State-Level Sexism and Gender Disparities in Health Care Access and Quality in the United States

The Synergistic Health Threats of State Laws Targeting Marginalized Groups in the United States

Discriminatory state laws have deleterious effects on the health of socially marginalized groups. Health care clinicians, institutions, researchers, and research funders have tended to view different discriminatory laws in isolation, focusing on particular issues or groups. In contrast, intersectionality calls attention to the overlapping and synergistic systems of oppression that discriminatory legislation promotes or upholds, warranting an integrated analysis of these laws. In this analytic essay, we assess discriminatory state laws simultaneously and discuss their implications for health care clinicians, institutions, and researchers. We present a multifunctional model of law and population health that describes how discriminatory law affects health outcomes among marginalized groups. We then draw on publicly available legislation trackers to identify 30 states that have enacted legislation since 2020 that targets Black people and other people of color; lesbian, gay, bisexual, and queer people; transgender and nonbinary people; and women and other birthing people. Finally, we call for a coordinated, multilateral, and forceful effort by health care professionals, institutions, researchers, and research funders to counter these laws and address their predictable health consequences. (Am J Public Health. Published online ahead of print September 19, 2024:e1-e9. https://doi.org/10.2105/AJPH.2024.307830).

Bridging health self-efficacy and patient engagement with patient-centered culturally sensitive health care for Black American adults

This study investigates whether systems-level interventions, specifically patient-centered culturally sensitive health care (PC-CSHC) from healthcare providers, office staff, and the clinic environment, moderate the relationship between health self-efficacy and patient engagement among Black American adults. An online survey was completed by 198 Black American adults. PC-CSHC from healthcare providers, office staff, and the clinic environment did not mitigate the adverse effects of low health self-efficacy on patient engagement. However, PC-CSHC from healthcare providers (b = 0.38) was as significant as health self-efficacy (b = 0.37) in predicting patient engagement, R2 = 0.47, F(9, 177) = 19.61, p < 0.001. Provider-delivered PC-CSHC can enhance patient engagement among Black American adults. This systems-level approach has the potential to reach more patients than intrapersonal interventions alone and alleviates the undue burden placed on Black Americans to leverage intrapersonal strengths in the face of health disparities rooted in structural racism.

Client preferences for the design and delivery of injectable opioid agonist treatment services: Results from a best-worst scaling task

BACKGROUND AND AIMS

Clinical trials support injectable opioid agonist treatment (iOAT) for individuals with opioid use disorder (OUD) for whom other pharmacological management approaches are not well-suited. However, despite substantial research indicating that person-centered care improves engagement, retention and health outcomes for individuals with OUD, structural requirements (e.g. drug policies) often dictate how iOAT must be delivered, regardless of client preferences. This study aimed to quantify clients' iOAT delivery preferences to improve client engagement and retention.

DESIGN

Cross-sectional preference elicitation survey.

SETTING

Metro Vancouver, British Columbia, Canada.

PARTICIPANTS

124 current and former iOAT clients.

MEASUREMENTS

Participants completed a demographic questionnaire package and an interviewer-led preference elicitation survey (case 2 best-worst scaling task). Latent class analysis was used to identify distinct preference groups and explore demographic differences between preference groups.

FINDINGS

Most participants (n = 100; 81%) were current iOAT clients. Latent class analysis identified two distinct groups of client preferences: (1) autonomous decision-makers (n = 73; 59%) and (2) shared decision-makers (n = 51; 41%). These groups had different preferences for how medication type and dosage were selected. Both groups prioritized access to take-home medication (i.e. carries), the ability to set their own schedule, receiving iOAT in a space they like and having other services available at iOAT clinics. Compared with shared decision-makers, fewer autonomous decision-makers identified as a cis-male/man and reported flexible preferences.

CONCLUSIONS

Injectable opioid agonist treatment (iOAT) clients surveyed in Vancouver, Canada, appear to prefer greater autonomy than they currently have in choosing OAT medication type, dosage and treatment schedule.

Intersection of social determinants of health with ventricular assist device therapy: An integrative review

BACKGROUND

Social determinants of health (SDOH) may influence the clinical management of patients with heart failure. Further research is warranted on the relationship between SDOH and Ventricular Assist Device (VAD) therapy for heart failure.

OBJECTIVES

The purpose of this integrative review was to synthesize the state of knowledge on the intersection of SDOH with VAD therapy.

METHODS

Guided by Whittemore and Knafl's methodology, this literature search captured three concepts of interest including VAD therapy, SDOH, and their domains of intersection with patient selection, decision-making, treatment outcome, and resource allocation. CINAHL, Embase, PsycINFO, PubMed, and Web of Science were searched in March 2023. Articles were included if they were peer-reviewed publications in English, published between 2006 and 2023, conducted in the United States, and examined VAD therapy in the context of adult patients (age ≥ 18 years).

RESULTS

22 quantitative studies meeting the inclusion criteria informed the conceptualization of SDOH using the Healthy People 2030 framework. Four themes captured how the identified SDOH intersected with different processes relating to VAD therapy: patient decision-making, healthcare access and resource allocation, patient selection, and treatment outcomes. Most studies addressed the intersection of SDOH with healthcare access and treatment outcomes.

CONCLUSION

This review highlights substantial gaps in understanding how SDOH intersect with patient and patient selection for VAD. More research using mixed methods designs is warranted. On an institutional level, addressing bias and discrimination may have mitigated health disparities with treatment outcomes, but further research is needed for implementing system-wide change. Standardized assessment of SDOH is recommended throughout clinical practice from patient selection to outpatient VAD care.

Health consequences of structural sexism: Conceptual foundations, empirical evidence and priorities for future research

A nascent body of work has begun exploring the health consequences of structural sexism. This article provides an overview of the concept of structural sexism and an elaboration of the potential pathways connecting it to health. Next, it reviews existing measurement approaches and the current state of empirical evidence on the relationship between structural sexism and health in the United States. Finally, it highlights key priorities for future research, which include: expanding and refining measures, increasing public data availability, broadening the scope of inquiry to include a wider range of outcomes, exploring mechanisms, incorporating intersectionality, and applying a life course lens.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

Structural Sexism and Preventive Health Care Use in the United States

Preventive health care use can reduce the risk of disease, disability, and death. Thus, it is critical to understand factors that shape preventive care use. A growing body of research identifies structural sexism as a driver of population health, but it remains unknown if structural sexism is linked to preventive care use and, if so, whether the relationship differs for women and men. Gender performance and gendered power and resource allocation perspectives lead to competing hypotheses regarding these questions. This study explores the relationship between structural sexism and preventive care in gender-stratified, multilevel models that combine data from the Behavioral Risk Factor Surveillance System with state-level data (N = 425,454). We find that in states with more structural sexism, both men and women were less likely to seek preventive care. These findings support the gender performance hypothesis for men and the gendered power and resource allocation hypothesis for men and women.

East Tennessee older women's perceptions of Medicare, Medicaid, and related health policies

Older women face unique challenges regarding health disparities. This study aims to provide an understanding of older women's perceptions and situated experiences regarding the gendered health disparities they face, which are characterized by the policies related to older women's health and the geopolitical and social norms in which they live. The purpose of this project is to provide policy and decision-makers with insights and a better understanding of older women's experiences and perceptions of the policies that impact their health and healthcare. The data for this study was collected through semi-structured interviews with twelve women in Appalachian East Tennessee. Areas examined include: the women's perceived impact of federal, state, and local policies on the participants, particularly of Medicare and Medicaid; the role of social norming and health narratives, particularly stigmatization, discrimination, and health marginalization of older women; and the role of place and place-based drivers on these areas. This study sought to determine if these factors impact the participants' awareness or lack of awareness of policies related to older women. Findings showed that older women in East Tennessee lacked knowledge of health policies, that older women perceive systemic and individual discrimination in policymaking, clinical care, and health research, and that they perceive that place-based drivers have impacted their access to healthcare. These findings have implications for policymaking and intervention design in co-production with older women in order to mitigate older women's health disparities.

Common Patterns of Cisgender Use in Public Health Articles and Their Implications for Gender Inclusivity Efforts, 2013‒2020

Objectives. To identify how "cisgender" has been used in public health articles in recent years relative to the historical origins of the term to mark normative gender and describe systems of social power. Methods. I analyzed 352 US-focused public health articles (2013-2020) using a summative content analysis approach. I traced cisgender use by year and compared it by sample population (cisgender-only, mixed, not cisgender). Results. I identified 4 interlocking and mutually reinforcing patterns of cisgender use: limited and narrow use, undertheorized use, use as the default gender, and reinforcing binary categorization. These patterns largely result from the narrowing of cisgender to a demographic label. Conclusions. Cisgender is primarily used to categorize individual research participants as not transgender rather than to reflect participants' actual identity and experiences within gendered systems of power, which undermines cisgender's potential to support gender-inclusivity efforts and deepen understandings of gender-based health disparities. Public Health Implications. Two paths for creating more robust use of cisgender are (1) supporting gender inclusivity by clarifying and standardizing how and when the demographic category is used and (2) expanding the analytic potential of cisgender by returning to its historical origins as a framework for exposing and explaining patterns of power. (Am J Public Health. 2024;114(2):202-208. https://doi.org/10.2105/AJPH.2023.307441).

Osteopathic Manipulative Treatment in Dysmenorrhea: A Systematic Review

The majority of women experience dysmenorrhea during their lifetime. The current standard-of-care treatment consists of nonsteroidal anti-inflammatory drugs, oral contraceptive pills, or intrauterine devices. Osteopathic manipulative treatment (OMT) is a beneficial tool for improving non-musculoskeletal (non-MSK) conditions such as migraines, gastroesophageal reflux disease (GERD), and anxiety. OMT should be utilized to improve other non-MSK conditions, such as dysmenorrhea. The current review aims to evaluate the effects of OMT in women with dysmenorrhea. An extensive search was conducted in Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Biomedical Reference Collection: Comprehensive, and Nursing & Allied Health Collection: Comprehensive from inception to June 2022. Studies evaluating the use of OMT in patients with dysmenorrhea were included, while editorial/opinion articles were excluded. Three independent reviewers evaluated the studies. Ten studies evaluating the use of OMT in patients with dysmenorrhea were included. Overall, OMT was shown to provide relief of symptoms, including back and menstrual pain; however, there was no guideline on which OMT techniques are the most successful. Numerous positive effects were found, including a reduction in the duration of pain, reduction of pain intensity, and reduction of analgesic use. However, the low number of studies supports the need for further investigations. Dysmenorrhea patients could benefit from a prospective randomized controlled trial targeting spinal facilitation and viscerosomatic reflexes to decrease pain duration, pain intensity, and analgesic use. Non-MSK-focused OMT has a large body of mostly anecdotal evidence for relief of conditions such as migraine, GERD, and anxiety. It has helped when traditional standards of care have failed. Non-MSK-focused OMT research represents a relatively untouched field of research that can have a profound and positive global impact, particularly in areas with poor income/healthcare access.

The Relations between Systems of Oppression and Oral Care Access in the United States

We applied a structural intersectionality approach to cross-sectionally examine the relationships between macro-level systems of oppression, their intersections, and access to oral care in the United States. Whether and the extent to which the provision of government-funded dental services attenuates the emerging patterns of associations was also assessed in the study. To accomplish these objectives, individual-level information from over 300,000 respondents of the 2010 US Behavioral Risk Factor Surveillance System was linked with state-level data for 2000 and 2010 on structural racism, structural sexism, and income inequality, as provided by Homan et al. Using multilevel models, we investigated the relationships between systems of oppression and restricted access to oral health services among respondents at the intersections of race, gender, and poverty. The degree to which extended provision of government-funded dental services weakens the observed associations was determined in models stratified by state-level coverage of oral care. Our analyses bring to the fore intersectional groups (e.g., non-Hispanic Black women and men below the poverty line) with the highest odds of not seeing a dentist in the previous year. We also show that residing in states where high levels of structural sexism and income inequality intersect was associated with 1.3 greater odds (95% confidence interval, 1.1-1.5) of not accessing dental services in the 12 mo preceding the survey. Stratified analyses demonstrated that a more extensive provision of government-funded dental services attenuates associations between structural oppressions and restricted access to oral health care. On the basis of these and other findings, we urge researchers and health care planners to increase access to dental services in more effective and inclusive ways. Most important, we show that counteracting structural drivers of inequities in dental services access entails providing dental care for all.

The Most Vulnerable Hispanic Immigrants in New York City: Structural Racism and Gendered Differences in COVID-19 Deaths

This paper explores the structural and group-specific factors explaining the excess death rates experienced by the Hispanic population in New York City during the peak years of the coronavirus pandemic. Neighborhood-level analysis of Census data allows an exploration of the relation between Hispanic COVID-19 deaths and spatial concentration, conceived in this study as a proxy for structural racism. This analysis also provides a more detailed exploration of the role of gender in understanding the effects of spatial segregation among different Hispanic subgroups, as gender has emerged as a significant variable in explaining the structural and social effects of COVID-19. Our results show a positive correlation between COVID-19 death rates and the share of Hispanic neighborhood residents. However, for men, this correlation cannot be explained by the characteristics of the neighborhood, as it is for women. In sum, we find: (a) differences in mortality risks between Hispanic men and women; (b) that weathering effects increase mortality risks the longer Hispanic immigrant groups reside in the U.S.; (c) that Hispanic males experience greater contagion and mortality risks associated with the workplace; and (d) we find evidence corroborating the importance of access to health insurance and citizenship status in reducing mortality risks. The findings propose revisiting the Hispanic health paradox with the use of structural racism and gendered frameworks.

Intersectional disparities in climate vulnerability and cancer risk

Despite significant progress in the early detection, treatment, and survivorship of cancer in recent decades, cancer disparities continue to plague segments of the US population. Many of these cancer disparities, especially those among historically marginalized racial and ethnic groups and those with lower socioeconomic resources, are caused and perpetuated by social and structural barriers to health. These social and structural barriers, which operate beyond the framework of cancer control, also systematically increase vulnerability to and decrease adaptive capacity for the deleterious effects of anthropogenic climate change. The established and emerging overlap between climate vulnerability and cancer risk presents complex challenges to cancer control, specifically among populations who suffer compounding hazards and intersectional vulnerabilities. By embracing these intersections, we may be able to conceptualize promising new research frameworks and programmatic opportunities that decrease vulnerability to a wide range of climate and health threats to advance health equity.

Mental Health Trajectories of Latinx Female Caregivers and Young Children During COVID-19: A Longitudinal Analysis

Studies of the impact of COVID-19 on mental health symptoms suggest that there may be a unique impact of COVID-19 on minoritized individuals, young children (children five and younger), and their caregivers. Longitudinal studies with representative samples including minoritized populations are needed to accurately reflect the experience of families during COVID-19. The current study used a longitudinal design to assess trajectories of mental health among Latinx female caregivers and their young children over time, beginning prior to the onset of the COVID-19 pandemic and over the course of 12 months. In fall of 2019, Latinx female caregivers (N = 213; 93.0% biological mother) of young children (M age  = 5.38, SD = 0.34) reported on their own and their child's (52.6% female) mental health symptoms, as well as parenting stress, at three time points through Fall of 2020. Growth curve models showed that self-report of caregiver global mental health worsened over time, though caregiver depression and parenting stress did not change significantly, nor did caregiver-report of their children's mental health. Results suggest that while female caregiver well-being was adversely affected by COVID-19, caregivers showed resilience in the face of this pandemic, which in turn may have buffered the impact of the pandemic on Latinx child mental health. Methodological and contextual implications of these results are considered.

Is Support for Feminism Enough for Change? How Sexism and Gender Stereotypes Might Hinder Gender Justice

Even though formal processes (i.e., gender quotes) are necessary to achieve gender justice, attitudinal changes (i.e., support of egalitarian social norms) are also essential. The endorsement of sexism and gender stereotypes perpetuate inequality on a daily basis, and can be seen as barriers that prevent societies from reaching social justice. Therefore, changing sexist social norms can be understood as a fundamental step in accomplishing gender justice. With the aim of studying Chileans’ sexist norms, we conducted a survey with a representative sample (N = 490) exploring levels of sexism and gender stereotypes, as well as support for the feminist movement. Using Latent Profile Analysis, we identified four groups of citizens: (1) a first group that shows high levels of sexism and low support for the feminist movement (9%); (2) a second group, with low levels of sexism and high support for the feminist movement (20%); (3) a third group with high levels of sexism and high support for the feminist movement (65%); and (4) a fourth group with mid-levels of sexism and support of the feminist movement (6%). We called these groups the Sexist, Feminist, Inconsistent, and Moderate Group, respectively. The four groups showed similar high endorsement of gender stereotypes. These results are twofold. First, they hint that although nowadays gender equality seems to be generally accepted, this coexists with a high prevalence of sexist social norms, represented by the inconsistent group being the most prevalent. Second, gender stereotypes are still deeply rooted in Chilean culture, surprisingly even among feminist citizens.