1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).
The project that I am currently working on, the Patient Engagement Project (PEP), is an evaluation of an intervention delivered at four inpatient services, which included workshops, campaign messaging, report cards, and formative feedback to improve shared-decision making. Shared decision-making (SDM) is a process by which a patient and a physician make a medical decision together, incorporating patient values and the best clinical evidence. SDM has been associated with increased treatment adherence, lower health care expenditures, and decreased disease severity.
We measured SDM of patient encounters at each service using a standardized instrument before and after the intervention and collected demographic information of the patient including race, ethnicity, gender, admitting diagnosis, etc. and of the rounding team such as composition, size, etc. Currently, it is unknown whether or not disparities exist in shared-decision making so this research best fits the first generational framework. However, there have been other studies suggesting that physicians hold unconscious biases that discriminate against African Americans in terms of treatment decisions and perceived level of health literacy.
One can therefore hypothesize that similar disparities exist for shared-decision making. If physicians are less conversant with racial and ethnic minorities due to lower perceived health literacy and/or a desire to engage in the medical decision making process, then one would expect lower levels of SDM among certain minorities. As such, a second generation study could address why SDM differs by race and ethnicity. A third generation framework would involve an intervention addressing the causes of SDM disparities, such as physician training or awareness exercises. Finally, a fourth generation framework would incorporate a comprehensive, multilevel intervention at many levels of the socioecological model, utilize PHCR, self-reflection by the researcher, and a comprehensive evaluation.
2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Gottleib article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level.
Assuming that ethnic and racial disparities exist in shared-decision making, an intervention such as the one proposed by Gottleib may ameliorate these differences by providing equitable resources to all patients regardless of their race. The navigation intervention could overcome deficits in SDM by physicians by providing patients with the resources to understand their options and what their diagnoses mean. This is not sufficient, though, because many decisions are made by the provider and thus an after-the-fact discussion is not beneficial for the patient in all circumstances. Furthermore, this would not address the social determinants of health or social determinants of equity as Jones proposes.
To address social determinants of health, changes to the health care system and non-health systems such as education are necessary. In addition to educating physicians about their unconscious biases and how to approach shared decision-making, educational systems could teach patients of the value of engaging in their own health decisions, how to approach this discussion, and how to navigate the health system. Addressing social determinants of equality requires a broader intervention that will alter the policies, decision-making, values, practices, and norms of society. For instance, a policy that allocates funding to health systems based on their performance of shared decision-making could be an effective solution to SDM disparities.
3. Please respond to one other classmate's responses to this assignment – post this response as a separate post in the forum.
Please see response to Rebecca Plevin.