1. How do individual physicians contribute to health care disparities? Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities, or to decrease this effect?
Clinicians can bring conscious and unconscious biases to a health care encounter with an individual patient or to larger public health problems. Ethnic or racial groups can be lumped together and stereotyped leading to presumptive judgement on how to best proceed with caring. These biases are complex and can be a result of training, poor understanding of health disparities or personal experience. As the readings from this week highlighted, these biases can contribute to poor health outcomes due to clinicians incorporating assumptions into diagnoses and treatment.
Discrimination and abuse during childbirth is a research area gaining traction over the past decade. In 2011, a seminal landscape analysis by Bowser and Hill (2011) on disrespect and abuse in facility-based childbirth catalyzed a wave of research on quality of care as a principal barrier for maternal health access (1). Consequently, the World Health Organization released a statement utilizing a human rights framework for the prevention and elimination of disrespect and abuse during facility-based childbirth. The bulk of the existing research focuses on the provider-patient relationship in terms of racism, cultural competency and human dignity during childbirth. An area I am particularly interested in is the effect of discrimination on health care utilization on prenatal care and childbirth in healthcare facilities for subsequent deliveries.
2) Structural issues within health care delivery are implicated in health care disparities. Please brainstorm 4 structural issues that might contribute to these disparities. Which of these are relevant to your particular area of research, and how?
1. Access to flexible resources: according to Link & Phelan (1995), an individual with greater resources such as money, power, prestige and social connections is able to avoid disease risks, have access to an array of medicines and treatment than those with less resources (2). For childbirth in low income settings like Guatemala, even public health facilities have fees for service that create barriers for women who do not have access to flexible resources and deliver without a skilled birth attendant.
2. Language Barriers: as highlighted in the article by Fernandez et al (2010) discordant language between patient and provider can lead to health disparities. Among indigenous women in Guatemala, many have limited Spanish proficiency and speak Mayan dialects. Often health clinics do not have interpretation services which can lead to non-consented care, barriers to utilization and discrimination during childbirth.
3. Geographic barriers: distance to a health facility affects screening and treatment options for many patients. This is particularly true during the prenatal care period when women need to interface with the health care systems ideally at least 3-4 times during pregnancy. This is complicated by rural residence, childcare and resources to travel to a facility located far from the family residence.
4. Cultural barriers: This is particularly relevant when considering the meaning of birth and how a facility can override those priorities for a family with application of a strict medical model. This can manifest in birth position, ritual and assistance during labor.
1. http://www.tractionproject.org/sites/default/files/Respectful_Care_at_Birth_9-20-101_Final.pdf
2. Phelan, J., Link, B., Tehranifar, P. (2010). Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and Plicy Implications. Journal of Health and Social Behavior 51(S) S28-S40.