Mediators of Racial Differences in COVID-19 Vaccine Acceptance and Uptake: A Cohort Study in Detroit, MI

Despite their disparate rates of infection and mortality, many communities of color report high levels of vaccine hesitancy. This paper describes racial differences in COVID-19 vaccine uptake in Detroit, and assesses, using a mediation model, how individuals’ personal experiences with COVID-19 and trust in authorities mediate racial disparities in vaccination acceptance. The Detroit Metro Area Communities Study (DMACS) is a panel survey of a representative sample of Detroit residents. There were 1012 respondents in the October 2020 wave, of which 856 (83%) were followed up in June 2021. We model the impact of race and ethnicity on vaccination uptake using multivariable logistic regression, and report mediation through direct experiences with COVID as well as trust in government and in healthcare providers. Within Detroit, only 58% of Non-Hispanic (NH) Black residents were vaccinated, compared to 82% of Non-Hispanic white Detroiters, 50% of Hispanic Detroiters, and 52% of other racial/ethnic groups. Trust in healthcare providers and experiences with friends and family dying from COVID-19 varied significantly by race/ethnicity. The mediation analysis reveals that 23% of the differences in vaccine uptake by race could be eliminated if NH Black Detroiters were to have levels of trust in healthcare providers similar to those among NH white Detroiters. Our analyses suggest that efforts to improve relationships among healthcare providers and NH Black communities in Detroit are critical to overcoming local COVID-19 vaccine hesitancy. Increased study of and intervention in these communities is critical to building trust and managing widespread health crises.

Women’s experiences of the injury, recovery and desire for rehabilitation after a second-degree vaginal tear—a qualitative study

Introduction and hyposthesis Eighty-five percent of all vaginal deliveries cause some form of obstetric tear injury. To our knowledge, there are no studies exploring experiences after second-degree tear. Therefore, our study aimed to investigate the experiences of a second-degree vaginal tear regarding aspects of the recovery and need for healthcare and rehabilitation. Methods Individual semi-structured interviews were performed and analysed with a qualitative, inductive descriptive approach. Results A group of 18 women with a second-degree vaginal tear after delivery were included. Four main categories with associated subcategories were found: (1) feeling uncertainty, with subcategories: not knowing what is normal, concern, confusion and uncertainty regarding pelvic floor muscle training; (2) feeling of security, with subcategories: I have no/I can handle the symptoms, trust in the healthcare system and I have sufficient knowledge; (3) not prioritizing myself, with the subcategories: I cannot find time and others have bigger problems; (4) lack of trust in healthcare providers, with the subcategories: feeling forgotten, not being taken seriously, distrust of the competence of the healthcare providers and resignation. Conclusion Women who suffer from a second-degree vaginal tear after pregnancy can feel safe when needs are met but uncertainty is also common when available healthcare and information are perceived as insufficient. The women also feel uncertainty about what is normal after the tear and how to perform pelvic floor exercises. Trial registration This trial was registered in “FoU in Sweden” (Research and Development in Sweden). Registration number: 214591.

I felt so much conflict instead of joy: an analysis of open-ended comments from people in British Columbia who declined care recommendations during pregnancy and childbirth

Background No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended. Methods In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations. Results More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences. Conclusions Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

Introduction to Provider Conflicts of Interest in Health Care

This chapter evaluates provider conflicts of interest in healthcare. Healthcare providers and institutions typically balance an array of competing interests, such as economic gain, the desire to favor colleagues, to advance in one's academic or professional career, or the needs of other patients. Conflicts of interest pervade most healthcare systems and pose considerable risks, both systemic and patient-focused, including increasing costs, harming patients, limiting choice, biasing publication decisions, and eroding trust in healthcare providers and institutions. A key element common to most interpretations of conflicts of interest is the provider's exposure to undue influence from a secondary interest. A second key element is that a conflict of interest can occur when there is merely the perception of undue influence by a secondary interest. Perception that a healthcare provider's independence has been compromised leads to reputational risk and undermines the trust of other stakeholders.

I felt so much conflict instead of joy: An analysis of narratives from pregnant people in British Columbia who declined care recommendations

Background No Canadian studies to date have examined the experiences of people who decline care during pregnancy and birth. The current analysis bridges this gap by describing narratives from 892 people in British Columbia (BC) who refused a test or procedure that their care provider recommended. Methods In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study that captured experiences of receiving maternity care, including novel items describing provider-patient interactions. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations. Results Close to half of people who participated in the survey (n = 892; 46%) declined a test or procedure. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences. Conclusions Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

Priorities among HIV-positive individuals for tuberculosis preventive therapies

BACKGROUND: There has been slow uptake of isoniazid preventive therapy (IPT) among people living with HIV (PLWH).METHODS: We surveyed adults recently diagnosed with HIV in 14 South African primary health clinics. Based on the literature and qualitative interviews, sixteen potential barriers and facilitators related to preventive therapy among PLWH were selected. Best-worst scaling (BWS) was used to quantify the relative importance of the attributes. BWS scores were calculated based on the frequency of participants' selecting each attribute as the best or worst among six options (across multiple choice sets) and rescaled from 0 (always selected as worst) to 100 (always selected as best) and compared by currently receiving IPT or not.RESULTS: Among 342 patients surveyed, 33% (n = 114) were currently taking IPT. Having the same standard of life as someone without HIV was most highly prioritized (BWS score = 67.3, SE = 0.6), followed by trust in healthcare providers (score, 66.3 ± 0.6). Poor standard of care in public clinics (score, 30.6 ± 0.6) and side effects of medications (score, 33.7 ± 0.6) were least prioritized. BWS scores differed by IPT status for few attributes, but overall ranking was similar (spearman's rho = 0.9).CONCLUSION: Perceived benefits of preventive therapy were high among PLWH. IPT prescription by healthcare providers should be encouraged to enhance IPT uptake among PLWH.

EXAMINATION OF TRUST IN THE HEALTH CARE SYSTEM AMONG OLDER IMMIGRANTS RESIDING IN THE MIDWEST

Ethnic minority populations, such as immigrants, have demonstrated lower levels of trust in the health care system and their health care providers compared with non-migrant populations (Navaza et al., 2012; Renzaho, Polonsky, McQuilten, & Waters, 2013). This medical mistrust may adversely influence older adult immigrants’ use of and satisfaction with health services (Hong et al., 2018a; Jang, Kim, & Chiriboga, 2005). Thus, the current project aimed to characterize influences of medical mistrust (healthcare system and healthcare providers) in older adult immigrant populations living in the United States of America (U.S.). We interviewed 142 older adult immigrants and refugees (aged 60+ years) who identified as Bosnian, Chinese, Indian, Korean, Latino, and Vietnamese about their perceptions on living in the U.S., of the healthcare system, and healthcare utilization as a part of the Successful Aging among Immigrants in Midlife (SAIM) project. Linear regression models predicting trust in the healthcare system and trust in healthcare providers were tested with healthcare knowledge (measured with a single item about flu shots) , acculturation, length of time in the U.S. , and age as predictors. We found that older age and healthcare knowledge was predictive of higher levels of trust in healthcare providers for Chinese. Although healthcare knowledge was predictive of trust in the health care system for the Chinese participants, greater length of time and higher acculturation were associated with higher trust in the healthcare system among Indian participants. The implications of the different predictive variables in each of the hypothesized models will be discussed.

Once BITTEN, Twice Shy: An Applied Trauma-Informed Healthcare Model

Nurses need a pragmatic theory to understand and respond to the impact of vulnerable patients’ previous healthcare experiences, as these are likely to influence response and adherence to treatment plans. The authors of this paper present the new BITTEN (Betrayal history by health-related institutions, Indicator for healthcare engagement, Traumas related to healthcare, Trust in healthcare providers, patient Expectations and Needs) Model of Trauma-Informed Healthcare. BITTEN identifies patients’ current healthcare expectations and needs as a function of their previous betrayal by healthcare systems, which operates in conjunction with their current health indicators to potentially trigger trauma symptoms and impact trust in healthcare providers.