Search

This study examines the association between perceived discrimination and underutilization of needed medical and mental health care, in a representative, multi-ethnic community sample. Data were derived from a cross sectional survey of 10,098 White, U.S.-born Black, African-born Black, American Indian, Hispanic, and Southeast Asian adults in Hennepin County, Minnesota. Even after controlling for socio-demographic characteristics, health care access, and physical and mental health, perceived discrimination was associated with underutilization of medical care among Whites, U.S.-born Blacks, and American Indians and was associated with underutilization of mental health care among Whites, U.S.-born Blacks, Southeast Asians, and American Indians. Correlates of different types of discrimination (major, everyday, health care) on underutilization of care varied among ethnic groups. The higher prevalence of discrimination among racial and ethnic minorities may contribute to their underutilization of health care services. Future research is needed to understand the impacts of different types of discrimination on different groups.

Objective. The purpose of this qualitative analysis is to increase our understanding of minority smokers' experiences and beliefs about guideline-recommended smoking cessation treatments. Methods. We conducted sixteen focus groups ( N = 95) among current and former smokers from four ethnic minority communities in Minneapolis/St. Paul in 2005. Focus groups were conducted separately for American Indians, Vietnamese, Hmong and African Americans. Results. Participants reported little experience with counseling and views on seeking help from physicians were mixed. African American and American Indian participants expressed feelings of mistrust and negative experiences with doctors. Hmong and Vietnamese smokers viewed doctors positively but did not regard them as an important resource to help with quitting, and especially for Vietnamese, the cultural value of mental control and self-determination was seen as most important to quit smoking. Across all the groups, pharmacotherapy was rarely utilized and participants had low knowledge and poor understanding of the benefits of pharmacotherapy. Conclusions. Personal beliefs, views toward doctors, and lack of knowledge are important determinants of the use of tobacco treatments among ethnic minority smokers. In order to increase minority smokers' utilization of evidence-based tobacco cessation treatments, effective strategies are needed to deliver accurate information about treatment from trusted sources.

Objective Physician knowledge of the complex contributors to obesity varies. We do not know whether today’s medical students are graduating with deep understanding of the causes of obesity. Our objective was to assess beliefs about causes of obesity in a national sample of 4th year medical students. Method We randomly selected 2000 4th year students from a random sample of 50 U.S. medical schools and asked them to rate the importance of several factors as causes of obesity. Of those invited, 1244 (62%) responded. We conducted latent class analysis to identify groups with similar response patterns. Results Most students demonstrated knowledge that obesity has multiple contributors. Students fell into 1 of 4 classes: (1) more likely to endorse all contributors (28%), (2) more likely to endorse physiological contributors (27%), (3) more likely to endorse behavioral or social contributors (24%), and (4) unlikely to endorse contributors outside of overeating and physical activity (22%). Conclusion Though students were generally aware of multiple causes, there were 4 distinct patterns of beliefs, with implications for patient care. Practice implications Targeted interventions may help to improve depth of knowledge about the causes of obesity and lead to more effective care for obese patients.

Objectives. A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery. Methods. Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery. Results. Race significantly influenced physician recommendations among male, but not female, patients. Physicians’ perceptions of patients’ education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations. Conclusions. Our findings point to the importance of research and intervention strategies addressing the ways in which providers’ beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.

Although intrafirm knowledge transfer is linked with higher productivity and organizational survival, information sharing across units remains a challenge. Using qualitative and quantitative method...

This paper applies social cognition research to understanding and ameliorating the provider contribution to racial/ethnic disparities in health care. We discuss how fundamental cognitive mechanisms such as automatic, unconscious processes (e.g., stereotyping) can help explain provider bias. Even well-intentioned providers who are motivated to be nonprejudiced may stereotype racial/ethnic minority members, particularly under conditions of that diminish cognitive capacity. These conditions-time pressure, fatigue, and information overload-are frequently found in health care settings. We conclude with implications of the social-cognitive perspective for developing interventions to reduce provider bias.

Improving health outcomes for racial and ethnic minorities in the United States has been a national priority since the Institute of Medicine identified equity as one of the six areas of priority focus for improving health care quality in the United States.1Finding Answers: Disparities Research for Change is a national program funded by the Robert Wood Johnson Foundation that seeks to facilitate efforts to improve health care equity in part by conducting and disseminating systematic reviews of the literature on effective strategies for reducing disparities.2 This issue of JGIM features five systematic reviews, conducted by the Findings Answers program, which summarize the published literature on interventions aimed at reducing disparities in asthma, human immunodeficiency virus (HIV), colorectal cancer, prostate cancer and cervical cancer. Reading these reviews, one is heartened by the progress that has been made in the decade since the Institute of Medicine report was released. Yet, it is striking that, while the Finding Answers initiative is explicitly aimed at reducing racial and ethnic disparities in care, only a few of the 178 intervention studies included in the five systematic reviews published in this issue actually examined reduction in disparities as an outcome measure. The vast majority of interventions focused on improvement in processes or outcomes of care for members of minority groups, rather than reductions in disparities; a point noted by the authors of the systematic reviews, and consistent with the findings of other systematic reviews of disparities interventions.3 The distinction between the goals of “reducing health disparities” and “improving minority health” is rarely explicitly addressed in published studies, but has important implications for healthcare organizations as they choose and implement interventions, as we describe below.

Objectives. We examined whether a proactive care smoking cessation intervention designed to overcome barriers to treatment would be especially effective at increasing cessation among African Americans receiving care in the Veterans Health Administration. Methods. We analyzed data from a randomized controlled trial, the Veterans Victory over Tobacco study, involving a population-based electronic registry of current smokers (702 African Americans, 1569 Whites) and assessed 6-month prolonged smoking abstinence at 1 year via a follow-up survey of all current smokers. We also examined candidate risk adjustors for the race effect on smoking abstinence. Results. The interaction between patient race and intervention condition (proactive care vs usual care) was not significant. Overall, African Americans had higher quit rates than Whites (13% vs 9%; P Conclusions. African Americans quit at higher rates than Whites. These findings may be a result of the large number of veterans receiving smoking cessation services and the lack of racial differences in receipt of these services as well as racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans.

Background Southeast Asian communities in the United States have suffered from high rates of tobacco use and high rates of chronic diseases associated with firsthand and secondhand smoking. Research is needed on how best to reduce and prevent tobacco use and exposure to secondhand smoke in these communities. The objective of this study was to examine how tobacco use patterns in Minnesota’s Southeast Asian communities have been shaped by culture, immigration, and adjustment to life in America in order to inform future tobacco control strategies. Methods The study consisted of semi-structured interviews with 60 formal and informal leaders from Minnesota’s Hmong, Khmer (Cambodian), Lao, and Vietnamese communities and incorporated principles of community-based participatory research. Results Among Khmer, Lao and Vietnamese, tobacco in the homeland was a valued part of material culture and was used to signify social status, convey respect, and support social rituals among adult men (the only group for whom smoking was acceptable). Among the Hmong, regular consumption of tobacco was unacceptable and rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. In Minnesota, social norms have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, smoking functioned to reduce the stress of social isolation, economic hardship, prior trauma, and the loss of power and status. Youth and younger women no longer felt as constrained by culturally-rooted social prohibitions to smoke. Conclusions Leaders from Minnesota’s Southeast Asian communities perceived key changes in tobacco-related attitudes, beliefs, and behaviors which were embedded in the context of shifting power, status, and gender roles within their communities. This has practical implications for developing policy and interventions. Older Southeast Asians are likely to benefit from culturally-tailored programs (e.g., that value politeness and the importance of acting in ways that benefit the family, community, and clan) and programs that work with existing social structures, as well as initiatives that address smokers’ psychological distress and social isolation. Leaders remained uncertain about how to address smoking uptake among youth, pointing to a need for additional research.

Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians' behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians' behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.

Two studies examined the influence of plan quality on participants' postplanning affective self-reports. Most Study 1 participants reported positive affect after planning for self-change; such positive reports were more prominent among those who constructed vague, unstructured plans than among those who constructed detailed, structured plans. Experimental Study 2 demonstrated that the relation between plan quality and consequent affect is mediated in part by planners' perceptions of imminent goal attainment, that poor planning confers the benefit of energization, and that good planning confers the affective liability of anxiety and agitation. Results of both studies suggest that the act of constructing a vague self-change plan provides immediate affective and cognitive benefits. Thus, plan construction can be a reinforcing activity, in and of itself.

We examined a nationwide effort to encourage young adults to vote in the 1996 U.S. presidential election. During the year before the election, individuals were given the chance to sign and self-address one of two kinds of postcards pledging to vote; these cards were mailed back to the individuals within 2 weeks prior to the election. It is important to note that some individuals completed pledge cards that prompted them to provide their own reason for voting by completing the sentence, "I will vote because ______," whereas other individuals completed pledge cards that did not contain this sentence prompt. We conducted a large-scale survey of individuals who filled out pledge cards and determined that receiving a pledge card with the sentence prompt had a positive influence on voting. Moreover, this effect was found above and beyond demographic and psychological predictors of voting. Implications of these findings are discussed.

The authors examined whether the influence of persuasive messages emphasizing reward versus threat was moderated by authoritarianism. Five days before the 1996 presidential election, participants (N = 86) received either a reward-related message (emphasizing the positive benefits of voting) or a threatrelated message (emphasizing the negative consequences of failing to vote) recommending that they vote in the election. We found that high authoritarians perceived the threat message as stronger in argument quality than the reward message, and low authoritarians perceived the reward message as stronger in argument quality than the threat message. In turn, subjective perceptions of message quality exerted a direct influence on participants’ postmessage attitudes toward voting in the election. Finally, behavioral intentions mediated the influence of voting attitudes on actual voting behavior. Discussion focuses on the implications of the message frame and authoritarianism.

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, one's own psychological or physiological state, as well as from demands inherent in the task at hand.Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design.Ninety-eight primary care physicians from the Veterans Affairs Healthcare System.Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure.There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%).Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment.

A refined model of sex-role spillover theory (SRST), which posits a role for gender subtypes and harasser motivations in understanding perceptions of sexual harassment, is tested. Fifty male and 61 female undergraduates were asked to assess female targets on stereotypic characteristics, and to make attributions of harasser motivations for six scenarios describing three types of harassment (unwanted sexual attention, gender harassment, sexual coercion) at two levels of severity (nonphysical and physical) toward women in two different types of occupations (traditional and nontraditional). As predicted, scenarios about traditionally and nontraditionally employed female targets elicited different gender subtypes and different attributions of harasser motivations, depending on the type of sexual harassment experienced. Theoretical implications of this research are discussed.

This experimental study examined the ways in which knowledge of a woman's occupation type influenced how different types of sexual harassment were perceived. A total of 53 male and 58 female undergraduates were asked to evaluate six scenarios describing three types of harassment (unwanted sexual attention, gender harassment, and sexual coercion) at two levels of severity (nonphysical and physical) toward women in two different types of occupations (traditional and nontraditional). The results indicated that participants were less likely to perceive incidents of sexual coercion as harassing when a woman is in a nontraditional occupation. The results also provided evidence of a perceptual gap between men and women for incidents of unwanted sexual attention and gender harassment but not for incidents of sexual coercion. Results provide support for the sex-role spillover model of sexual harassment proposed by Gutek. Theoretical and legal implications of this research are discussed.

This study assessed whether postal follow-up to a web-based physician survey improves response rates, response quality, and representativeness. We recruited primary care and gastroenterology chiefs at 125 Veterans Affairs medical facilities to complete a 10-min web-based survey on colorectal cancer screening and diagnostic practices in 2010. We compared response rates, response errors, and representativeness in the primary care and gastroenterology samples before and after adding postal follow-up. Adding postal follow-up increased response rates by 20–25 percentage points; markedly greater increases than predicted from a third e-mail reminder. In the gastroenterology sample, the mean number of response errors made by web responders (0.25) was significantly smaller than the mean number made by postal responders (2.18), and web responders provided significantly longer responses to open-ended questions. There were no significant differences in these outcomes in the primary care sample. Adequate representativeness was achieved before postal follow-up in both samples, as indicated by the lack of significant differences between web responders and the recruitment population on facility characteristics. We conclude adding postal follow-up to this web-based physician leader survey improved response rates but not response quality or representativeness.

There is evidence that Black patients may experience stereotype threat--apprehension about being negatively stereotyped--in healthcare settings, which might adversely affect their behavior in clinical encounters. Recent studies conducted outside of healthcare have shown that a brief self-affirmation intervention, in which individuals are asked to focus on and affirm their valued characteristics and sources of personal pride, can reduce the negative effects of stereotype threat on academic performance and on interpersonal communication.This randomised controlled trial examined whether a self-affirmation (SA) intervention would decrease the negative effects of stereotype threat (negative mood, lower state self-esteem, greater perceptions of racial discrimination) and increase communication self-efficacy among Black primary care patients. Self-affirmation was induced by having patients complete a 32-item values affirmation questionnaire.Patients in the SA condition had lower levels of performance self-esteem and social self-esteem than patients in the control. There were no differences between the SA and the control groups on negative mood, communication self-efficacy, and perceptions of discrimination.Our SA intervention lowered state self-esteem among Black patients. Future research is needed to determine the type of SA task that is most effective for this population.

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

“I n contrast to patients’ trust in clinicians, clinicians’ trust in patients has not been investigated.” So write Moskowitz et al., whose study, published in this issue of JGIM is the first to show that primary care providers’ trust in their patients (indigent patients with HIV who were part of a longitudinal study of pain) was lower for non-whites than whites, despite the fact that there were no actual racial differences in patient characteristics that might be expected to affect trust, such as patients’ self-reported illicit drug use and misuse of opioids. Trust in this study was assessed using a scale that asked providers to indicate how confident they were that the patient would engage in various behaviors indicating that the patient could be trusted (e.g., “will not manipulate the office visit for secondary gain” such as “inappropriate disability certification or prescription of controlled substances”; “will follow the treatment plan you recommend.”) Notably, in multivariate analyses, non-white race was the largest predictor of provider mistrust, followed by providers’ number of years in practice and patients’ current drug use, while patients’ reports of opioid analgesic misuse and lifetime alcohol abuse/ dependencewere not significant predictors. These results are troubling because lower levels of provider trust in their non-white patients with pain may contribute to racial disparities in pain treatment, particularly where opioid analgesics are concerned, since opioids require a certain amount of trust by physicians that the patient will not divert or abuse the prescription. Such racial disparities in pain treatment, in turn, may contribute to the greater prevalence of pain and greater functional impairments due to pain experienced by racial minorities, compared to whites. Although disturbing, the finding that non-white race was associated with lower levels of provider trust is not surprising, as it is consistent with numerous studies showing that many individuals in the United States, including healthcare providers, manifest a pro-white bias, at the conscious and unconscious level. In fact, the existence of racial bias among healthcare providers and its role as a potential contributor to racial healthcare disparities were discussed in the seminal Institute of Medicine report, Unequal Treatment, published in 2003. What is surprising, though, is that the Moskowitz et al. study, published in 2011, is the first to examine the effect of patient race on clinicians’ trust, in contrast to the many published studies examining patient trust. This imbalance underscores what is arguably the dominant way in which the problem of racial healthcare disparities is framed, in which the focus is on identifying and addressing the characteristics of racial minority patients, rather than the characteristics of providers, that contribute to disparities. The prevailing tendency to frame racial healthcare disparities in terms of patient race rather than providers’ racial stereotypes and biases is reflected in the prevailing training approaches aimed at improving the care of racial minority patients. Although it was almost a decade ago that Unequal Treatment recommended that providers receive training to understand and address ways in which they may unintentionally contribute to racial healthcare disparities, there are few programs aimed at helping providers overcome their own racerelated beliefs and stereotypes (such as the belief that white patients are more trustworthy than nonwhite patients), that contribute to racially disparate care. By contrast, the most popular training approach for reducing racial healthcare disparities focuses on improving providers’ “cultural competency,” defined as “the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences by recognizing the importance of social and cultural influences on patients.” Although some cultural competency programs do address issues of provider bias, the primary focus is on characteristics of the patient.” It is noteworthy that the number of cultural competency training programs is growing, despite the fact that there is a lack of evidence that cultural competency training reduces racial/ethnic healthcare disparities. This dominant framing of disparities is also consistent with the views of many providers, who believe that disparities are due mainly to patient factors rather than provider factors. For example, in a study of primary care clinicians by Sequist et al. published in JGIM in 2008, among the 52% who reported that racial disparities in the quality of diabetes care existed in their own health care system, less than 10% attributed these disparities to provider differences in prescribing medications and differences in referral to specialists and about 20% attributed disparities to providers’ miscommunication with patients. By contrast, about 40% attributed disparities to patient preferences; 45% to patient attitudes and beliefs about the provider; and over 70% to patient health behaviors. Presently there is a commitment by a number of researchers and educators to shift the focus away from patient race, as a cause of racial healthcare disparities, to provider-level and system-level factors. The National Institutes of Health and the National Cancer Institute, for instance, recently sponsored a Published online Ju , 2011

Background Family caregivers of individuals with stigmatized conditions can experience stigma-by-association and discrimination. Moderate-to-severe traumatic brain injury (TBI) may elicit a stigma response if there are visible physical or neurobehavioral effects of the injury. Stigma is a considerable source of stress and may contribute to caregiver strain and stress-related mental health outcomes. We measured the frequency of perceived stigma and discrimination among caregivers of veterans with TBI and examined whether perceived stigma and discrimination are associated with caregiver strain, social isolation, depression, and anxiety. Methods Seventy caregivers of veterans with TBI completed a mailed survey that assessed perceptions of discrimination toward themselves or their care recipient, stigma associated with caregiving, and whether they felt the need to cover up or provide an explanation for their care recipient’s injury. Caregiver strain, social isolation, depression, and anxiety were also assessed via the questionnaire. Multivariate linear regression was used to test the associations between stigma and discrimination measures and outcomes, controlling for potential confounders and other caregiver or care recipient characteristics. Results Both perceptions of caregiver discrimination and stigma associated with caregiving were significantly associated with caregiver strain, social isolation, depression, and anxiety. Perceived discrimination against the individual with TBI was associated with caregiver strain and social isolation. Conclusions Our findings suggest that perceived discrimination and stigma experienced by caregivers of individuals with TBI are stressors that may lead to poor caregiver mental health outcomes. In order to promote both caregiver and care recipient health, we suggest that mental health support services consider these important stressors.

The prevalence of cigarette smoking is particularly high among American Indian communities in the Upper Midwest.To evaluate the predictors of smoking cessation among a population-based sample of American Indians in the Upper Midwest during a quit attempt aided with nicotine replacement therapy (NRT).This study used the subsample of American Indian adults (n = 291, response rate = 55.4%) from a cohort study of smokers engaging in an aided NRT quit attempt. Eligible participants filled an NRT prescription between July 2005 and September 2006 through the Minnesota Health Care Programs (e.g., Medicaid). Administrative records and follow-up survey data were used to assess outcomes approximately 8 months after the NRT fill date. This analysis was conducted in 2009-2010.Approximately 33% of American Indian respondents trying to quit smoking reported complete home smoking bans. Adoption of a complete home smoking ban and greater perceived advantages of NRT were cross-sectionally associated with 7-day smoking abstinence in univariate and multivariate analyses. Consistent with previous research, older age was a significant predictor of 7-day abstinence. Having a history of clinician-diagnosed anxiety in the past year was associated with decreased likelihood of 7-day abstinence in the unadjusted analysis, but not significant in multivariate analyses.Results of this study suggest potential modifiable targets of interventions for future research to help American Indians quit smoking: (1) improved delivery of behavioral interventions to increase the intensity of smoking cessation treatment; (2) promotion and adoption of complete home smoking bans; and (3) education to increase awareness of the benefits of NRT.

Racial inequality in medical treatment is a problem whose sources are not fully understood. To gain better insight into how race may affect treatment, semi-structured interviews were conducted with 26 doctors and nurses. Using an open coding scheme, the explanations of racial inequality in treatment were coded by two people. Four major categories of responses emerged to explain why Black patients are less likely to receive the same levels of medical care as Whites: access to care, physician bias, Black patients' perceived shortcomings, and White patients' demands. Interviewees commonly cited access and patient factors before naming physician bias. The majority questioned the validity of studies reporting disparities. Educational campaigns should emphasize evidence that racial disparities persist even after controlling for factors such as insurance and patient characteristics. Educational programs should also address subconscious racial bias and how it may operate in a clinical setting.

We examined the interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer (CRC) screening adherence.In this study, 2,416 average risk patients aged 50-75 from 24 Veterans Affairs medical facilities responded to a mailed survey with phone follow-up (response rate 81%). Survey data (attitudes, behaviors, demographics) were linked to facility (organizational complexity) and medical records data (diagnoses, screening history). Patients with a fecal occult blood test within 15 months, sigmoidoscopy or barium enema within 5.5 years, or colonoscopy within 11 years of the survey were considered adherent. Logistic regressions estimated the association between adherence and background, cognitive, and environmental factors. Deviance ratios examined interrelationships between factors. Population attributable risks (PAR) were used to identify intervention targets.The association of background factors with adherence was partially explained by cognitive and environmental factors. The association of environmental factors with adherence was partially explained by cognitive factors. Cognitive and environmental factors contributed equally to adherence. Factors with the highest PARs for non-adherence were age 50-64, less than two comorbidities, and lack of physician recommendation.Efforts to increase physician screening recommendations for younger, healthy patients at facilities with the lowest screening rates may improve CRC adherence in this setting.

INTRODUCTION This study examines the presence and correlates of gender disparities in smoking cessation among lower income smokers prescribed nicotine replacement medication. METHODS We examined quit rates (7-day abstinence point prevalence) among a cohort of smokers who filled prescriptions for nicotine replacement (N = 1,782), using Minnesota Health Care Programs' (e.g., Medicaid) pharmacy claims databases (2005-2006) and mixed-mode survey protocols. A cohort of smokers who recently filled a prescription for nicotine replacement was stratified by race, and then subjects were selected by simple random sample from each race, oversampling the nonWhite groups (N = 1,782). The primary outcome was point prevalence of 7-day abstinence, and outcomes were assessed about 8 months after the nicotine replacement therapy (NRT) index prescription fill date using a mixed-mode survey protocol. Final interaction models were constructed using backward elimination. RESULTS Abstinence rates were 11.4% among women and 19.2% among men (p = .02) and remained marginally significant after controlling for demographics, mental and physical health, period of cigarette abstinence, social environment, religious attendance, perceived stress, and NRT prescription type (p = .08). There was a significant Gender x Employment interaction (p = .02). Among men, quit rates were higher among the employed (26%) compared with the unemployed (16%); among women, quit rates were lower among those who were employed (8%) compared with those who were unemployed (14%). DISCUSSION Results suggest the need for research on factors specific to women's work roles or workplaces that inhibit cessation as well as cessation programs tailored to low-income, employed female smokers. On-site workplace interventions and flexible counseling programs may be especially beneficial.

We examined the presence and correlates of Black/White racial disparities in adherence to guidelines for colorectal cancer screening (CRCS).The sample included 328 Black and 1827 White patients age 50-75 from 24 VA medical facilities who responded to a mailed survey with phone follow-up (response rate: 73% for Blacks and 89% for Whites). CRCS adherence and race were obtained through surveys and supplemented with administrative data. Logistic regressions estimated the contribution of demographic, health, cognitive, and environmental factors to racial disparities in adherence to CRCS guidelines.In unadjusted analyses, Blacks had slightly lower rates of adherence to CRCS guidelines than Whites (72% versus 77%, p0.05). This racial disparity in CRCS adherence was explained by race differences in demographic, health, and environmental factors but not by cognitive factors. Tests for interactions revealed that the association of race with adherence varied significantly across levels of income, education, and marital status. In particular, among those who were married with higher levels of education, CRCS adherence was significantly higher for Whites; whereas among those who were unmarried, with low levels of education, adherence was significantly higher for Blacks.We found that disparities in CRCS are greatly attenuated in the VA system and both Whites and Blacks have substantially higher rates of CRCS than the national average. These results point to the success of the VA at implementing CRCS system-wide. Our findings also suggest additional initiatives may be needed for unmarried low income white men and higher income black men.

Objective To assess colorectal cancer (CRC) screening mode preferences and correlates of these preferences among US veterans at average risk for CRC. Method A cross-sectional survey of a nationally representative sample of VA patients was conducted between January 2005 and December 2006. We report preference distributions for screening modes among 2068 average-risk veterans and across patient subgroups based on personal, behavioral, and environmental factors. Independent predictors of preferences are identified through hierarchical logistic regression models. Results Colonoscopy (37%) was the most preferred mode followed by fecal occult blood test (FOBT) (29%). The strongest predictors of preferences were previous screening experience, provider recommendation, and use of non-VA healthcare services. Participants in higher socioeconomic groups were more likely to choose colonoscopy and less likely to indicate no preference. Conclusion Screening programs that offer only one mode fail to accommodate the preferences of a substantial proportion of patients. Within the VA, adding screening colonoscopy to programs currently offering only FOBT is likely to increase preferences for colonoscopy, as patients incorporate provider recommendations for and personal experience with colonoscopy into their preferences. This is likely to disproportionately benefit lower socioeconomic groups who do not currently have access to non-VA colonoscopy services.

Objective Studies have found that women are less likely than men to undergo colorectal cancer (CRC) screening. While one source of these disparities may be gender differences in barriers and facilitators to screening, another may be differences in reporting bias. Method In this study of 345 male and female veterans, conducted in 2006 in Minneapolis, MN, we examined CRC screening adherence rates by gender using medical records and self-report and assessed whether any differences were due to reporting bias. Results We found a significantly higher rate of colonoscopy use among men when using self-report data, but no significant differences in either overall or test-specific screening adherence when using medical record data. Analyses examining the prevalence and determinants of concordance between self-report and medical records screening revealed that compared to women, men were less accurate in reporting sigmoidoscopy and colonoscopy and over-reported screening by colonoscopy. Men were also more likely to have missing self-report data and how missing data were handled affected differences in screening behavior. Accuracy in screening behavior was not explained by demographic variables, good physical or mental health, or physician recommendation for screening. Conclusions Reported gender disparities in CRC screening adherence may be a result of reporting bias.

Previous research has found that lesbian, gay, bisexual and transgender (LGBT) individuals are at risk for a variety of mental health disorders. We examined the extent to which a recent experience of a major discriminatory event may contribute to poor mental health among LGBT persons.Data were derived from a cross-sectional strata-cluster survey of adults in Hennepin County, Minnesota, who identified as LGBT (n=472) or heterosexual (n=7,412).Compared to heterosexuals, LGBT individuals had poorer mental health (higher levels of psychological distress, greater likelihood of having a diagnosis of depression or anxiety, greater perceived mental health needs, and greater use of mental health services), more substance use (higher levels of binge drinking, greater likelihood of being a smoker and greater number of cigarettes smoked per day), and were more likely to report unmet mental healthcare needs. LGBT individuals were also more likely to report having experienced a major incident of discrimination over the past year than heterosexual individuals. Although perceived discrimination was associated with almost all of the indicators of mental health and utilization of mental health care that we examined, adjusting for discrimination did not significantly reduce mental health disparities between heterosexual and LGBT persons.LGBT individuals experienced more major discrimination and reported worse mental health than heterosexuals, but discrimination did not account for this disparity. Future research should explore additional forms of discrimination and additional stressors associated with minority sexual orientation that may account for these disparities.

Secondhand smoke poses risks to children, particularly those from low socioeconomic backgrounds. Recently, there has been an increase in tobacco-control policies designed to reduce children's exposure to secondhand smoke, including interventions to change parental smoking behaviors. However, little attention has been paid to understanding potential unintended consequences of such initiatives on mothers who smoke. As such, the objectives of this paper are to explore the potential consequences of tobacco-control policies designed to reduce children's exposure to secondhand smoke on socially disadvantaged mothers who smoke and to provide recommendations for research, policy, and practice.A theory-guided, qualitative narrative review of the perceived discrimination, stigma, and stress and coping literature was conducted. MEDLINE and PsycINFO were searched to identify relevant articles from 1980 to October 2008 for review.There is evidence that strategies designed to reduce secondhand smoke have contributed to smoking stigmatization. However, there is little research on the consequences of these initiatives or how they affect low-income mothers who smoke. Stigmatization research suggests that such policies may have unanticipated outcomes for socially disadvantaged mothers who smoke, such as decreased mental health; increased use of cigarettes or alcohol; avoidance or delay in seeking medical care; and poorer treatment by healthcare professionals. Recommendations for researchers, practitioners, and policymakers are presented.Further research is needed to understand how initiatives to reduce children's exposure to secondhand smoke, as well as broader tobacco-control initiatives, can be designed to minimize potential harm to mothers who smoke.

This qualitative study was designed to explore beliefs and experiences related to smoking and cessation among the Hmong population in the United States. Three separate focus groups were conducted with male and female Hmong smokers. Analysis revealed that the Hmong viewed smoking as prevalent in their community and perceived numer- ous barriers to cessation. Barriers to cessation differed based on gender and acculturation. For instance, women were concerned about having their smoking status revealed if they were to seek help, because of cultural prohibitions against female smokers. Less accultur- ated Hmong believed U.S. commercial tobacco to be more addictive than the homegrown tobacco they were used to. This formative research suggests that smoking is becoming an increasing problem among the Hmong in the United States and points to a need for additional research to inform the development of effective tobacco control strategies for this community.

Objectives The objective of the study was to compare the effect of two approaches to requesting medical records on survey response rates, sample representativeness, and the quality of self-reported screening. Study Design and Setting Eight hundred ninety veterans aged 50–75 years from the Minneapolis VA Medical Center were randomly assigned to (1) records request included with a colorectal cancer screening survey (“with-survey” group) or (2) request in a separate mailing following a completed survey (“after-survey” group). Analyses compared response rates, the proportion and characteristics of patients providing records, and the validity of self-reported screening, by group. Results Response rates did not vary by group (with-survey 76%; after-survey 78%, P = 0.45). 54% of with-survey and 47% of after-survey participants provided complete medical records ( P = 0.06). In the with-survey group, patients with complete medical records were significantly more likely to be married and to have a diagnosis of posttraumatic stress disorder; in the after-survey group, they were more likely to be aged 65–75 years, Caucasian, to have a family history of colorectal cancer, and to report being screened. Validity of self-reported screening did not vary significantly by group. Conclusion The with-survey approach did not significantly reduce response rates or the quality of self-reported screening and produced a higher number and more representative sample with complete records.

The paper sets forth a set of evidence-based recommendations for interventions to combat unintentional bias among health care providers, drawing upon theory and research in social cognitive psychology. Our primary aim is to provide a framework that outlines strategies and skills, which can be taught to medical trainees and practicing physicians, to prevent unconscious racial attitudes and stereotypes from negatively influencing the course and outcomes of clinical encounters. These strategies and skills are designed to: l) enhance internal motivation to reduce bias, while avoiding external pressure; 2) increase understanding about the psychological basis of bias; 3) enhance providers’ confidence in their ability to successfully interact with socially dissimilar patients; 4) enhance emotional regulation skills; and 5) improve the ability to build partnerships with patients. We emphasize the need for programs to provide a nonthreatening environment in which to practice new skills and the need to avoid making providers ashamed of having racial, ethnic, or cultural stereotypes. These recommendations are also intended to provide a springboard for research on interventions to reduce unintentional racial bias in health care.

Importance Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy. Objective To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers. Design, Setting, and Participants The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention. Interventions Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services. Main Outcomes and Measures The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization. Results A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care ( P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]). Conclusions and Relevance Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates. Trial Registration clinicaltrials.gov Identifier:NCT00608426

Background Most smokers do not receive comprehensive, evidence-based treatment for tobacco use that includes intensive behavioral counseling along with pharmacotherapy. Further, the use of proven, tobacco treatments is lower among minorities than among Whites. The primary objectives of this study are to: (1) Assess the effect of a proactive care intervention (PRO) on population-level smoking abstinence rates (i.e., abstinence among all smokers including those who use and do not utilize treatment) and on utilization of tobacco treatment compared to reactive/usual care (UC) among a diverse population of smokers, (2) Compare the effect of PRO on population-level smoking abstinence rates and utilization of tobacco treatments between African American and White smokers, and (3) Determine the cost-effectiveness of the proactive care intervention. Methods/Design This prospective randomized controlled trial identifies a population-based sample of current smokers from the Department of Veterans Affairs (VA) electronic medical record health factor dataset. The proactive care intervention combines: (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or face-to-face). Proactive outreach includes mailed invitation materials followed by an outreach call that encourages smokers to seek treatment with choice of services. Proactive care participants who choose telephone care receive VA telephone counseling and access to pharmacotherapy. Proactive care participants who choose face-to-face care are referred to their VA facility's smoking cessation clinic. Usual care participants have access to standard smoking cessation services from their VA facility (e.g., pharmacotherapy, smoking cessation clinic) and from their state telephone quitline. Baseline data is collected from VA administrative databases and participant surveys. Outcomes from both groups are collected 12 months post-randomization from participant surveys and from VA administrative databases. The primary outcome is self-reported smoking abstinence, which is assessed at the population-level (i.e., among those who utilize and those who do not utilize tobacco treatment). Primary analyses will follow intention-to-treat methodology. Discussion This randomized trial is testing proactive outreach strategies offering choice of smoking cessation services, an innovation that if proven effective and cost-effective, will transform the way tobacco treatment is delivered. National dissemination of proactive treatment strategies could dramatically reduce tobacco-related morbidity, mortality, and health care costs. Clinical trials registration ClinicalTrials.gov: NCT00608426.

INTRODUCTION Painful conditions such as osteoarthritis are common and represent a growing proportion of chronic pain diagnoses in primary care [1]. Patients with these conditions may either obtain unacceptable pain relief or functional improvement or may suffer intolerable side effects or organ toxicity from taking salicylates, acetaminophen, or nonsteroidal anti-inflammatory agents. Pain specialists advocate treating moderate-to-severe chronic noncancer pain with opioids [2-4], because they provide effective musculoskeletal pain relief with improved function and low risk of abuse or side effects in many patients [5-9]. Regulatory boards and the clinical community have come to support prescribing strong opioids for treating chronically painful musculoskeletal conditions [10-11]. However, many practicing physicians are still strongly prejudiced against opioid analgesics and do not prescribe them for conditions such as osteoarthritis and low back pain [12-13]. Reasons cited include fears of patient addiction, misuse, or sanctioning by medical boards; increased time and efforts required for documentation and follow-up; and negative attitudes of physicians and staff toward patients with chronic pain from "benign" conditions [14-17]. Physicians often overestimate the risks of using opioids chronically to treat pain because of their inaccurate knowledge about different opioid formulations, side effects, and the difference between physiological dependence and addiction. Although the careful selection and monitoring of opioid use are important when chronic noncancer pain is treated, withholding them because of unfounded concerns and lack of knowledge has likely caused needless suffering in patients who could have safely benefited from their use [18]. Little is known about the attitudes and beliefs of residents toward using opioids to treat conditions such as low back pain [19]. But if less experienced physicians have the same negative attitudes and lack of knowledge about using opioids for treating noncancer pain as their instructors and peers, understanding the causes would be useful for designing educational interventions leading to more enlightened approaches to managing chronic pain [20]. The objective of this study was to assess and compare residents' beliefs and concerns about using opioids for treating noncancer low back pain (NLBP) and cancer-related pain. METHODS Setting In January 2003, we conducted a 4-hour workshop titled "Using Opioids to Treat Chronic Noncancer Pain" for resident physicians in the Medicine and Medicine-Pediatrics programs at the University of Minnesota, Minneapolis, Minnesota. At the beginning of the workshop, participants were asked to complete a survey questionnaire. Participants Medicine residents were in either their first, second, or third year of a 3-year training program. Medicine-Pediatrics is a 4-year residency; thus, some participants could have been in a fourth postgraduate year. Selection Process At the time of the study, 96 residents (75 Medicine, 21 Medicine-Pediatrics) were enrolled in the two programs. All residents were required to attend this workshop instead of their regularly scheduled continuity clinic. Some did not attend because of approved absences, on call duties, or other personal reasons. Survey Instrument One author performed a Medline search for studies assessing efficacy, safety, and attitudes of physicians and students about using opioids to treat chronic noncancer pain. From this information, we developed a 28-item assessment questionnaire (Figure). Residents were asked to rate their level of concern, worry, or fear (0 = "No concern" to 10 = "Very concerned") about the consequences of prescribing opioids for chronic cancer pain compared with NLBP and the consequences for their patients. We aligned answers to each question side-by-side to encourage comparison of the two types of pain. …

Background Current guidelines advise providers to assess smokers’ readiness to quit, then offer cessation therapies to smokers planning to quit and motivational interventions to smokers not planning to quit.

Background There is a paucity of evidence on how to train medical students to provide equitable, high quality care to racial and ethnic minority patients. We test the hypothesis that medical schools’ ability to foster a learning orientation toward interracial interactions (i.e., that students can improve their ability to successfully interact with people of another race and learn from their mistakes), will contribute to white medical students’ readiness to care for racial minority patients. We then test the hypothesis that white medical students who perceive their medical school environment as supporting a learning orientation will benefit more from disparities training. Methods Prospective observational study involving web-based questionnaires administered during first (2010) and last (2014) semesters of medical school to 2394 white medical students from a stratified, random sample of 49 U.S. medical schools. Analysis used data from students’ last semester to build mixed effects hierarchical models in order to assess the effects of medical school interracial learning orientation, calculated at both the school and individual (student) level, on key dependent measures. Results School differences in learning orientation explained part of the school difference in readiness to care for minority patients. However, individual differences in learning orientation accounted for individual differences in readiness, even after controlling for school-level learning orientation. Individual differences in learning orientation significantly moderated the effect of disparities training on white students’ readiness to care for minority patients. Specifically, white medical students who perceived a high level of learning orientation in their medical schools regarding interracial interactions benefited more from training to address disparities. Conclusions Coursework aimed at reducing healthcare disparities and improving the care of racial minority patients was only effective when white medical students perceived their school as having a learning orientation toward interracial interactions. Results suggest that medical school faculty should present interracial encounters as opportunities to practice skills shown to reduce bias, and faculty and students should be encouraged to learn from one another about mistakes in interracial encounters. Future research should explore aspects of the medical school environment that contribute to an interracial learning orientation. Electronic supplementary material The online version of this article (doi:10.1186/s12909-016-0769-z) contains supplementary material, which is available to authorized users.

Background Rates of chronic pain are rising sharply in the United States and worldwide. Presently, there is evidence of racial disparities in pain treatment and treatment outcomes in the United States but few interventions designed to address these disparities. There is growing consensus that chronic musculoskeletal pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental factors, some of which differ by race. Methods/Design The primary aim of this randomized controlled trial is to test the effectiveness of a non-pharmacological, self-regulatory intervention, administered proactively by telephone, at improving pain outcomes and increasing walking among African American patients with hip, back and knee pain. Participants assigned to the intervention will receive a telephone counselor delivered pedometer-mediated walking intervention that incorporates action planning and motivational interviewing. The intervention will consist of 6 telephone counseling sessions over an 8–10 week period. Participants randomly assigned to Usual Care will receive an informational brochure and a pedometer. The primary outcome is chronic pain-related physical functioning, assessed at 6 months, by the revised Roland and Morris Disability Questionnaire, a measure recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). We will also examine whether the intervention improves other IMMPACT-recommended domains (pain intensity, emotional functioning, and ratings of overall improvement). Secondary objectives include examining whether the intervention reduces health care service utilization and use of opioid analgesics and whether key contributors to racial/ethnic disparities targeted by the intervention mediate improvement in chronic pain outcomes Measures will be assessed by mail and phone surveys at baseline, three months, and six months. Data analysis of primary aims will follow intent-to-treat methodology. Discussion We will tailor our intervention to address key contributors to racial pain disparities and examine the effects of the intervention on important pain treatment outcomes for African Americans with chronic musculoskeletal pain. Trial registration ClinicalTrials.gov: NCT01983228. Registered 6 November 2013.