Health Disparities Research Framework Research Articles

Understanding Disparities in the Pediatric ICU: A Scoping Review.

Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.

Relationships Among Determinants of Health, Cancer Screening Participation, and Sexual Minority Identity: A Systematic Review.

Purpose: To address cancer screening disparities and reduce cancer risk among sexual minority (SM) groups, this review identifies individual, interpersonal, and community/societal determinants of cancer screening (non)participation among differing SM identities. Methods: Seven scientific databases were searched. Inclusion criteria were as follows: (1) used quantitative methods; (2) English language; (3) cancer screening focus; and (4) at least one SM group identified. Articles were excluded if: (1) analysis was not disaggregated by SM identity (n = 29) and (2) quantitative analysis excluded determinants of cancer screening (n = 19). The Sexual and Gender Minority Health Disparities Research Framework guided literature synthesis. Results: Twelve studies addressed cervical (n = 4), breast (n = 3), breast/cervical (n = 3), or multiple cancers (n = 2). Other cancers were excluded due to inclusion/exclusion criteria. The total sample was 20,622 (mean 1525), including lesbian (n = 13,409), bisexual (n = 4442), gay (n = 1386), mostly heterosexual (n = 1302), and queer (n = 83) identities. Studies analyzing individual-level determinants (n = 8) found that socioeconomic status affected cervical, but not breast, cancer screening among lesbian and bisexual participants (n = 2). At the interpersonal level (n = 7), provider-patient relationship was a determinant of cervical cancer screening among lesbian participants (n = 4); a relationship not studied for other groups. Studies analyzing community/societal determinants (n = 5) found that rurality potentially affected cervical cancer screening among lesbian, but not bisexual people (n = 3). Conclusions: This review identified socioeconomic status, provider-patient relationship, and rurality as determinants affecting cancer screening among SM people. While literature addresses diverse SM groups, inclusion/exclusion criteria identified studies addressing cisgender women. Addressing disparities in the identified determinants of cervical cancer screening may improve participation among SM women. Further research is needed to understand determinants of cancer screening unique to other SM groups.

Multilevel approaches to address disparities in lung cancer screening: a study protocol

BackgroundLow-dose computed tomography (lung cancer screening) can reduce lung cancer-specific mortality by 20–24%. Based on this evidence, the United States Preventive Services Task Force recommends annual lung cancer screening for asymptomatic high-risk individuals. Despite this recommendation, utilization is low (3–20%). Lung cancer screening may be particularly beneficial for African American patients because they are more likely to have advanced disease, lower survival, and lower screening rates compared to White individuals. Evidence points to multilevel approaches that simultaneously address multiple determinants to increase screening rates and decrease lung cancer burden in minoritized populations. This study will test the effects of provider- and patient-level strategies for promoting equitable lung cancer screening utilization.MethodsGuided by the Health Disparities Research Framework and the Practical, Robust Implementation and Sustainability Model, we will conduct a quasi-experimental study with four primary care clinics within a large health system (MedStar Health). Individuals eligible for lung cancer screening, defined as 50–80 years old, ≥ 20 pack-years, currently smoking, or quit < 15 years, no history of lung cancer, who have an appointment scheduled with their provider, and who are non-adherent to screening will be identified via the EHR, contacted, and enrolled (N = 184 for implementation clinics, N = 184 for comparison clinics; total N = 368). Provider participants will include those practicing at the partner clinics (N = 26). To increase provider-prompted discussions about lung screening, an electronic health record (EHR) clinician reminder will be sent to providers prior to scheduled visits with the screening-eligible participants. To increase patient-level knowledge and patient activation about screening, an inreach specialist will conduct a pre-visit phone-based educational session with participants. Patient participants will be assessed at baseline and 1-week post-visit to measure provider-patient discussion, screening intentions, and knowledge. Screening referrals and screening completion rates will be assessed via the EHR at 6 months. We will use mixed methods and multilevel assessments of patients and providers to evaluate the implementation outcomes (adoption, feasibility, acceptability, and fidelity).DiscussionThe study will inform future work designed to measure the independent and overlapping contributions of the multilevel implementation strategies to advance equity in lung screening rates.Trial registrationClinicalTrials.gov, NCT04675476. Registered December 19, 2020.

EFFECTIVE SOLUTIONS FOR CAREGIVERS OF OLDER ADULTS: A RAPID UMBRELLA REVIEW

Abstract The negative health impacts confronting over 35 million informal caregivers of older adults in the U.S. are well documented. Although targeted interventions aimed at informal caregivers have demonstrated efficacy in mitigating poor caregiver outcomes, gaps in the literature regarding cost, scalability, and the impact of policy remain. Such knowledge is essential, given the projected growth in the need for caregiving associated with a rapidly aging population coupled with the shrinking of the caregiving workforce. This rapid umbrella review aims to synthesize findings from systematic reviews of randomized clinical trials of interventions that targeted caregivers and specified caregiver outcomes. The National Institute on Minority Health and Health Disparities research framework guided this review to identify gaps in existing intervention research. Databases from diverse disciplinary perspectives, including PubMed, Scopus, APA PsycINFO, ABIM, ATLA, Sociological Abstracts, PAIS, and EconLit, were searched from 2018 to 2023. A total of 52 systematic reviews that met inclusion criteria and were published in English were included in the final review. Reviews described interventions targeting caregivers of older adults with the following conditions: dementia (30), stroke (4), cancer (4), heart disease (1), renal disease (1), mental illness (1), and mixed-diagnoses (11). Major findings reveal varied effects on caregiver burden, quality of life, and mental health, and the growing integration of telehealth interventions. Studies were commonly limited by heterogeneity of interventions and outcomes and small effect sizes. Future intervention development should consider targeting the specific needs of diverse caregivers and scaling effective interventions to broader caregiver populations.

Factors Influencing Eye Screening Adherence Among Latinx Patients With Diabetes: A Qualitative Study.

Latinx populations have the highest rates of visual impairment and blindness of any ethnic group in the United States, with most cases of diabetic retinopathy remaining undiagnosed. We aimed to identify factors influencing adherence with diabetic eye screening in Latinx communities. We conducted semistructured individual interviews with adult Latinx patients in Dane County, WI. Interviews were transcribed verbatim, translated from Spanish to English, and analyzed using QSR NVivo software. We performed both inductive open coding and deductive coding using the National Institute on Minority Health and Health Disparities Research Framework, as well as the Campbell and Egede Model. All participants (n = 20) self-identified as Latinx and were diagnosed with type 2 diabetes. The mean age was 61.5 years (range 33-79 years). Most participants were uninsured (60%), self-reported low or moderate health literacy (60%), and preferred to speak Spanish during their clinic appointments (75%). Individual-level barriers to diabetic eye screening included limited eye health literacy, lack of insurance coverage, and low self-efficacy with diabetes management. Health system-level facilitators included a recommendation to obtain eye screening from a primary care provider and the use of nonwritten forms of patient education. Community-level barriers included social isolation, concerns about inconveniencing others, machismo, and immigration status. We identified several health system- and community-level factors, in addition to individual-level factors, influencing adherence with diabetic eye screening in Latinx communities. Strategies addressing these factors may enhance the effectiveness of interventions to prevent blindness from diabetes and contribute to advancing health equity in Latinx communities.

Abstract A045: Adhering to a culturally responsive framework: Integrating kinship into a multilevel community-based intervention for American Indian adults with comorbid type 2 diabetes and cancer

Abstract The prolific disparities of type 2 diabetes (T2D) and cancer in tribal communities is well documented. American Indian (AI) adults living with T2D are at greater risk of not only developing cancer, but also dying from it, with cooccurrence becoming increasingly prevalent. On rural tribal reservations, common environmental diabetogenic factors (e.g., obesity, lack of physical activity, poor diet, and stress) are considered as sources of elevated risk for both T2D and cancer. Critically important in improving both diabetes and cancer-related health behaviors and outcomes, particularly for AI people, is psychosocial support from family and community ties (e.g., kinship). Despite supporting evidence, few interventions include kinship as a key factor to promote best outcomes for T2D management among AI adults with a dual diagnosis of cancer. To address this growing issue, there is an urgent need for culturally and contextually adapted interventions aiming to address the cooccurrence of T2D and cancer that are, ideally, led by tribal communities. In this session, healthcare professional Early-Stage Investigators (ESIs), some of whom also identify as AI, will present community-based participatory research (CBPR) principles used to develop a multilevel Tribally tailored intervention, with kinship as a moderating factor, for AI adults living with both T2D and cancer. The ESIs represent a unique pool of providers invested in the community within which they work by co-creating an intervention which utilizes pre-existing strong community and familial norms. The ESIs further look to break away from the common trend in research to overgeneralize interventions and findings to all AI Tribal communities by tailoring the intervention to each specific Tribal Community engaged in the research intervention. To foster innovative research methods by emphasizing important historic and socio-cultural influences relevant to understanding the holistic context of health disparities in tribal communities, the guiding framework is the NIMHD Minority Health and Health Disparities Research Framework adapted for AI and Alaska Native Nations. In this research, individuals are viewed within the context of the broader social system where they function daily, while families and community are key stakeholders and leaders in the successful management of T2D and cancer. The approach focuses on diabetes-related barriers by providing family and social units with skills for successful T2D and cancer management, healthy communication, and shared commitment. In addition to these domains of influence, involving community systems is critical for a sustainable intervention that effectively addresses health disparities for T2D and cancer. Citation Format: Sheila L. Hammer, Timian M. Godfrey. Adhering to a culturally responsive framework: Integrating kinship into a multilevel community-based intervention for American Indian adults with comorbid type 2 diabetes and cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A045.

Palliative Care Professionals' Perceptions of Communication With Sexual and Gender Minority Patients.

For sexual and gender minority (SGM) individuals who identify as lesbian, gay, bisexual, transgender, queer, or any other sexual orientation or gender identity (LGBTQ+), the quality of palliative care can depend upon how clinicians view and communicate with this historically minoritized group. Prior literature has demonstrated that SGM patients access care at lower rates, and palliative care clinicians have suggested that SGM patients are more likely to experience discrimination than heterosexual patients. This study examined palliative care clinicians' perspectives and experiences regarding patient communication, care settings, the built environment, and inclusive care for SGM older adults with serious illness. The health disparities research framework informed a descriptive qualitative analysis of interview data with palliative care professionals (N = 20) across diverse healthcare settings within Colorado regarding their experiences and beliefs about communication and the care of SGM patients. Three main themes emerged: (1) Limited sexual orientation and gender identity (SOGI) data collection; (2) Organizational and environmental inclusivity, and the "neutral" space viewed as safe; (3) Missing training platforms regarding SGM patients and a lack of opportunity to identify and discuss SGM patient needs. Study findings illuminated the following barriers to providing SGM-inclusive care: perspectives around (1) limitations and preferences regarding collection of SOGI data, (2) organizational and environmental inclusivity, and (3) education and training regarding cultural humility and communication with SGM patients. Findings indicate the need for multidimensional research to better understand and address SGM health disparities and promote equitable care.

Finding Common Barriers and Facilitators for Cervical Cancer Screening in Sexual and Gender Diverse People: An Integrative Review

Abstract: Background. Sexual and gender diverse (SGD) people have lower rates of cervical cancer screening than cisgender, heterosexual people, putting them at greater risk for disease. Few, if any, studies have examined facilitators and barriers to cervical cancer screening common to all subgroups of SGD people with a cervix. Methods. An integrative review regarding cervical cancer screening by SGD people was conducted using Whittemore and Knafl's framework. The National Institutes of Health's Sexual and Gender Minorities Health Disparities Research Framework was used to interpret the findings. An electronic database search identified 17 peer-reviewed articles for inclusion. Results. Quantitative and qualitative studies and reviews took various approaches. Barriers common to all subgroups exist at the personal, interpersonal, community, and societal levels, including lack of insurance, lack of primary care provider, poor provider communication, discrimination, and insufficient provider education. Conclusion. Identification of common barriers and facilitators can be used to enhance educational curricula and intervention development to increase cervical cancer screening among SGD people.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery. A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities. The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods. Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation. Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

Multi-Level Determinants of Food Insecurity among Racially and Ethnically Diverse College Students.

Compared with the general population, the prevalence of food insecurity (FI) is higher among college students. The COVID-19 pandemic exacerbated FI disparities and highlighted the need for further research to better understand and address FI in this population. Although race and ethnicity are two of the strongest predictors of FI among college students, little research is available on the determinants of FI among racial/ethnic minority college students. A cross-sectional study (n = 588) based on the National Institute of Minority Health and Health Disparities research framework was examined to identify population-specific determinants of FI among racially/ethnically diverse college students through the assessment of multiple domains (behavioral, environmental, socio-cultural) and levels of influence (individual, interpersonal, and community levels). Discrimination was the sole predictor of FI for non-Hispanic Black students. Coping mechanisms for FI (savings, reduced intake) and body mass index (BMI) were predictors of FI for Hispanic and non-Hispanic White students. Additionally, decreased holistic support from faculty and staff was also observed as a predictor of FI in Hispanic students. Implications include the need for further research and the development of multi-level, tailored interventions to address FI among college students with the goal of decreasing disparities.

Design and pilot implementation of the Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program in an urban underresourced population.

The Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program is a community-engaged framework to improve mammography maintenance and rates of genetic risk assessment, counseling, and testing using a multilevel approach that enhances patient navigation through mobile health and community education. The ACE-ITS program is based on the National Institute of Minority Health and Health Disparities research framework focused on the individual (genetic testing, screening navigation) and community (community-based breast health education) levels and targeted to the biological- (genetic risk), behavioral- (mammography screening), sociocultural- (underserved Black and Hispanic women), and the health care system (patient navigation, automated text messages)-related domains. We further integrate the Practical Robust Implementation and Sustainability Model to describe our program implementation. In collaboration with genetic counselors and community partners, we created educational modules on mammography maintenance and genetic counseling/testing that have been incorporated into the navigator-led community education sessions. We also implemented a universal genetic risk assessment tool and automated text message reminders for repeat mammograms into our mammography navigation workflow. Through the ACE-ITS program implementation, we have collaboratively conducted 22 educational sessions and navigated 585 women to mammography screening over the 2020-2021 calendar years. From January to December 2021, we have also conducted genetic risk assessment on 292 women, of whom 7 have received genetic counseling/testing. We describe a multilevel, community-engaged quality improvement program designed to reduce screening-related disparities in Black and Hispanic women in our catchment area.

Barriers and Facilitators to Gender-affirming Hormone Therapy in the Veterans Health Administration.

In 2011, the Veterans Health Administration (VHA) established a policy for the delivery of transition-related services, including gender-affirming hormone therapy (GAHT), for transgender and gender diverse (TGD) patients. In the decade since this policy's implementation, limited research has investigated barriers and facilitators of VHA's provision of this evidence-based therapy that can improve life satisfaction among TGD patients. This study provides a qualitative summary of barriers and facilitators to GAHT at the individual (e.g., knowledge, coping mechanisms), interpersonal (e.g., interactions with other individuals or groups), and structural (e.g., gender norms, policies) levels. Transgender and gender diverse patients (n = 30) and VHA healthcare providers (n = 22) completed semi-structured, in-depth interviews in 2019 regarding barriers and facilitators to GAHT access and recommendations for overcoming perceived barriers. Two analysts used content analysis to code and analyze transcribed interview data and employed the Sexual and Gender Minority Health Disparities Research Framework to organize themes into multiple levels. Facilitators included having GAHT offered through primary care or TGD specialty clinics and knowledgeable providers, with patients adding supportive social networks and self-advocacy. Several barriers were identified, including a lack of providers trained or willing to prescribe GAHT, patient dissatisfaction with prescribing practices, and anticipated or enacted stigma. To overcome barriers, participants recommended increasing provider capacity, providing opportunities for continual education, and enhancing communication around VHA policy and training. Multi-level system improvements within and outside the VHA are needed to ensure equitable and efficient access to GAHT.

Structural Violence and Stress Experiences of Young Pregnant Black People.

Approximately 10-20% of individuals suffer from mental health concerns during the prenatal period due to their vulnerability and emotional responses to stressful events. Mental health disorders are more likely to be disabling and persistent for people of color, and they are less likely to seek treatment due to stigma. Young pregnant Black people report experiencing stress due to isolation, feelings of conflict, lack of material and emotional resources, and support from significant others. Although many studies have reported the types of stressors experienced, personal resources, emotional stress responses on pregnancy, and mental health outcomes, there is limited data on young Black women's perceptions of these factors. This study utilizes the Health Disparities Research Framework to conceptualize drivers of stress related to maternal health outcomes for young Black women. We conducted a thematic analysis to identify stressors for young Black women. Findings revealed the following overarching themes: Societal stress of being young, Black, and pregnant; Community level systems that perpetuate stress and structural violence; Interpersonal level stressors; Individual level effects of stress on mom and baby; and Coping with stress. Acknowledging and naming structural violence and addressing structures that create and fuel stress for young pregnant Black people are important first steps to interrogating systems that allow for nuanced power dynamics and for recognizing the full humanity of young pregnant Black people.

Developing and evaluating a formal care decision‐making intervention for African American parent‐adult daughter dementia dyads: A mixed‐methods study

AbstractBackgroundAfrican American older adults are suggested to be two times more likely to develop Alzheimer’s disease and related dementias (ADRD) compared to non‐Latinx White older adults. As a result, there is a need for more African American caregivers. The largest group of caregivers of African American persons living with ADRD, African American adult daughters, must navigate decision making related to formal care. Formal care—paid health care services for older adults usually associated with an institution— is important in the treatment of ADRD and maintaining quality of life.MethodGuided by the NIA Health Disparities Research Framework, Black Family Social‐Ecological Context Model, and Superwoman Schema, this presentation will describe a clinical trial that is designing a culturally tailored prototype intervention to support the formal care decision‐making process for African American persons living with ADRD and evaluating the feasibility and efficacy of the prototype intervention. The prototype intervention focuses on both members of the dyad’s quality of life as well as formal care utilization by the African American person living with ADRD. The design process will recruit 76 African American dementia dyads (70 dyads for quantitative and qualitative data collection to aid in the development of the prototype intervention and 6 dyads to use design thinking approaches to develop the prototype intervention) and will be tested with 20 African American dementia dyads using a pretest posttest design with two follow ups at 1 month and 3 months post intervention.ResultData will be presented regarding factors influencing the feasibility of implementing a dyadic intervention as an early‐stage investigator. We will focus on the planning process (e.g., IRB approval, study setup, and project management), recruitment strategies (e.g., recruitment videos), recruitment challenges (e.g., consent and eligibility), and mutual engagement of both members of the dyad.ConclusionIn the early stages of planning and recruitment of dementia dyads, there are challenges and key strategies to consider when conducting a dyadic clinical trial as an early‐stage investigator.

An exploration of barriers to access to trial of labor and vaginal birth after cesarean in the United States: a scoping review.

Increasing the number of vaginal birth after cesarean (VBAC) deliveries is one strategy to reduce the cesarean rate in the United States. Despite evidence of its safety, access to trial of labor after cesarean (TOLAC) and VBAC are limited by many clinical and non-clinical factors. We used a scoping review methodology to identify barriers to access of TOLAC and VBAC in the United States and extract potential leverage points from the literature. We searched PubMed, Embase, Cochrane, and CINAHL for peer-reviewed, English-language studies published after 1990, focusing on access to TOLAC and/or VBAC in the United States. Themes and potential leverage points were mapped onto the Minority Health and Health Disparities Research Framework. The search yielded 21 peer-reviewed papers. Barriers varied across levels of influence and included factors related to restrictive clinical guidelines, provider reluctance, geographic disparities, and midwifery scopes of practice. While barriers varied in levels of influence, the majority were related to systemic and interpersonal factors. Barriers to TOLAC and VBAC exist at many levels and are both clinical and non-clinical in nature. The existing body of literature can benefit from more research examining the impact of recent revisions to clinical guidelines related to VBAC as well as additional qualitative studies to more deeply understand the complexity of provider reluctance.

Racial and ethnic disparities in postpartum weight retention: A narrative review mapping the literature to the National Institute on Minority Health and Health Disparities Research Framework.

A Review of the Literature Using the National Institutes of Health, National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to Create a Roadmap of the Studies Investigating Racial and Ethnic Disparities in Excess Weight Retained After Pregnancy. Three out of four people who give birth retain excess weight at 1-year post-pregnancy. This is concerning, as weight that is retained following pregnancy is associated with increased risk for the development of disease. People from racial and ethnic minority groups experience weight retention more frequently post-pregnancy. Black and Hispanic/Latina/o/x birthing people are more likely to begin pregnancy overweight or obese. They are also more likely to retain excess weight following pregnancy. Investigating these risks in people from racially/ethnically diverse backgrounds may be an important way to address disparities in excess weight retained post-pregnancy. This review of the literature used a tool called the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to map the literature to date on racial and ethnic disparities in excess weight retained post-pregnancy. We used the NIMHD Research Framework as a visual guide of the existing research about excess weight retained following pregnancy. Results illustrate the levels and domains at which research has been investigated. These results reveal that efforts have been focused at the individual level, with most attention given to diet and activity. Mapping the literature to the NIMHD Research Framework sheds light on gaps in the research. Mapping the literature has revealed a need for investigations that make connections between the levels and domains of the Framework, so that we may understand underlying factors that contribute to health disparities.

EMBRACING GENDER DIVERSITY: REIMAGINING HEALTH AND HEALTH EQUITY FOR TRANSGENDER OLDER ADULTS

Abstract This presentation will share results of in-depth focus groups exploring eight transgender older adults’ (TOAs) experiences of health and healthcare and related themes, explain weathering and factors contributing to health and healthcare disparities, and apply the Sexual and Gender Minority Health Disparities Research Framework to explore strategies to address individual, interpersonal, community, and societal factors to foster health and health equity. TOAs represent an underserved population at elevated risk for lower socioeconomic status, higher rates of disability and chronic illness, and poorer overall physical and mental health compared to their non-transgender LGBQ and cisgender peers. Due to their unique life experiences including difficult decisions about “coming out” and transitioning, lack of acceptance of being transgender, and physiological impacts of hormonal and surgical treatments, transgender individuals experience long-term chronic stress and accumulate health-related risks as they age, contributing to significant health disparities. Higher levels of illness, disability, and premature death among historically disadvantaged groups can be explained by weathering, the accumulated impact of social disadvantages and socio-political inequalities over the life course producing premature biological aging. A 2019 systematic review of LGBTQ aging literature found that only 10% of studies included trans-identified participants and few addressed the needs of transgender older adults. Understanding the lived experiences of TOAs including healthcare access and receipt, and psychological, social, and financial experiences across the life course, is crucial to understanding current disparities in health and healthcare, developing strategies to improve care and reduce inequities, and fostering health and health equity of transgender older adults.

"If You Don't Trust Your Doctor That Much...You'd Feel Less Confident Doing a Research Study": Factors Influencing Black Patient Participation in Hematology Trials

Background Racial disparities exist in incidence and survival from hematological cancers. These differences are driven by multiple factors, including disease biology and access to high-quality cancer care (e.g., enrollment in a clinical trial). Black persons constitute 5-7% of participants in therapeutic cancer clinical trials (Bhatnagar et al. 2017, S. Al Hadidi et al. 2020, S. Al Hadidi et al. 2022), despite accounting for 14% of the US population. While previous studies have broadly focused on understanding factors that underpin that disparity in clinical trials, very few have focused explicitly on populations with hematological cancers. Further, research evaluating the perspectives of hematologists on factors that influence clinical trial enrollment for the Black population remains limited. The objective of this study was to understand factors that influenced Black participant enrollment in hematology-focused clinical trials by examining the perspectives of Black patients with multiple myeloma and their hematologists. Methods Between August 2021-January 2022, hematologists were recruited to participate in single semi-structured 60-minute virtual interviews, while patients diagnosed with multiple myeloma were asked to participate in focus group discussions (FGDs) lasting up to 90 minutes via videoconferencing. Through the Sort and Sift, Think, and Shift approach (Maietta et al. 2021),analytic memoing and diagramming of key quotations were used to assess topics and identify larger conceptual themes. We tabled and grouped themes, topics, and associated quotations at multiple levels using the National Institute on Minority Health and Health Disparities Research framework. Topics and themes from FGDs and hematologist interviews were then distilled into key claims. Results We conducted 6 FGDs with 23 patients and 13 semi-structured interviews with hematologists. Hematologists perceived trust at multiple levels (e.g., patient-provider, patient-health care system) as an influential determinant of Black patients' enrollment in clinical trials (Table 1). Factors that fostered patient-hematologist trust included the length of the relationship, use of transparent and empathic communication, and shared racial identities of patients and hematologists. For patients, trust in the hematologist, health care system, and proposed trial intervention were determinants of whether Black patients enrolled in a clinical trial. Patients also emphasized the importance of hematologists acknowledging the historical events that led to the intentional harm of Black persons engaged in research-related activities and recommended additional efforts to foster shared medical decision-making. Some hematologists perceived clinical trial discussions as potentially harmful when building trust in their patient relationships. Hematologists also considered patient context--such as geographic location, socioeconomic challenges, and health literacy along with study eligibility criteria--when deciding to offer a clinical trial (Figure 1). Hematologists also viewed lack of time, trial availability, and adequate clinical trial infrastructure as barriers to discussing and enrolling Black patients in clinical trials. Conclusion Black patients and hematologists perceived trust at multiple levels as critical to enhancing the enrollment of Black participants in hematology-focused cancer clinical trials. Additionally, hematologists' perceptions about patients, including the additional burdens associated with clinical trial participation, also impacted whether or not Black patients are given the opportunity to participate in a clinical trial. Addressing disparities in clinical trial enrollment among Black participants requires multilevel interventions such as 1) fostering patient-clinician relationships, 2) increasing clinical trial availability and partners in community-based settings, 3) providing support to overcome logistical barriers, 4) acknowledging and finding strategies to address physician biases. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Diverse perspectives on social determinants of multicultural adolescents: A focus group study

Abstract Background As Korea transforms into a multicultural society, social vulnerability of the multicultural adolescents (MAs) puts them at risk for poor health and health disparities. However, there is shortage of evidence on social determinants of health (SDH), which refers to the circumstances of people from birth to death, which affects their health outcomes, for MAs. Thus, this study aims to explore the SDH of MAs from diverse stakeholders’ perspectives. Methods This qualitative study comprised 17 focus group interviews with 99 participants (MAs, peers, parents, teachers, neighbors, and community leaders), conducted from June to September 2020. The directed content analysis was conducted using the Minority Health and Health Disparities Research Framework with a high rigor level based on the four criteria of Lincoln and Guba’s trustworthiness. Results The participants addressed SDH of MAs in five domains: biological (vulnerability and mechanism); behavioral (health behavior, family/school/peer functioning, and policies and laws); physical/built environment (school/community environment); sociocultural environment (MAs'/parental sociodemographic, language proficiency, MAs'/parental acculturation, social network, and response to/interpersonal/local/societal structural discrimination); and health care system (insurance coverage, MAs'/parental health literacy, availability of services, and health care policies). However, limited SDH in biological and physical/built environment domains were identified. Conclusions SDH in sociocultural environment domain and interpersonal influence level were the most commonly addressed. Interpersonal discrimination of both MAs and parents were found to be the most important SDH. These findings suggest that future programs to enhance MAs’ health may be targeted toward reducing discrimination and involving their parents. Key messages • Sociocultural environment was found to be the most salient SDH domain to affect MAs’ health. • SDH of MAs are linked to discrimination and their parents’ sociocultural aspects such as acculturation.

“COVID knocked me straight into the dirt”: perspectives from people experiencing homelessness on the impacts of the COVID-19 pandemic

BackgroundPeople experiencing homelessness are uniquely susceptible and disproportionately affected by the impacts of the COVID-19 pandemic. Understanding context-specific challenges, responses, and perspectives of people experiencing homelessness is essential to improving pandemic response and mitigating the long-term consequences of the pandemic on this vulnerable population.MethodsAs part of an ongoing community-based participatory research study in partnership with a homeless service organization in Indiana, semi-structured interviews were conducted with a total of 34 individuals experiencing homelessness between January and July 2021. Guided by the NIMHD Health Disparities Research Framework, which builds on the socio-ecological model, data was thematically coded using Nvivo12 qualitative coding software and themes were organized by levels of influence (individual, interpersonal, community, societal) and domains of influence (biological, behavioral, physical/built environment, sociocultural environment, health care system).ResultsNarratives revealed numerous and compounding factors affecting COVID-19 risks and health outcomes among people experiencing homelessness across all levels and domains of influence. At the individual level, people experiencing homelessness face unique challenges that heightened their susceptibility to COVID-19, including pre-existing physical and mental health conditions, substance use and behavioral health risks, socioeconomic precarity, and low health literacy and COVID-related knowledge. At the interpersonal level, poor communication between people experiencing homelessness and service providers led to limited understanding of and poor compliance with COVID safety measures. At the community level, closures and service disruptions restricted access to usual spaces and resources to meet basic needs. At a policy level, people experiencing homelessness were disregarded in ways that made pandemic relief resources largely inaccessible to them.ConclusionsOur findings reveal important and mitigable issues with ongoing pandemic response efforts in homeless populations through direct, first-hand accounts of their experiences during COVID-19. These insights offer opportunities for multilevel interventions to improve outreach, communication, and impact mitigation strategies for people experiencing homelessness. This study highlights the importance of centering the voices of vulnerable communities to inform future pandemic response for homeless and other underserved and marginalized populations.