Financial Instability of Federal Navigator Program Challenges Organizations to Help Uninsured Enroll in Health Insurance Coverage.

Under the Affordable Care Act, the federal Health Insurance Navigator Program aims to reduce the rate of uninsured in the United States. Under this program, navigators help people obtain insurance coverage through federally facilitated Marketplaces. However, the program's financial instability and substantial budget cuts created a severe shortage of navigator assistance for the uninsured and underserved. The COVID-19 pandemic added further pressure to the already-strained program. Our study examined how unstable and unpredictable federal funding and the COVID-19 pandemic affected organizations' navigator work in the federal program in 2020. The results study show (1) that navigator organizations provide vital, year-round resources; (2) that organizations feel pushed to direct scarce resources to grant management and cut service provision; and (3) that there are policy changes that can support navigator organizations in the future. Increased and ongoing federal investment is needed to support this vital health workforce and expand enrollment assistance for underserved communities.

"This work that we're doing is bigger than ourselves": A qualitative study with community-based birth doulas in the United States.

CONTEXT: Community-based birth doulas support pregnant women, transgender men, and gender non-binary individuals during the perinatal period and provide essential services and expertise that address health inequities, often taking on additional roles to fill systemic gaps in perinatal care in the United States (US). Despite the benefits that community-based birth doulas provide, there is little research exploring the work-related conditions and stressors community-based doulas experience. To address this gap, we examined the work experiences, related stressors, and stress management strategies of individual community-based birth doulas. METHODS: In this qualitative, descriptive study we conducted 18 interviews in March through June 2021 with individuals who self-identified as community-based doulas working in underserved communities in the US. We analyzed the interviews for themes, which we defined and finalized through team consensus. RESULTS: The doulas reported engaging in specific strategies in their work to address perinatal inequities. They also described facing several work-related stressors, including witnessing discrimination against clients, experiencing discrimination in medical environments, and struggling with financial instability. To mitigate these stressors and job-related challenges, interviewees reported they relied on doula peer support and reconnected with their motivations for the work. CONCLUSIONS: Community-based doulas provide essential services and expertise which address inequities and systemic gaps in perinatal care. However, as they work to improve perinatal health, doulas themselves are providing equity work amidst an inequitable system and with insufficient political or financial support. Increased compensation and systemic support which acknowledges the breadth of services provided is needed to strengthen and sustain this critical part of the perinatal workforce.

Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States.

Purpose: Birth doulas support pregnant people during the perinatal period. Evidence of doulas' positive impacts on pregnancy and birth outcomes, particularly among underserved populations, supports expanding access. However, health workforce-related barriers challenge the development of robust doula services in the United States. This study examined the various approaches organizations have taken to train, recruit, and employ doulas as well as their perspectives on what system-level changes are needed to redress health inequities in underserved communities and expand access to birth doula services. Methods: In addition to literature and policy reviews, we conducted 16 semistructured interviews from March to August 2020 with key informants from organizations involved in training, certifying, advocating for, and employing doulas, and informants involved in state policy making. We analyzed data using qualitative analysis software to identify cross-cutting themes. Results: The landscape of organizations involved in doula training and certification is diverse. In discussing their training and curriculum, interviewees from large organizations and community-based organizations (CBOs) stressed the importance of incorporating a focus on structural racism in maternal health into training curricula. CBOs specifically offered three areas of systems-level change that can help equitably grow doula services: the importance of addressing structural racism, changing the balance of power in decision making and policy making, and a cautious approach to Medicaid reimbursement. Conclusion: This study provides evidence of how doula organizations move the field toward better serving the specific needs of underserved populations. It recognizes the expertise of CBOs in developing policy to expand doula services to communities in need. The information from this study highlights the complexities of facilitating consistency across doula training and certification requirements and implementing a sustainable funding mechanism while also meeting communities' unique needs.

Lack of Consistent Investment in Federal Insurance Navigator Program Undermines Navigators' Equity Work in Vulnerable Communities.

CONTEXT: Navigators in the federal Insurance Navigator Program ("Navigator Program"), who are employed by organizations in states with Federally Facilitated Marketplaces, provide enrollment assistance, outreach, and education to individuals who are eligible for health insurance coverage. Such work is central to public health efforts to address inequities but continues to be poorly understood and undervalued. More information is needed to understand the components of navigators' equity work and how decreases in program funding have affected their service provision. OBJECTIVE: To examine navigators' labor at a granular level to better understand and highlight the equity work they do, the training and skills required for this work, and the Navigator Program-based challenges they face. DESIGN: This was a descriptive qualitative study using data collected from interviews conducted in February-May 2021. We used a thematic analysis approach to develop major themes and subthemes. SETTING: This was a national study. PARTICIPANTS: We conducted 18 semistructured interviews with 24 directors, navigators, and other professionals at organizations funded as federally certified Navigator Programs. MAIN OUTCOME MEASURES: Components of navigators' work; required training and skills; and challenges faced in accomplishing the work. RESULTS: We identified 3 major themes: (1) navigators' health equity work goes beyond required responsibilities; (2) equity skills are built on the job; and (3) financial instabilities challenge navigators' health equity work. CONCLUSION: Navigators bring specialized and essential skills and services to underserved communities. They are trusted sources of information, advocates, resource connectors, and, most significantly, health equity workers. However, the Navigator Program fails to support navigators' work and the communities they serve in the long term. To facilitate organizations' capacities to train, keep, and support navigators in this health equity work and to guarantee long-term enrollment assistance for underserved communities, efforts to stabilize funding are needed.

Brief online implicit bias education increases bias awareness among clinical teaching faculty.

PROBLEM AND PURPOSE: Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness. MATERIALS AND METHODS: The course included the history of racism in medicine, social determinants of health, implicit bias in healthcare, and strategies to reduce the impact of implicit bias in clinical care and teaching. A sample of U.S. academic family, internal, and emergency medicine providers were recruited into the study from August to December 2019. Measures of provider implicit and explicit bias, personal and practice characteristics, and pre-post-bias awareness measures were collected. RESULTS: Of 111 participants, 78 (70%) were female, 81 (73%) were White, and 63 (57%) were MDs. Providers held moderate implicit pro-White bias on the Race IAT (Cohen's d = 0.68) and strong implicit stereotypes associating males rather than females with 'career' on the Gender-Career IAT (Cohen's d = 1.15). Overall, providers held no explicit race bias (Cohen's d = 0.05). Providers reported moderate explicit male-career (Cohen's d = 0.68) and strong female-family stereotype (Cohen's d = 0.83). A statistically significant increase in bias awareness was found after exposure to the course (p = 0.03). Provider implicit and explicit biases and personal and practice characteristics were not associated with an increase in bias awareness. CONCLUSIONS: Implicit bias education is effective to increase providers' bias awareness regardless of strength of their implicit and explicit biases and personal and practice characteristics. Increasing bias awareness is one step of many toward creating a positive learning environment and a system of more equitable healthcare.

Health Workforce Challenges Impact the Development of Robust Doula Services for Underserved and Marginalized Populations in the United States.

Evidence of doulas' positive impacts on maternal health outcomes, particularly among underserved populations, supports expanding access. Health workforce-related barriers challenge the development of robust doula services in the United States. We investigated organizations' barriers regarding training, recruitment, and employment of doulas. We conducted literature and policy reviews and 16 semi-structured interviews with key informants who contribute to state policymaking and from organizations involved in training, certifying, advocating for, and employing doulas. Our study shows barriers to more robust doula services, including varying roles and practices, prohibitive costs of training and certification, and insufficient funding. This study underscores the importance of doulas in providing support to clients from underserved populations. Health workforce-related challenges remain, especially for community-based organizations seeking to serve underserved communities.

Examining the racial and ethnic diversity of associate degree in nursing programs by type of institution in the US, 2012-2018.

BACKGROUND: Increasing nursing workforce diversity is essential to quality health care. Associate Degree in Nursing (ADN) programs are a primary path to becoming a registered nurse and an important source of nursing diversity. PURPOSE: To examine how the number of graduates and racial/ethnic student composition of ADN programs have changed since the Institute of Medicine's recommendation to increase the percentage of bachelor's-prepared nurses to 80%. METHODS: Using data from the Integrated Postsecondary Education System, we analyzed the number of graduates and racial/ethnic composition of ADN programs across public, private not-for-profit, and private for-profit institutions, and financial aid awarded by type of institution from 2012-2018. DISCUSSION: Racial/ethnic diversity among ADN programs grew from 2012-2018. Although private for-profits proportionally demonstrated greater ADN student diversity and provided financial aid institutionally to a higher percentage of students, public schools contributed the most to the number and racial/ethnic diversity of ADN graduates. CONCLUSION: Given concerns regarding private for-profits, promoting public institutions may be the most effective strategy to enhance diversity among ADN nurses.