Transcript Abortion Training at UCSF: The SFGH Model

Addressing Health Disparities
through Family Planning Education
Jody Steinauer, MD, MAS
Christine Dehlendorf, MD, MAS
Andrea Jackson, MD, MAS
Health Disparities
• Disparity: The condition or fact of being unequal
• Health disparity: Disparities in health outcomes
(with a caveat)
• Family planning disparities:
– Unintended pregnancy
– Abortion
– Unintended childbirth
Unintended Pregnancy Rates by Income and
Race/Ethnicity, 2006-2008
Finer et al. Contraception, 2011
Unintended Birth Rates by
Race/Ethnicity and SES
Demographics
Unintended Births per 1,000
Women
Educational Attainment
<HS graduate
46
HS graduate
30
Some college
19
College graduate
12
Race/Ethnicity
White
18
Black
37
Hispanic
45
Finer et al. Contraception, 2011
Teen Birth Rates 1990-2006
140
Rate per 1,000
120
100
Latina
80
White
60
Black
40
20
0
Year
Kost K, et al, U.S. Teenage Pregnancies,
Births and Abortions: 2010.
Abortion by Income and Race/Ethnicity,
2008
Jones et al, Perspect Sex Repro Health 2011
Disparities are Increasing
• In 2000, 27% of the abortions in the U.S. were to
poor women
• In 2008, poor women made up 42% of abortion
patients.
Jones RK, Finer LB, Singh S. Characteristics
of U.S. Abortion Patients, 2008.
New York, NY: Guttmacher Institute; 2010.
Percent of abortions provided to
whites has declined steadily
% of abortions
100%
80%
60%
40%
20%
0%
1973197519771979198119831985198719891991199319951997199920012003
White
Nonwhite
Black
Other
Source: Guttmacher Institute
What are the results of these
disparities?
• Unintended births associated with adverse
outcomes
– Poor infant and child outcomes
– Worse maternal mental health
– Lower education achievement for mothers
• Abortions are low risk, but still have consequences
– Health care costs
– Time off work
– Health consequences
• Overall, reproductive health disparities contribute
to cycle of disadvantage
More on Abortion Disparities
• Disparities in undesired pregnancies underlie
disparities in abortion….
• Therefore tendency to focus on prevention alone
– (Or, alternatively, to frame abortion as the problem)
• What about secondary prevention?
– Access to safe and timely abortion services
• Increasing challenges to accessing abortion
services affect disadvantaged women the most
Timing of Abortion:
Differences by Race/Ethnicity*
70%
60%
50%
40%
Black
30%
Hispanic
White
20%
10%
0%
<8 weeks
9-12 weeks
>12 weeks
•Data does not include CA and 3 other states
Can women truly make a choice?
• Women who wish to have an abortion may not be
able to have one
– Without public funding, 1/3 of Medicaid-eligible women in
North Carolina who would have preferred to have an
abortion carry their pregnancies to term
– More of an effect among Black women, young women, and
women with lower education
• Disadvantaged women may wish to continue a
pregnancy, but be financially unable to do so
As efforts to restrict abortion will have no
effect on [the underlying causes], and instead
will only result in more women
experiencing later abortions or having an
unintended childbirth, they are likely to
result in worsening health disparities. We
provide a review of the causes of
abortion disparities and argue for a
multifaceted public health approach to
address them. (Am J Public Health.
2013;103:1772–1779).
What are causes of disparities in
unintended pregnancies?
• Nuanced understanding of causes of disparities
are necessary to combat them
• What do you think?
– Discuss in groups of 2-4
Sex
Contraception
Unintended
Pregnancy
Abortion
Adverse
Outcomes
Unintended Birth
Adverse
Outcomes
Contraception Use
• Women at risk for unintended pregnancy not
using contraception
– By race/ethnicity
• 9% of Whites
• 9% of Hispanics
• 16% of Blacks
– By education
• 12% with <HS diploma
• 8% with Bachelor’s degree
• Disparities between whites and both blacks
and Hispanics in use of effective methods
– Varies by age and parity
Mosher, Natl Center Health Stat, 2011
Disparities in Use of Methods
• Efficacy of methods differ by race/ethnicity and
SES
– Across all methods, low-income and minority women
more likely to experience contraceptive failure
– Failure of condoms:
• 25% low-income vs. 9% high-income
• 24% Blacks vs. 12% whites
• Black and low-income women more likely to
discontinue methods
Vaughan et al, 2008
Trussell and Vaughan, 1999
Ranjit, 2001
Economic,
Social and
Cultural
Context
Sex
Contraception
Unintended
Pregnancy
Abortion
Adverse
Outcomes
Unintended Birth
Adverse
Outcomes
Contextual Factors
• Access and payment for contraceptive methods
• Differences in knowledge about contraceptive
methods
Contextual Factors
• Differences in opportunities and resources
– Life stressors associated with unintended pregnancy
– Difference in pregnancy ambivalence
• Contraceptive safety concerns more prevalent in
non-white communities
– Rooted in history of coercion and mistrust
• Difference in acceptability of the medical model of
information provision
• Racism and class discrimination
– Health care disparities: Disparities in the quality of health
care that are not due to access-related factors or clinical
needs, preferences or appropriateness of intervention.
Are there disparities in family planning
care?
• Phone survey of 1,800 women
– Minorities and women with lower education levels are
more likely to be report being dissatisfied with their
contraceptive method and their family planning
provider
• Survey of 500 Black women
– 67% reported race based discrimination when receiving
family planning care
Forrest and Frost, Fam Plann Perspect 1996
Thorbun and Bogart, Women’s Health, 2005
Are there disparities in family planning
care?
• Minority and low-income women are more likely
to report being pressured to use a birth control
method and limit their family size
• Providers are more likely to agree to sterilize
minority and poor women
Downing et al, AJPH, 2007
Harrison, Obstet Gynecol 1988
The “Patients”
The “Patients”
Study Findings
• Providers make different recommendations
to patients in different sociodemographic
groups
• Low SES minority women are more likely to
have the IUC recommended
Are there disparities in family planning
care?
• Lesser quality of care can contribute to
family planning disparities
• Differential pressure to control fertility,
specifically, can:
– Increase mistrust between patient and
provider
– Elicit resistance from patient, leading to
greater tendency to discontinue methods
Causes of family planning disparities
• Look beyond contraception use alone to
understand contextual factors
• Economic and structural inequalities are important
influences
– Health care disparities are an important area for
health care providers to be aware of
Health
disparities
Access
Health care
Racial or ethnic differences in the
quality of health care that are
disparities
not due to access-related factors or clinical needs, preferences,
and appropriateness of intervention.
Braveman, P. Ann Rev Pub Health. 2006
Institute of Medicine.
Unequal Treatment. 2003
Health care disparities in
cardiology
• Health disparity:
– Blacks have higher rates of cardiac disease,
including CAD
• Health care disparity:
– After adjusting for SES, disease severity,
comorbidities blacks were less likely to
receive standard of care-revascularizationcompared to whites1, 2
1. Popescu, I. JAMA 2007.
2. Ayanian, JZ. JAMA 1993.
Etiology of health care disparities
are complex
• Health care system factors
– Access
– Lack of interpreter services, health education
materials
– Difficult, confusing intake processes
• Patient level factors
– Patient trust in the medical system  delay in care
• Provider level factors
– Bias, prejudices and stereotyping when treating
minority patients
Institute of Medicine.
Unequal Treatment. 2003
Stereotyping is necessary and
unavoidable
• Stereotyping
– Fixed and oversimplified image or idea of a
particular type of person or thing
– Not necessarily negative
– Cognitive psychologist demonstrate it is
organize our complex world
– United States has a long history of racism that
makes racial and ethnic stereotyping
impossible to avoid
How do we use stereotyping in
medicine?
• Two learning and memory systems
• Slow learning
– Information is extracted and applied rapidly,
automatically and unconsciously implicit beliefs
• Fast binding
– Information is extracted and applied consciously and
deliberate
– When there is ample time to determine the answer
for a complex question explicit beliefs
• Which type of memory system do you think clinicians
most often use? And why?
How we naturally process
information contributes to unequal
care
• When we are tired, distracted, stressed or
under time pressure  automatic, slowlearning process are used to make decisions
• These conditions are typical of many clinical
settings
• Regardless of intention or motivation we all
fall prey to using automatic cognitions
(stereotypes)
Burgess, D. J Gen Intern Med 2004
Our conscious beliefs are
inconsistent with our unconscious
behavior
• Implicit vs. explicit cognition
– Study of white Americans
• When asked directly about bias-deny it (explicit)
• Emotions such as fear or distrust as well as behavioral
expectations-hostility and aggression (implicit)
• Implicit bias
– Positive or negative mental attitude towards a
person, thing or group that a person holds at an
unconscious level
Van Ryn, M. JAMA 2011
Burgess, D. J Gen Intern Med 2004
Implicit associations can be
measured
• Implicit association test (IAT)
– Computer based
– Various areas
• Race, substance abuse, mental health, sexual
orientation
– Done rapidly so that your slow-learning
(unconscious) decision making is in play
• 10 minutes or less
• https://implicit.harvard.edu/
Implicit Association Test
https://implicit.harvard.edu/
Implicit bias results in unequal care
• Implicit attitudes affect verbal communication and
non-verbal behavior (eye contact, indicators of
friendliness)
– When verbal and non-verbal do not match, patients
rely on non-verbal, believing verbal was not sincere
– Physicians whom implicitly favored whites over blacks
were more likely to have:
• Less patient-centered communication
• More negative tone during the visit
• Poorer ratings of care by black patients
Van Ryn, M. JAMA 2011
Burgess, D. J Gen Intern Med 2004
Implicit bias in family planning
• Young woman, postpartum
• My desire to give her
“highly effective”
contraception
• Her concern: autonomy
• Did I not trust her?
Research question
Does provider trust in patient vary by
patient race and ethnicity in family
planning clinical encounter?
How can we inspire learners to
eliminate health disparities?
Teaching about Health Disparities
• Integrated into curriculum
• Specific rotations in clinical sites with poor or
marginalized patients
– Jail clinic
– Abortion clinic
• Reflect on our role in health care disparities
– Face implicit bias and stereotyping
– Communication, empathy, professionalism
Teaching about Disparities in an
Abortion Clinic
Ryan Residency Training Program
– 68 Ob-gyn residency programs
Percentage of residents that encountered abortion-related
restrictions which negatively affected patient services, by region
Addressing Implicit Racial Bias
• Focus on individual qualities
– Individuation v. categorization
• Enhance individual motivation
– IAT/ what would/should I do?
• Open discussion of stereotypes
• Improve confidence in interacting with
dissimilar group
• Empathy – perspective-taking
• Partnership building with patients Burgess, JGIM, 2004
Addressing Implicit Racial Bias
• Cultural Competence Training
– Reserve categorization until necessary
– Must include learning about stereotyping/ prejudice
• Implicit Bias – small group workshop using IAT
– Conscious investment in social justice
– Identifying common identities
– Counter-stereotyping
– Perspective taking
» Appreciating experience of stigmatized
group decreases stereotypes
Stone, Med Educ, 2011
Effects of Implicit Bias Workshop
• Workshop using Implicit Attitude Test
• Facilitated small group discussion
– Discussion
» Reactions, clinical experiences, and strategies
– Noted differences after sessions in strategies
» Focus on recognition of bias
» Shift from self-reliance to talking with others
» Consider possible bias before seeing patient
Teal, JGIM, 2010
Clinical Teaching: TEST model
• Diagnose learner, teach rapidly, give feedback
• Use actual cases to teach principles
– A 25 year-old Latina woman needing pregnancy
options counseling
» “We don’t need an interpreter – her husband is
translating.”
– A 30 year-old Black woman with 4 children
» “I can’t convince her to use an IUD”
– A 20 year-old woman who was not using
patch correctly when became pregnant
» Low health literacy
Glick, JGIM, 2009
Empathy
• Empathy is associated with positive outcomes
– Increased dx accuracy, pt. participation,
compliance, satisfaction, quality of life
Empathy
Neumann, Acad Med, 2011; Shapiro, Phil Ethics Humanities, 2008.
Empathy Decline
• Empathy is associated with positive outcomes
– Increased dx accuracy, pt. participation,
compliance, satisfaction, quality of life
• Empathy decreases in clinical students and
residents – patient care
– Increased vulnerability, distance themselves
– Increased responsibility
– Increased burnout
– Increasingly think of patients as “other”
Neumann, Acad Med, 2011; Shapiro, Phil Ethics Humanities, 2008.
Empathy
Strategies to Teach Empathy
• Mindfulness-based Stress Reduction1
• Balint groups,2 support groups,3 self-awareness
training
• Reflection4 and narratives
• Home visits, service programs
• Perspective-taking5 by medical students – RCT of
intervention increased standardized patient scores
Recall a recent patient interaction. Put yourself in his/her
position and think about how you would feel. Write down your
feelings. When you see this patient engage in the same process.
1. Krasner, JAMA, 2009; 2. Adams, AJOG, 2006; 3. Harris, Soc Science Med, 2011; 4. Learman,
AJOG, 2008; 5. Blatt, Acad Med, 2010.
Teaching and Learning Professionalism
Self-awareness
Recognize feelings,
judgments
Understanding the
experience and
feelings of another
Empathy
Acceptance
Compassion
Sympathetic
consciousness of
another’s distress
Pt. is in your care.
Quality Care and Communication
Teaching and Learning Professionalism
Self-awareness
Why would someone have three
unintended pregnancies? What
might be going on in her life?
Empathy
What upsets you about
her having had many
abortions?
Does her race/ethnicity
influence your feelings?
Compassion
Do you think she’s having a hard
time? Can you feel for her?
Acceptance
How can you care for
her professionally?
Quality Care and Communication
What happens when ob-gyn residents uncomfortable with
abortion go to abortion clinic?
• Quantitative study (n=65)
– Highly-valued rotation
– Significant experience with u/s, counseling,
pre- and postoperative care, miscarriage
management
– Wide spectrum of partial participation
• Qualitative study (n=26)
– More empathy for patients and providers
Steinauer, et al. Contraception. In press.
Self-awareness
Empathy
Compassion
“My eyes were opened to people’s situations. You know, the
more people you see, the more situations you understand,
the more empathy that you can start to feel
for these folks that are placed in often times very hard situations.
And so I think that’s probably one of the greatest things that I
came away with.”
- 33 year old male resident from the Midwest
Conclusions
• Working to reduce and eliminate health
disparities is critical.
• Facing our role in health care disparities is also
critical – requires reflection, discussing
stereotypes, commitment to social justice,
perspective-taking, finding common ground
and seeing each patient as an individual.