Health Equity最新文献

The legacy of racism and structural inequality has taken a heavy toll on the health care system and the health outcomes of patients and members of community catchment areas. To achieve optimal health outcomes for all, health systems will need to enact structural change that is meaningful, measurable, and rooted in evidence. We describe an antiracism campaign organized into three pillars of focus (Leadership/Employees/Culture, Patient Care Equity, and Community Health and Policy Advocacy) and implemented across Mass General Brigham, a large integrated health system in the northeast of the United States. Our study ranges from the foundational to the aspirational and examples of data-driven areas of focus, programs (e.g., staff education, social risk mitigation, and new models of clinical service), and metrics developed for the health care workforce, patients, and surrounding communities are presented.

Medicine has a longstanding history of racism that promulgates existing health inequities. Current medical education, largely based on the biomedical framework, omits critical discourse on racism and White supremacy, which continue to harm individuals and communities of color. Such ahistorical and apolitical orientation inadequately trains learners to identify and address racism in clinical practice. Although curricula on racial health disparities, social determinants of health, cultural competency, and implicit bias have been operationalized by several medical schools, they do not identify the racism embedded in systems of care, nor do they provide transformative steps toward true health equity and justice. As such, this article proposes bold radical frameworks as the foundation for reimagining medical education in the United States. Founded on critical race theory, abolition, and decolonization, the authors provide a view of an antiracist medical education, one that highlights the history and legacy of racism in medicine and positions medical trainees and practicing physicians as active agents in medicine's antiracist transformation.

Introduction: In an attempt to address health inequities, many U.S. states have considered or enacted legislation requiring antibias or implicit bias training (IBT) for health care providers. California's "Dignity in Pregnancy and Childbirth Act" requires that hospitals and alternative birthing centers provide IBT to perinatal clinicians with the goal of improving clinical outcomes for Black women and birthing people. However, there is as yet insufficient evidence to identify what IBT approaches, if any, achieve this goal. Engaging the experiences and insights of IBT stakeholders is a foundational step in informing nascent IBT policy, curricula, and implementation.

Methods: We conducted a multimethod community-based participatory research study with key stakeholders of California's IBT policy to identify key challenges and recommendations for effective clinician IBT. We used focus groups, in-depth interviews, combined inductive/deductive thematic analysis, and multiple techniques to promote rigor and validity. Participants were San Francisco Bay Area-based individuals who identified as Black or African American women with a recent hospital birth (n=20), and hospital-based perinatal clinicians (n=20).

Results: We identified numerous actionable challenges and recommendations regarding aspects of (1) state law; (2) IBT content and format; (3) health care facility IBT implementation; (4) health care facility environment; and (5) provider commitment and behaviors. Patient and clinician insights overlapped substantially. Many respondents felt IBT would improve outcomes only in combination with other antiracism interventions.

Health equity implications: These stakeholder insights offer policy-makers, health system leaders, and curriculum developers crucial guidance for the future development and implementation of clinician antibias interventions.

Background: The past two decades have been marked by increased efforts to advance equity in various disciplines, including social sciences, public health, environmental health, and medicine. In 2020, a national movement of municipalities declared racism a public health crisis. These efforts have coincided and likely shaped a growing sphere of federal and philanthropic funding for health equity, which frequently calls for practical interventions toward reducing and ultimately eliminating disparities. Disparities in health such as maternal mortality, infant mortality, diabetes, cancer, and stroke have been linked to root causes such as racism. Often, root causes are also linked to disparities in other sectors (i.e., finance/wealth attainment, educational attainment, career attainment, and home ownership). In 2021, in a study published in the New England Journal of Medicine, suggested that racist policies were root causes of U.S. racial health inequities. While racism, sexism, and classism, etc., are characterized as root causes, we posit that there is a deeper driver that has yet to be advanced. This presents a disparity-inequity model that maps disparities and inequities to the societal value system, not root causes.

Methods: The KKey Values Inequities Disparities Model described in this article combines a case study of the Flint Water Crisis to explore the historic impact of human devaluation and its role in systemic racism and classism, which ultimately creates and exacerbates inequities that produce disparities in communities. The model integrates the value system and its contribution to societal causes (formerly known as root causes).

Conclusions: A broadly defined values-inequities-disparities model will allow researchers, practitioners, decision makers, lawmakers, and community members to (1) assess the core root of inequities and disparities; (2) identify solutions in the human value domain; (3) design appropriate course corrective programming, interventions, processes, and procedures; and (4) create actions to integrate new systemic procedures and practices in our laws and governance to advance equity.

Introduction: Reproductive policies' impact on disparities in neonatal outcomes is understudied. Thus, we aimed to assess whether an index of reproductive autonomy is associated with black-white disparities in preterm birth (PTB) and low birthweight (LBW).

Methods: We used publicly available state-level PTB and LBW data for all live-births among persons aged 15-44 from January 1, 2016, to December 31, 2018. The independent measure was an index of state laws characterizing each state's reproductive autonomy, ranging from 5 (most restrictive) to 43 (most enabling), used continuously and as quartiles. Linear regression was performed to evaluate the association between both the index score (continuous, primary analysis; quartiles, secondary analysis) and state-level aggregated black-white disparity rates in PTB and LBW per 100 live births.

Results: Among 10,297,437 black (n=1,829,051 [17.8%]) and white (n=8,468,386 [82.2%]) births, rates of PTB and LBW were 6.46 and 8.24 per 100, respectively. Regression models found that every 1-U increase in the index was associated with a -0.06 (confidence interval [CI]: -0.10 to -0.01) and -0.05 (CI: -0.08, to -0.01) per 100 lower black-white disparity in PTB and LBW rates (p<0.05, p<0.01), respectively. The most enabling quartiles were associated with -1.21 (CI: -2.38 to -0.05) and -1.62 (CI: -2.89 to -0.35) per 100 lower rates of the black-white disparity in LBW, compared with the most restrictive quartile (both p<0.05).

Conclusion: Greater reproductive autonomy is associated with lower rates of state-level disparities in PTB and LBW. More research is needed to better understand the importance of state laws in shaping racialized disparities, reproductive autonomy, and birth outcomes.

Introduction: Women experience numerous barriers to patient-centered health care (e.g., lack of continuity). Such barriers are amplified for women from marginalized communities. Virtual care may improve equitable access. We are conducting a partner-engaged, qualitative evidence synthesis (QES) of patients' and providers' experiences with virtual health care delivery for women.

Methods: We use a best-fit framework approach informed by the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework and Public Health Critical Race Praxis. We will supplement published literature with qualitative interviews with women from underrepresented communities and their health care providers. We will engage patients and other contributors through multiple participatory methods.

Results: Our search identified 5525 articles published from 2010 to 2022. Sixty were eligible, of which 42 focused on women and 24 on provider experiences. Data abstraction and analysis are ongoing.

Discussion: This work offers four key innovations to advance health equity: (1) conceptual foundation rooted in an antiracist action-oriented praxis; (2) worked example of centering QES on marginalized communities; (3) supplementing QES with primary qualitative information with populations historically marginalized in the health care system; and (4) participatory approaches that foster longitudinal partnered engagement.

Health equity implications: Our approach to exploring virtual health care for women demonstrates an antiracist praxis to inform knowledge generation. In doing so, we aim to generate findings that can guide health care systems in the equitable deployment of comprehensive virtual care for women.

Background: The New York State (NYS) Department of Health (DOH) AIDS Institute (AI) Clinical Education Initiative (CEI) trains the NYS health care workforce to improve health outcomes related to HIV, sexual health, hepatitis C, and for people who use drugs.

Methods: In 2019, CEI began consistently integrating health equity into CEI activities through a working group that mapped NYS DOH AI health equity competencies for providers onto planned clinical education. We conducted a convergent mixed methods study on qualitative and quantitative participant feedback form (PFF) data to evaluate these competencies between April 1, 2021, and September 30, 2022, and conducted an annual survey of NYS clinician needs in 2021 and 2022.

Results: The CEI Health Equity Working Group analyzed 25 measures within 4 health equity competencies that were grouped into 4 interventions: resources, internal tools, activity creation, and evaluation. Eighty-nine percent of PFF respondents (n=20,166) strongly agreed/agreed that CEI activities included multiple viewpoints; qualitative comments described informative and helpful activities. When asked how they address patient-identified social determinants of health (SDOH) needs, 84% and 71% of annual survey respondents reported they made the highest number of referrals for health insurance coverage assistance in 2021 and 2022, respectively.

Discussion: CEI continues to address participant feedback and seamless incorporation of health equity components into their work.

Health equity implications: Health equity in clinical practice and trainings is crucial in acknowledging and addressing SDOH that continue to impact NYS clinicians and their patients.

Background: Racial inequities in maternal health outcomes, the result of systemic racism and social determinants of health, require maternity care systems to implement interventions that reduce disparities. One such approach may be support from a community doula, a health worker who provides emotional support, peer education, navigation, and advocacy for pregnant, birthing, and postpartum people who share similar racial identities, cultural backgrounds, and/or lived experiences. While community support during birth has a long tradition within communities of Black Indigenous and People of Color (BIPOC), the reframing of community doula support as a social intervention that reduces disparities in clinical outcomes is recent.

Methods: We conducted a pragmatic randomized trial at an urban safety net hospital, comparing standard maternity care with standard care plus enhanced community doula support. We tested the effectiveness of a community doula program embedded in a safety net hospital in improving birth outcomes and explored the association between community doula support and health equity. Participants were nulliparous, insured by publicly funded health plans, and had lower risk pregnancies. The primary outcome was cesarean birth. Secondary outcomes included preterm birth and breastfeeding outcomes. Exploratory subgroup analysis was conducted by race-ethnicity.

Results: Three hundred sixty-seven participants were included in the primary analysis. In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (p=0.08). There was a statistically nonsignificant 12% absolute reduction in cesarean birth and 11.5% increase in exclusive breastfeeding during delivery hospitalization among Black non-Hispanic participants.

Discussion: While outcomes for the study sample were similar between randomization groups, health outcomes were improved for Black birthing people in cesarean and breastfeeding rates.

Conclusion: This study demonstrates the need for larger studies of community doula support for Black birthing people. Clinicaltrials.gov ID: NCT02550730.