Addressing Health Disparities through Family Planning Education

Jody Steinauer, MD, MASChristine 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

2

Unintended Pregnancy Rates by Income and Race/Ethnicity, 2006-2008

3Finer 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

4

Finer et al. Contraception, 2011

19901991

19921993

19941995

19961997

19981999

20002001

20022003

20042005

20060

20

40

60

80

100

120

140

Teen Birth Rates 1990-2006

Latina

White

Black

Year

Rate

per

1,0

00

Kost K, et al, U.S. Teenage Pregnancies, Births and Abortions: 2010.

Abortion by Income and Race/Ethnicity, 2008

6Jones et al, Perspect Sex Repro Health 2011

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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

0%

20%

40%

60%

80%

100%

1973197519771979198119831985198719891991199319951997199920012003

White Nonwhite Black Other

Source: Guttmacher Institute

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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

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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*

<8 weeks 9-12 weeks >12 weeks0%

10%

20%

30%

40%

50%

60%

70%

BlackHispanicWhite

• Data does not include CA and 3 other states

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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

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As efforts to restrict abortion will have noeffect on [the underlying causes], and instead will only result in more womenexperiencing later abortions or having an unintended childbirth, they are likely toresult in worsening health disparities. We provide a review of the causes ofabortion disparities and argue for a multifaceted public health approach toaddress 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

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Unintended

Pregnancy

Sex

15

Contraception

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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

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• 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, 2008Trussell and Vaughan, 1999Ranjit, 2001

Disparities in Use of Methods

Unintended

Pregnancy

Sex

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Contraception

Economic, Social and Cultural Context

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Contextual Factors

• Access and payment for contraceptive methods• Differences in knowledge about contraceptive

methods

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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.

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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 1996Thorbun and Bogart, Women’s Health, 2005

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• 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, 2007Harrison, Obstet Gynecol 1988

Are there disparities in family planning care?

The “Patients”

The “Patients”

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Study Findings • Providers make different recommendations

to patients in different sociodemographic groups

• Low SES minority women are more likely to have the IUC recommended

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• 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

Are there disparities in family planning care?

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

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Health disparities

Access

Health care disparities

Social determinants

of health

Braveman, P. Ann Rev Pub Health. 2006 Institute of Medicine. Unequal Treatment. 2003

Racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.

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-revascularization-compared 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 patientsInstitute 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, slow-learning 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

Burgess, D. J Gen Intern Med 2004 Van Ryn, M. JAMA 2011

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/

https://implicit.harvard.edu/

Implicit Association Test

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, post-partum

• 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

Percentage of residents that encountered abortion-related restrictions which negatively affected patient services, by region

Ryan Residency Training Program– 68 Ob-gyn residency programs

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

• 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

Addressing Implicit Racial Bias

• 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

Effects of Implicit Bias Workshop

Teal, JGIM, 2010

• 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

Clinical Teaching: TEST model

Glick, JGIM, 2009

Empathy

• Empathy is associated with positive outcomes– Increased dx accuracy, pt. participation, compliance,

satisfaction, quality of life

Neumann, Acad Med, 2011; Shapiro, Phil Ethics Humanities, 2008.

Empathy

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

1. Krasner, JAMA, 2009; 2. Adams, AJOG, 2006; 3. Harris, Soc Science Med, 2011; 4. Learman, AJOG, 2008; 5. Blatt, Acad Med, 2010.

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.

Teaching and Learning Professionalism

Self-awareness

Quality Care and Communication

AcceptancePt. is in your care.

Empathy Compassion

Recognize feelings, judgments

Sympathetic consciousness of another’s distress

Understanding the experience and feelings of another

Teaching and Learning Professionalism

Self-awareness

Quality Care and Communication

Acceptance

Empathy Compassion

What upsets you about her having had many abortions?

Why would someone have three unintended pregnancies? What might be going on in her life?

Do you think she’s having a hard time? Can you feel for her?

How can you care for her professionally?

Does her race/ethnicity influence your feelings?

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.

CompassionEmpathy

“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.