1) 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?
When thinking about the disparities in contraceptive access, some structural barriers include…
A) Differential upfront costs to different contraceptive methods: This is less of a structural barrier now that the Affordable Care Act has provisions for coverage of contraceptive care in insurance plans. However, this is not uniform in available insurance plans to due to religious exceptions and with the threat of ACA repeal, contraceptive coverage as we currently have may become a things of the past. Prior to the ACA, contraception was covered to varying degree depending on individual plans. There is a vast upfront cost differential between long acting methods (intrauterine device), as compared to shorter-acting, daily methods (such as birth control pills). The cost of an IUD plus the cost of the insertion, without insurance coverage could be as high as $1500. This is obviously prohibitive for many. Thusly, women can be limited to in their choice of contraception based on their financial means. This is obviously true for the uninsured, but even true for some with insurance.
B) Limited medical education regarding sexual health and contraception/Implicit (and explicit) bias surrounding sexual and reproductive health: There is strong and pervasive societal mythology surrounding sexuality and contraceptive use. Some examples include, IUDs increase the risk of sexually transmitted diseases; contraceptive use in adolescents increase sexual activity and condom-less sexual activity; some racial groups are more sexually promiscuous than others. These myths are also believed, to varying degrees, in medical practitioners. Contraception and contraceptive counseling are often not taught in medical education, and when they are this teaching is very limited. This can lead to barriers of appropriate contraceptive counseling and access for women. Women who are historically disempowered (women of color, women with low SES, immigrants, etc) are more likely to be affected by provider biases.
C) Language barriers: Language discordance between physician and patient is common. This can often be compounded by differences in culture and social norms as it pertains to sexuality and contraception. This type of counseling can be complex, especially when done in a patient-centered manner. The use of interpreters, while often helpful, can be harmful if information is lost in translation. Additionally, the time limitations present in medicine can also lead to poor counseling when there is a language barrier since additional time is required for using an interpreter.
D) Barriers to accessing care: Some examples include limited clinic hours; limited ability of providers to counsel due to increasing proportion of Catholic affected health care systems; difficulty picking up birth control pill on monthly basis (due to prescription only being filled one month at a time); difficulty returning for injectable contraception every 3 months.
2) 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?
Health care providers can have implicit—and sometimes explicit—biases, as they are humans affected by their experiences. Several studies have been done to further understand how these biases impact differences in contraceptive use across groups of women. Specifically looking at race, Dr Dehlendorf did a study examining how provider perception of race and SES affects contraceptive method recommendation. She found that women of color and women with perceived lower SES, were more likely to be recommended long-acting reversible contraceptives (IUDs and implant). An educational intervention could be designed for providers, and then their contraceptive counseling encounters could be examined as compared to those who did not get the intervention (randomized).