557-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Lauren T Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Nina R O'Connor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Hinnant A, Boman CD, Hu S, Ashley RR, Lee S, Dodd S, Garbutt JM, Cameron GT. The Third Rail of Pediatric Communication: Discussing Firearm Risk and Safety in Well-Child Exams. HEALTH COMMUNICATION 2021; 36:508-520. [PMID: 31833783 PMCID: PMC7771016 DOI: 10.1080/10410236.2019.1700883] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
This research endeavors to understand how pediatricians and parents discuss - or do not discuss - firearm risks for children during well-child visits. Through individual semi-structured interviews with 16 pediatric providers and 20 parents, the research explores discursive barriers to open conversation, perspectives on anticipatory guidance, and new ideas for culturally competent messaging. The research focuses particularly on how parents' and providers' perspectives on firearm risk communication are tied to cultural norms and expectations. One salient theme that emerged is that the American Academy of Pediatrics recommendation that pediatricians ask parents about ownership status is deemed undesirable by pediatricians and parents because of the delicate intercultural setting. Born out of pediatric and parent experiences, and mindful of culturally salient barriers, this study offers alternative strategies for discussing firearm risk in well-child exams.
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Affiliation(s)
| | | | - Sisi Hu
- School of Journalism, University of Missouri
| | | | | | - Sherry Dodd
- Department of Pediatrics, Washington University School of Medicine
| | - Jane M Garbutt
- Departments of Medicine and Pediatrics, Washington University School of Medicine
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Casanova-Perez R, Apodaca C, Bascom E, Mohanraj D, Lane C, Vidyarthi D, Beneteau E, Sabin J, Pratt W, Weibel N, Hartzler AL. Broken down by bias: Healthcare biases experienced by BIPOC and LGBTQ+ patients. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2021:275-284. [PMID: 35308990 PMCID: PMC8861755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Bias toward historically marginalized patients affects patient-provider interactions and can lead to lower quality of care and poor health outcomes for patients who are Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender and Gender Diverse (LGBTQ+). We gathered experiences with biased healthcare interactions and suggested solutions from 25 BIPOC and LGBTQ+ people. Through qualitative thematic analysis of interviews, we identified ten themes. Eight themes reflect the experience of bias: Transactional Care, Power Inequity, Communication Casualties, Bias-Embedded Medicine, System-level problems, Bigotry in Disguise, Fight or Flight, and The Aftermath. The remaining two themes reflect strategies for improving those experiences: Solutions and Good Experiences. Characterizing these themes and their interconnections is crucial to design effective informatics solutions that can address biases operating in clinical interactions with BIPOC and LGBTQ+ patients, improve the quality of patient-provider interactions, and ultimately promote health equity.
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Affiliation(s)
| | | | | | | | | | | | - Erin Beneteau
- University of Washington, Seattle, Washington
- University of California San Diego, San Diego, California
| | | | - Wanda Pratt
- University of Washington, Seattle, Washington
| | - Nadir Weibel
- University of California San Diego, San Diego, California
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[Racism and mental health]. DER NERVENARZT 2020; 91:1017-1024. [PMID: 32930813 PMCID: PMC7490571 DOI: 10.1007/s00115-020-00990-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Der Beitrag gibt einen Überblick zu Rassismusdiskursen in Forschung und Praxis im Gesundheitsbereich und erörtert individuelle und institutionelle Auswirkungen von Rassismus und Diskriminierung auf die psychische Gesundheit. Daran anschließend wird erörtert, welche rassismuskritischen Transformationen in den Versorgungsstrukturen für psychisch erkrankte Personen notwendig sind, um eine gleichberechtigte Teilhabe von Menschen, die von Diskriminierung und Rassismus betroffen sind, zu ermöglichen.
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