Health Equity最新文献

Introduction: Cancer survivors experience gaps in access to timely and well-coordinated care. We describe stakeholder engagement activities across a university-based comprehensive cancer center and a primary care-focused federally qualified health center, which informed implementation and sustainability of community-focused cancer care coordination interventions to optimize care for underserved cancer patients in specialty and primary care.

Methods: Methods were systematic, iterative, and flexible to establish and maintain trust, honesty, and collaborative decision-making between academic, community, and clinical partners. First, we collaboratively identified clinical (N = 43) and patient (N = 16) stakeholders and their needs through in-depth interviews and focus groups. Then, we planned, implemented, evaluated, and modified strategies to improve cancer care coordination in response to challenges and new information.

Results: Primary care providers reported needing more information about cancer survivorship care and wanting more complete information about their patients' cancer treatment. Patients described concerns about cancer recurrence, challenges managing comorbid conditions, and economic concerns. These findings influenced the focus and implementation of a community navigation program at the academic cancer center and informed bi-directional information-sharing interventions with primary and oncology care partners, which included face-to-face meetings, service-learning opportunities, and improving data transmission through the electronic health record.

Health equity implications: Health systems' mutual learning and resource sharing enhance patient cancer care coordination to address social determinants of health. Engaging partners at different levels within health systems (e.g., administrative staff and clinical leadership) ensures sustainability of relationships, interventions, and advocacy for cancer patients with significant social needs.

Introduction: Screening for social determinants of health (SDOH) is a critical strategy to advance health equity among underserved and vulnerable populations. Despite growing adoption, few validated, quantitative tools exist to measure patients' experiences with screening tools and clinical workflows. The Patient Experience of Social Needs Screening (PESNS) questionnaire was developed to fill this gap.

Objective: To develop and validate a 9-item PESNS questionnaire to measure patient perceptions of SDOH screening tools and workflows in ambulatory, inpatient, and emergency department settings, with a focus on supporting health equity and patient-centered care.

Methods: A comprehensive literature review informed the development of 27 constructs. Using a modified Delphi process with eight experts, 29 preliminary items were refined across four rounds, resulting in a final 9-item questionnaire. Spanish translation followed best practices, including cognitive testing with six patients. The PESNS questionnaire was administered via telephone to 262 Medicare and Medicaid patients. Principal component analysis, exploratory factor analysis, and polychoric correlations assessed construct validity. Internal consistency was measured using Cronbach's α.

Results: Two components emerged-Enhancing User Experience Essentials and Patient-Centered User Experience-accounting for 60% of variance. Cronbach's α was 0.841 overall, with factors 1 and 2 scoring 0.790 and 0.848, respectively. All items showed acceptable correlations (0.438-0.669), supporting scale reliability and construct validity. Component 1 captures the usability and effectiveness of the PESNS questionnaire, and Component 2 assesses privacy and environmental comfort. These dimensions align with health equity goals by highlighting patient-centered barriers and facilitators to SDOH screening.

Conclusion: The PESNS questionnaire offers a reliable, valid, and equity-focused tool to assess patient experience with SDOH screening. Its adoption can inform quality improvement and support more inclusive and effective health care delivery.

Introduction: The effectiveness of evidence-based mental health programs across sexual orientation and minoritized gender identity groups is not well-understood.

Objectives: To evaluate outcomes of an employer-offered, evidence-based telemental health program (video-based psychotherapy sessions supplemented by asynchronous, guided practice sessions) across gender identity and sexual orientation groups.

Methods: This retrospective cohort analysis included 29,860 U.S.-based adults with clinically elevated anxiety and/or depression symptoms, who began a culturally responsive, telemental health program between April 2021 and April 2023. The primary outcomes were changes in anxiety (Generalized Anxiety Disorder-7) and depression symptoms (Patient Health Questionnaire-9) during, and at the end of, care.

Results: Participants self-identified as female (63.7%), male (31.5%), and transgender and gender diverse (1.4%); participants also self-identified as bisexual (5.5%), gay or lesbian (4.1%), additional sexual orientation groups (5.4%), and straight (78.0%). Rates of end-of-care reliable improvement or recovery in anxiety or depression symptoms ranged from 82.4 - 87.5% across gender identity groups, and 84.3 - 86.9% across sexual orientation groups. In growth curve models, anxiety and depression symptoms significantly decreased during treatment. Compared with straight adults, bisexual adults and adults reporting additional sexual orientation groups exhibited statistically significantly less steep initial reductions in anxiety and depression symptoms. Compared with female adults, male adults had statistically significantly steeper initial reductions in anxiety and depression symptoms. Across these outcomes, statistically significant differences by gender identity and sexual orientation groups were small.

Discussion: This employer-offered telemental health program provided clinically beneficial services to populations with diverse gender identities and sexual orientations, suggesting a potential pathway for accessing equitable mental health care.

Background: The postpartum period is a critical time to support birthing people and infants, address and mitigate perinatal health inequities, and promote joy and connection. Yet many birthing people do not perceive value in postpartum visits, particularly when measured against the competing demands and barriers to care faced by those experiencing poverty and other systemic oppression. These inequities are particularly acute for Black birthing people insured by Medicaid due to structural and interpersonal racism, as well as economic disenfranchisement. We implemented an opt-in postpartum care at home program led by midwives at a federally qualified health center to increase the perceived value of postpartum care and increase patient engagement.

Methods: We evaluated implementation using the reach, effectiveness, adoption, implementation, and maintenance framework. We assessed reach and effectiveness using electronic health record data for 2022 (pre-implementation) and 2023 (implementation).

Results: Among 473 birthing people eligible during the evaluation period, 118 (28%) had a postpartum home care visit. Postpartum visit attendance rates increased from 78% in 2022 to 84% in 2023. In-home postpartum care increased family involvement, enabled longer and more comprehensive visits, and improved provider satisfaction.

Conclusions: Postpartum care at home can reduce barriers to care, increase visit attendance, and promote joy. In-home postpartum care with a midwife has the potential to mitigate health inequities experienced by Black birthing people by fostering trust and shifting the power dynamic in the patient-provider relationship. Community-based care must be designed and implemented with antiracist and emancipatory approaches.

Background: Maternal mortality and morbidity rates in the United States among racially minoritized populations have continued to worsen over the past decade. Reviews have examined the maternity care experiences and outcomes of Black individuals in the United States. However, few reviews have examined maternal health care providers' experiences in the United States.

Purpose: To comprehensively assess the current evidence and knowledge gaps related to maternal health care providers' perspectives on providing respectful maternity care to Black patients.

Method: The methodology is in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews guidelines, and the Joanna Briggs Institute enhanced scoping review framework. A literature search using medical subject headings on the terms "Maternity care providers," "Perspective," "Respectful maternity care," "Person-centered maternity," "Compassionate maternity care" together with BOOLEAN operators ("AND"/"OR") will be conducted via PubMed, Embase, Web of Science, and CINAHL. The search will be limited to studies conducted in the United States, in English, and from 2013 to 2024. A Gray literature search will be conducted. Retrieved articles will be imported into Zotero to remove duplicates and imported to Covidence. Studies will be appraised using the Mixed Methods Appraisal Tool. A random-effects meta-analysis will be conducted based on the homogeneity of the included studies. If quantitative synthesis or meta-analysis is not appropriate due to the heterogeneity of the included studies, a combination of narrative and thematic synthesis methodology will be employed.

Ethics and dissemination: Ethics approval is not required for the scoping review, and these findings will be submitted for open-access publication in peer-reviewed journals and presented at scientific conferences.

Discussion: The findings from this scoping review will help provide a comprehensive summary of clinicians' perspectives on delivering facility-based maternity care free of discrimination and maltreatment, which can significantly inform policies to enhance quality and equitable maternity care services.

Introduction: The persistent disparities in the field of obstetrics and gynecology (OBGYN) have become increasingly visible in the public eye, while at the same time public discourse regarding the appropriateness and efficacy of diversity, equity and inclusion (DEI) education has become increasingly politically polarized.

Background: While it has long been accepted that DEI training is an essential component of curricula offered in academic OBGYN departments, there remains a great deal of uncertainty regarding the best practices for developing and provisioning such training.

Methods: In this article, the authors outline lessons learned from the process of developing an evidence-based department-wide needs assessment in order to evaluate the knowledge, attitudes, and behavior of members of a large academic OBGYN department, including an evaluation of the impact of prior DEI educational programming.

Results: Of the 113 clinicians, nurses and administrative staff, the majority desired more DEI training and endorsed significant barriers to accessing it. There were also significant opportunities for improvement of health equity knowledge and clinical practice.

Discussion: Although DEI training has been lauded for addressing health inequities, the findings of this needs assessment highlight existing gaps between desired and actual outcomes. It is essential that academic departments design, implement, and evaluate DEI strategies that are inclusive of the entire medical team, offer iterative and ongoing training opportunities, provide support for minoritized groups within the department, and involve a variety of stakeholders to improve our ability to provide equitable reproductive health care for all.

Background: Oral cancer is one of the 10 most common cancers globally and represents a public health problem. Cultural practices and access to care are recognized as determinants of oral diseases, including cancer. Understanding the perceptions of indigenous communities is crucial for developing culturally appropriate interventions. This study aims to evaluate the perceptions, beliefs, and knowledge about oral and familial cancer within a specific indigenous community (Quechua and Aymara) in Chile using a mixed-methods approach.

Methods: This exploratory study was conducted in two phases: an oral cavity clinical examination and a qualitative phase, consisting of semi-structured interviews with a subset of participants from the clinical examination. A total of 77 volunteers with no prior history of oral cancer underwent an oral cavity clinical examination, and 53% reported a familial history of cancer. The interview was conducted with 18 participants.

Results: No significant differences were found in the clinical oral health status between the indigenous and nonindigenous populations. However, a lack of knowledge of oral cancer was noted in the indigenous community. A higher proportion of participants from the indigenous population reported a family history of cancer.

Conclusion: The community demonstrated limited knowledge about oral cancer. Therefore, it is necessary to implement culturally and linguistically appropriate strategies for oral health promotion and oral cancer prevention to address the specific needs of these communities.

Background: Persons experiencing housing instability (PEHIs) are medically vulnerable and at increased risk for poor health outcomes, high clinical service utilization, and mortality. Unstable housing is just one of many social determinants of health or nonmedical factors influencing health outcomes.

Methods: Focus groups were conducted on-site at two Kentucky homeless shelters to assess the structure and perceived effectiveness of Medicaid managed care organizations (MCOs) and community-based organizations (CBOs) partnerships. We share perspectives of homeless Medicaid enrollees who are living without housing on the interaction between Medicaid MCOs and homeless shelters addressing unmet social needs.

Results: Three themes emerged from our qualitative analysis: (1) Benefits of and barriers to receiving various services through Medicaid, (2) Medicaid does not appear to interface well with community-based shelters, and (3) Medicaid enrollees living without housing perceive a lack of information from Medicaid. Concerns raised by participants included barriers to receiving services, strengthening resource and referral processes, and increasing communication with both CBOs and Medicaid enrollees. These concerns must be addressed to improve care and outcomes.

Conclusions: PEHIs rely on homeless shelters to help them enroll and utilize Medicaid rather than relying on Medicaid to identify and utilize CBOs. There are opportunities for improvement in how MCOs interact with PEHI enrollees. PEHIs utilize Medicaid and navigate cross-sector relationships in different ways than other Medicaid enrollees.

Introduction: Black Americans have the highest prevalence of hypertension among all racial or ethnic groups in the United States. They are 40% more likely to have uncontrolled blood pressure (BP) and are five times more likely to die from hypertension compared with non-Hispanic Whites. Experiences of discrimination in health care, clinician and institutional bias, and socioeconomic and environmental inequities driven by structural racism contribute to uncontrolled hypertension in this population. Multilevel, multicomponent interventions have effectively improved BP control among Black Americans but remain inadequately implemented in the clinical setting. An integrated nursing/public health quality improvement study was designed to address this gap between evidence and integration into clinical practice.

Methods: Using a one group pre/posttest design, we examined the effect of an innovative, evidence-based 12-week intervention on BP among Black Americans with uncontrolled hypertension aged 18 and older in the primary care setting. Intervention components included remote BP monitoring, weekly phone coaching with culturally congruent care, medication intensification, and a standardized hypertension protocol.

Results: The average age of the participants (n = 35) was 64 years, and two thirds (n = 23) were female (66%). The mean difference in systolic BP from pre to postintervention decreased significantly (M = 23, standard deviation [SD] = 14.0), t(34) = -9.7, p < 0.001). A significant reduction in the mean difference in diastolic BP from pre to postintervention was also observed (M = 11, SD = 11.8), t(34) = -5.5, p < 0.001). At 12 weeks, 87% of participants had achieved BP control. The intervention also improved medication adherence and hypertension knowledge (p < 0.001).

Conclusion: A multicomponent, culturally congruent quality improvement intervention may effectively improve BP among Black Americans.

Health equity implications: Scaled up implementation of equity-centered, culturally congruent approaches is needed to reduce racial disparities in hypertension control.

Importance: The U.S. medical education system attracts and trains the next generation of physicians to advance the health care needs of a growing and increasingly diverse nation. This system can be credited for supplying a physician workforce achieving remarkable growth and innovation, yielding one of the world's most technologically advanced health care systems on the planet. This system, unfortunately, also contributes to educational, workforce, and health disparities.

Observations: The successes and challenges of the medical education and health care system align with broader economic, health, and educational patterns in the United States. An ecological model can be employed to unite a network of partners spanning four developmental stages to support a greater diversity of students for and from underrepresented communities to enter the physician workforce, enjoy the rewards granted by a career in medicine, and enact needed changes to eliminate health, economic, and educational disparities.

Conclusions and relevance: Comprehensive and ecologically attuned pathways to the physician workforce could be especially beneficial to states and communities suffering from the looming high school enrollment cliff, outflows of residents to other states, challenges in recruiting and retaining physicians, and significant educational and health disparities. The ecosystem model spurs significant changes in how we think about the developmental pathways to the physician workforce and how we may mobilize resources to promote progress and ease transitions, especially for underrepresented students who face many fewer opportunities and many more challenges along their journey.