Barriers to quality health care for the transgender population

The transgender community is arguably the most marginalized and underserved population in medicine. A special issue focusing on men's health would be incomplete without mention of this vulnerable population, which includes those transitioning to and from the male gender. Transgender patients face many barriers in their access to healthcare including historical stigmatization, both structural and financial barriers, and even a lack of healthcare provider experience in treating this unique population. Historical stigmatization fosters a reluctance to disclose gender identity, which can have dire consequences for long-term outcomes due to a lack of appropriate medical history including transition-related care. Even if a patient is willing to disclose their gender identity and transition history, structural barriers in current healthcare settings lack the mechanisms necessary to collect and track this information. Moreover, healthcare providers acknowledge that information is lacking regarding the unique needs and long-term outcomes for transgender patients, which contributes to the inability to provide appropriate care. All of these barriers must be recognized and addressed in order to elevate the quality of healthcare delivered to the transgender community to a level commensurate with the general population. Overcoming these barriers will require redefinition of our current system such that the care a patient receives is not exclusively linked to their sex but also considers gender identity.     

Transgender,Mental Health,and Older People: An Appreciative Approach Towards Working Together

It cannot be assumed by healthcare providers that transgender people routinely receive care and treatment that is of the quality and sensitivity that should be expected. In particular there are concerns from within the transgender community that they experience discrimination and disrespect from both individual practitioners and the healthcare system as a whole. This causes an avoidance of contact that is undesirable for both users and providers of healthcare services. Older transgender people are vulnerable to a range of mental health problems and, like all elderly, increasingly to dementia; failure to access specialist services in a timely manner may result in unnecessary distress and potentially to crisis. This paper reports on the use of an appreciative inquiry approach towards identifying the opportunities for one health board in North Wales to work more closely with older members of the transgender community it serves.     

Gender and Cardiovascular Disease Risk: Beyond the Binary

Transgender and gender-nonconforming people have a full spectrum of health needs, yet they face significant barriers to care and associated health disparities. Prevention and management of cardiovascular disease, a core function of primary care, is influenced by gender. Current evidence on epidemiology and mechanisms of cardiovascular disease risk in transgender and gender-nonconforming people is reviewed, clinical best practices are identified, and priorities to help nurse practitioners deliver high-quality care to these populations are outlined.     

Identifying priority actions for improving patient satisfaction with outpatient cancer care

In parallel to developing new cancer therapies, the healthcare community has the responsibility of creating positive treatment experiences for patients. Data from 5907 cancer outpatients treated at 23 hospitals across the United States were analyzed to identify the top priorities for service improvement in outpatient cancer treatment facilities. They included meeting patients' emotional needs, providing information to patients and family members, reducing waiting times, and providing convenience and coordinated care among physicians and other care providers.     

Integrative Medicine in Family Medicine Residency

Background

As specialists who care for families and communities, family physicians have a responsibility to respond to evolving views of healthcare among their patients. Americans are using complementary and alternative medicine (CAM) with increasing frequency and family physicians are well suited to becoming the guides for ensuring the safe and effective integration of conventional and complementary approaches to healthcare.

Methods

US National Institutes of Health National Centers for Complementary and Alternative Medicine funding was used to design, implement and evaluate an educational intervention for residents and faculty members in our family medicine residency programme at the Maine Medical Center (Portland, ME, USA). Key components of the project were a series of half-day workshops, faculty development and a resident curriculum. The resident curriculum includes experiences designed to address physician Wellness, communication with patients and coordination of care with community CAM providers. The project engaged community CAM practitioners as teachers and in patient care.

Results

Faculty members and residents reported an increase in knowledge and confidence in discussing and utilising CAM modalities. They reported improvement in their ability to find reliable information on CAM and a dramatic increase in level of comfort discussing CAM with patients.

Conclusions

Our experience suggests that family physicians are well suited to becoming patient guides for the safe and effective integration of conventional and complementary approaches to healthcare.     

Getting on Target with Community Health Advisors (GOTCHA): an innovative stroke prevention project

Health disparities along with insufficient numbers of healthcare providers and resources have created a need for effective and efficient grassroots approaches to improve community health. Community-based participatory research (CBPR), more specifically the utilization of community health advisors (CHAs), is one such strategy. The Getting on Target with Community Health Advisors (GOTCHA) project convened an interdisciplinary team to answer the call from 10 counties in the rural Mississippi Delta area of 'The Stroke Belt' to meet the region's identified health needs, and to impact the health of a disparaged state. This article explores this CBPR project including the community involvement strategies, innovative CHA training curriculum, evaluation plan, and implications to healthcare professionals, particularly nurses.     

Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years

Problem: Medical educators, clinicians, and health policy experts widely acknowledge the need to increase the diversity of our healthcare workforce and build our capacity to care for medically underserved populations and reduce health disparities. Intervention: The Program in Medical Education for the Urban Underserved (PRIME-US) is part of a family of programs across the University of California (UC) medical schools aiming to recruit and train physicians to care for underserved populations, expand the healthcare workforce to serve diverse populations, and promote health equity. PRIME-US selects medical students from diverse backgrounds who are committed to caring for underserved populations and provides a 5-year curriculum including a summer orientation, a longitudinal seminar series with community engagement and leadership-development activities, preclerkship clinical immersion in an underserved setting, a master's degree, and a capstone rotation in the final year of medical school. Context: This is a mixed-methods evaluation of the first 4 years of the PRIME-US at the UC Berkeley–UC San Francisco Joint Medical Program (JMP). From 2006 to 2010, focus groups were conducted each year with classes of JMP PRIME-US students, for a total of 11 focus groups; major themes were identified using content analysis. In addition, 4 yearly anonymous, online surveys of all JMP students, faculty and staff were conducted and analyzed. Outcome: Most PRIME-US students came from socioeconomically disadvantaged backgrounds and ethnic backgrounds underrepresented in medicine, and all were committed to caring for underserved populations. The PRIME-US students experienced many program benefits including peer support, professional role models and mentorship, and curricular enrichment activities that developed their knowledge, skills, and sustained commitment to care for underserved populations. Non-PRIME students, faculty, and staff also benefited from participating in PRIME-sponsored seminars and community-based activities. Challenges noted by PRIME-US students and non-PRIME students, faculty, and staff included the stress of additional workload, perceived inequities in student educational opportunities, and some negative comments from physicians in other specialties regarding primary care careers. Lessons Learned: Over the first 4 years of the program, PRIME-US students and non-PRIME students, faculty, and staff experienced educational benefits consistent with the intended program goals. Long-term evaluation is needed to examine the participants' medical careers and impacts on California's healthcare workforce and patient outcomes. Attention should also be paid to the challenges of implementing new medical education enrichment programs.     

Healthcare provider perceptions of the role of interprofessional care in access to and outcomes of primary care in an underserved area

To meet the needs of an aging population who often have multiple chronic conditions, interprofessional care is increasingly adopted by patient-centred medical homes and Accountable Care Organisations to improve patient care coordination and decrease costs in the United States, especially in underserved areas with primary care workforce shortages. In this cross-sectional survey across multiple clinical settings in an underserved area, healthcare providers perceived overall outcomes associated with interprofessional care teams as positive. This included healthcare providers’ beliefs that interprofessional care teams improved patient outcomes, increased clinic efficiency, and enhanced care coordination and patient follow-up. Teams with primary care physician available each day were perceived as better able to coordinate care and follow up with patients (p = .031), while teams that included clinical pharmacists were perceived as preventing medication-associated problems (p < .0001). Healthcare providers perceived the interprofessional care model as a useful strategy to improve various outcomes across different clinical settings in the context of a shortage of primary care physicians.     

Identifying community priorities for neighborhood livability: Engaging neighborhood residents to facilitate community assessment

Identifying community-driven priorities to improve health outcomes is crucial toward achieving health equity. Seldom are communities experiencing health disparities included in community health assessment (CHA) and health improvement planning efforts (Pennel, McLeroy, Burdine, Matarrita-Cascante, & Wang, 2017). The purpose of this project was to conduct a CHA using a socio-ecological framework and community engagement (CE) process. In this paper we describe an exemplar engaging local residents as community facilitators to assess indicators of neighborhood livability, challenges and lessons learned, and implications for public health and community/public health nursing. Community residents were trained to facilitate focus groups and participated in analyzing these data. Data analysis yielded five neighborhood livability indicators and priorities reflecting the social determinants of health. Engaging community residents as stakeholders in CHA and health improvement planning is critical for identifying structural factors affecting neighborhood livability and priorities to improve health and well-being. Public health and health care system partnerships employing inclusive CE practices are necessary to improve overall population health outcomes. Public health nursing's role as strategy and system leaders can contribute toward the success of these cross-sector partnerships with diverse communities and populations.     

Delivering Culturally Sensitive Care to LGBTQI Patients

Many health care providers are uncomfortable having conversations with patients about their sexual identity or sexual behaviors. Avoiding this discomfort is causing a serious threat to the mental and physical health of Americans, particularly those in the lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) community. The health-related disparities among LGBTQI patients range from bullying and physical assault to refusal of health care and housing. Many individuals choose not to seek health care due of fear of being judged, marginalized, or abused. This article focuses on the many disparities faced by the LGBTQI community and describes how simple changes in the practices of health care providers can potentially improve their health outcomes.     

Perspectives of women with disabilities on reaching those who are hard to reach.

Healthcare needs of women with disabilities are often neglected, even for women who are well connected to the community and to the healthcare system. So-called "hard-to-reach" women, whose degree of disability impedes use of community resources, have even greater difficulty obtaining health care. The purpose of this study was to gain insight into the perceptions of women with mobility and sensory limitations about several healthcare issues that may affect them: barriers to obtaining care, sources of information about health issues, ways to improve access to care, and ways to help hard-to-reach women overcome barriers to health care and health information. Researchers conducted six focus groups, comprising 43 women with limitations of mobility, hearing, or vision. To validate the women's input, researchers conducted two additional focus groups: the first comprised female physicians with special interest in the health care of women with disabilities, and the second included professional administrative staff of agencies that provide services for people with disabilities. In several cases, members of the physician and agency focus groups were themselves women with disabilities. In addition, 16 women with disabilities participated in an online survey; their responses were used to validate the findings of the face-to-face focus groups. Transcribed data were content analyzed and 10 themes identified. Seven of those themes are discussed in this article: communication barriers; lack of knowledge and awareness among healthcare providers; access issues; working the system; system issues; outreach to healthcare providers; and reaching hard-to-reach women. The findings of this study can provide direction to development of more effective outreach to hard-to-reach women with disabilities, resulting in better integration of healthcare services for this population.     

A Toolkit on Patient Centered Transgender Care for Nurse Practitioner Faculty and Clinicians

The purpose of the Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians is to improve clinical care and reduce health disparities by closing the gap in knowledge of nurse practitioner faculty and practicing clinicians by providing evidence-based information on caring for this population. Resources, vetted by practicing clinicians in the field of transgender care who are also nurse practitioner/certified nurse midwife faculty, are provided. Faculty and clinicians can use this multimedia information to create evidence-based learning modules for students or clinicians and modify clinical services to address the needs of transgender individuals and provide solutions to those needs.     

Primary Care Practice for Gender-Diverse Patients Using Gender-Affirming Hormone Therapy

Transgender and gender-diverse individuals face discrimination, bias, stigma, socioeconomic barriers, lack of knowledgeable, and/or supportive gender-affirming health care across the nation. Many primary care providers have not been educated about gender-affirming hormone therapy and the health care considerations using these necessary hormones for patients ≥16 years old. This review highlights basic gender-affirming hormone therapy management with monitoring parameters and some common primary care practice applications for transgender and gender-diverse patients. Evidence-based guidelines, resources, and advocacy links are provided and in alignment with the latest version of the World Professional Association for Transgender Health Standards of Care.     

Pain attitudes and knowledge among RNs, pharmacists, and physicians on an inpatient oncology service

Patients with cancer often experience pain, yet studies continue to document inadequate and inappropriate assessment and management of cancer-related pain. This study aimed to evaluate the attitudes and knowledge of inpatient oncology healthcare providers toward pain management by surveying nurses, pharmacists, and physicians working on the inpatient oncology units at an academic medical center. Healthcare providers generally reported positive attitudes toward pain management but were deficient in their knowledge of pain management. The authors suggest that pharmacists become more integral members of palliative care teams and actively participate in rounds. A need exists for educational programs in pain management for healthcare providers, especially for those who do not routinely care for patients with cancer.     

Compassion fatigue and satisfaction: A cross‐sectional survey among US healthcare workers

Professional quality of life among healthcare providers can impact the quality and safety of patient care. The purpose of this research was to investigate compassion satisfaction and compassion fatigue levels as measured by the Professional Quality of Life Scale self‐report instrument in a community hospital in the United States. A cross‐sectional survey study examined differences among 139 RNs, physicians, and nursing assistants. Relationships among individual and organizational variables were explored. Caregivers for critical patients scored significantly lower on the Professional Quality of Life subscale of burnout when compared with those working in a noncritical care unit. Linear regression results indicate that high sleep levels and employment in critical care areas are associated with less burnout. Identification of predictors can be used to design interventions that address modifiable risks.     

System and patient barriers to appropriate HIV care for disadvantaged populations: the HIV medical care provider perspective.

Little is known about the perception of system and patient barriers to adequate HIV care by an essential resource in the provision of HIV care, HIV medical care providers. To evaluate such perceptions, between November 2000 and June 2001 a survey was mailed to 526 HIV medical care providers who cared for HIV-infected individuals in Atlanta, Baltimore, Los Angeles, and Miami. Logistic regression analysis of survey results revealed significant differences in perceptions of system barriers between Black and Hispanic providers versus White providers and non-medical doctor providers versus medical doctor providers. Female providers differed significantly from male providers in assessing the importance of certain system and patient barriers. The authors observed that there are seeming disparities in perceptions of system and patient barriers to HIV medical care by providers of different race/ethnic groups, genders, and professions. More research needs to be conducted to determine if these disparities reflect differences in the provision of adequate HIV care for disadvantaged individuals.     

Is the Front Line Prepared for the Changing Faces of Patients? Predictors of Cross-Cultural Preparedness Among Clinical Nurses and Resident Physicians in Lausanne,Switzerland

Phenomenon: Assuring quality medical care for all persons requires that healthcare providers understand how sociocultural factors affect a patient's health beliefs/behaviors. Switzerland's changing demographics highlight the importance of provider cross-cultural preparedness for all patients—especially those at risk for social/health precarity. We evaluated healthcare provider cross-cultural preparedness for commonly encountered vulnerable patient profiles. Approach: A survey on cross-cultural care was mailed to Lausanne University hospital's “front-line healthcare providers”: clinical nurses and resident physicians at our institution. Preparedness items asked “How prepared do you feel to care for … ?” (referring to example patient profiles) on an ascending 5-point Likert scale. We examined proportions of “4 – well/5 – very well prepared” and the mean composite score for preparedness. We used linear regression to examine the adjusted effect of demographics, work context, cultural-competence training, and cross-cultural care problem awareness, on preparedness. Findings: Of 885 questionnaires, 368 (41.2%) were returned: 124 (33.6%) physicians and 244 (66.4%) nurses. Mean preparedness composite was 3.30 (SD = 0.70), with the lowest proportion of healthcare providers feeling prepared for patients “whose religious beliefs affect treatment” (22%). After adjustment, working in a sensitized department (β = 0.21, p = .01), training on the history/culture of a specific group (β = 0.25, p = .03), and awareness regarding (a) a lack of practical experience caring for diverse populations (β = 0.25, p = .004) and (b) inadequate cross-cultural training (β = 0.18, p = .04) were associated with higher preparedness. Speaking French as a dominant language and physician role (vs. nurse) were negatively associated with preparedness (β = ?0.26, p = .01; β = ?0.22, p = .01). Insights: The state of cross-cultural care preparedness among Lausanne's front-line healthcare providers leaves room for improvement. Our study points toward institutional strategies to improve preparedness: notably, making sure departments are sensitized to cross-cultural care resources and increasing provider diversity to reflect the changing Swiss demographic.     

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

ObjectivesTo report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.DesignThe review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.Data sourcesA search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.Review methodsThe review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.Results69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients’ control. Triadic streams of influence concurrently affect care engagement that include a person’s psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream’s influence on HIV care engagement varies at any given point to reflect an individual’s evolving and unique experiences with HIV infection throughout the illness trajectory.ConclusionThere is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.