1. Addressing Health Disparities through Family Planning Education Jody Steinauer, MD, MAS Christine Dehlendorf, MD, MAS Andrea Jackson, MD, MAS

2. 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

3. Unintended Pregnancy Rates by Income and Race/Ethnicity, 2006-2008 3 Finer et al. Contraception, 2011

4. Unintended Birth Rates by Race/Ethnicity and SES DemographicsUnintended Births per 1,000 Women Educational Attainment <HS graduate46 HS graduate30 Some college19 College graduate12 Race/Ethnicity White18 Black37 Hispanic45 4 Finer et al. Contraception, 2011

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

6. Abortion by Income and Race/Ethnicity, 2008 6 Jones et al, Perspect Sex Repro Health 2011

7. 7 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.

8. Percent of abortions provided to whites has declined steadily Source: Guttmacher Institute

9. 9 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

10. 10 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

11. Timing of Abortion: Differences by Race/Ethnicity* Data does not include CA and 3 other states

12. 12 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

13. 13 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).

14. 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 14

15. Unintended Pregnancy Sex Unintended Birth Adverse Outcomes Abortion Adverse Outcomes 15 Contraception

16. 16 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

17. 17 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 Disparities in Use of Methods

18. Unintended Pregnancy Sex Unintended Birth Adverse Outcomes Abortion Adverse Outcomes 18 Contraception Economic, Social and Cultural Context

19. 19 Contextual Factors Access and payment for contraceptive methods Differences in knowledge about contraceptive methods

20. 20 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.

21. 21 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

22. 22 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 Are there disparities in family planning care?

23. The “Patients”

25. 25 Study Findings Providers make different recommendations to patients in different sociodemographic groups Low SES minority women are more likely to have the IUC recommended

26. 26 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?

27. 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 27

29. 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.

30. 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 whites 1, 2 1.Popescu, I. JAMA 2007. 2.Ayanian, JZ. JAMA 1993.

31. 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

32. 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

33. 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?

34. 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

35. 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

36. 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/

37. Implicit Association Test

38. 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 2011Burgess, D. J Gen Intern Med 2004

39. 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?

40. Research question Does provider trust in patient vary by patient race and ethnicity in family planning clinical encounter?

41. How can we inspire learners to eliminate health disparities?

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. Strategies to Teach Empathy Mindfulness-based Stress Reduction 1 Balint groups, 2 support groups, 3 self-awareness training Reflection 4 and narratives Home visits, service programs Perspective-taking 5 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.

51. Teaching and Learning Professionalism Self-awareness Quality Care and Communication Acceptance Pt. is in your care. Empathy Compassion Recognize feelings, judgments Sympathetic consciousness of another’s distress Understanding the experience and feelings of another

52. 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?

53. 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.

54. Self-awareness 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

55. 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.