The development of accessible and sustainable transgender health education for rural-serving medical providers in Appalachia.

Context and issues: Rural regions in Southeastern USA are predominantly under-resourced and have poorer health outcomes compared to national averages. People living in rural Appalachia with intersectional identities often have limited choices in providers along with other systemic barriers to obtaining good health care. Barriers to competent and safe health care disproportionately impact people who are marginalized because of their identity. For transgender patients in South Central Appalachia, intersectional identities constitute barriers to receiving competent health care and increase the risk of poorer health outcomes. Literature indicates providers nationally receive on average between 45 minutes and 5 hours of training on transgender healthcare provision, which may exacerbate poor care experiences in South Central Appalachia. The present study aimed to develop and implement a training program for rural-serving medical residents in primary care in South Central Appalachia. A six-stage pilot development study is described. Lessons learned: This project developed a cultural competency training for rural-serving medical providers specific to transgender health needs. The Kern Model was utilized to structure the development of this training. Data from clinic stakeholders, resident liaisons, and transgender community members were utilized throughout phases of development. Two major themes arose from planning with these key stakeholders: accessibility/reusability of the material and usefulness of the material to the residents. Stakeholders were asked to identify areas of competency that would be beneficial for their practices and what baseline information would be necessary for all participants to know. Trainings were a hybrid of virtual and live delivery to pivot in response to space allocations at each clinic and to allow residents who were on hospital rotations to attend. An educational consultant was utilized to inform the best style of training design to meet the stated pedagogical goals. Previous studies have indicated that medical providers receive limited training on transgender health needs. However, there is also literature suggesting differences in general medical education due to resource competition. Therefore, developing sustainable, accessible, and useful medical education is imperative. The inclusion of resident and community member feedback in the content creation of this project allowed customization to community and resident needs. Stakeholder input on the pedagogy of this project was also imperative due to physical space constraints with social distancing guidelines. This training highlights the value in engaging virtual curricula, as it allows optimal accessibility for rural clinics. This project aimed to develop a training specific for South Central Appalachian providers that was informed by transgender people in the region and tailored specifically for regional providers based on stakeholder input. The resulting training may be an invaluable tool for future medical providers in a rural-serving region that is medically, educationally under-resourced and experiences inflated intersectional discrimination at systemic and interpersonal levels.

The Buckle of the Bible Belt: Sexual Minority Emerging Adults' Minority Stress in South Central Appalachia.

Introduction: Sexual minority emerging adults in Appalachia face multiple sources of stigma and discrimination. Methods: We conducted four focus groups and five one-on-one interviews with sexual minority young adults and community stakeholders. Results: Themes emerged from qualitative analysis: 1) Appalachian culture engenders discrimination and isolation; 2) A need to identify safe spaces; 3) Lack of access to identity-affirming health services; and 4) participants draw strength from limited but persistent resistance, advocacy, and visibility. Conclusion: Sexual minority emegerging adults experience intersectional stigma in a socially conservative Appalachian setting. Attention to their unique experiences points towards specific service and community support needs.

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis.

Introduction: Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care. Materials and Methods: Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically. Results: Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling. Conclusions: A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Emergence of COVID-19 and Patterns of Early Transmission in an Appalachian Sub-Region.

Background: In mid-March 2020, very few cases of COVID-19 had been confirmed in the Central Blue Ridge Region, an area in Appalachia that includes 47 jurisdictions across northeast Tennessee, western North Carolina, and southwest Virginia. Authors described the emergence of cases and outbreaks in the region between March 18 and June 11, 2020. Methods: Data were collected from the health department websites of Tennessee, North Carolina, and Virginia beginning in mid-March for an ongoing set of COVID-19 monitoring projects, including a newsletter for local healthcare providers and a Geographic Information Systems (GIS) dashboard. In Fall 2020, using these databases, authors conducted descriptive and geospatial cluster analyses to examine case incidence and fatalities over space and time. Results: In the Central Blue Ridge Region, there were 4432 cases on June 11, or 163.22 cases per 100,000 residents in the region. Multiple days during which a particularly high number of cases were identified in the region were connected to outbreaks reported by local news outlets and health departments. Most of these outbreaks were linked to congregate settings such as schools, long-term care facilities, and food processing facilities. Implications: By examining data available in a largely rural region that includes jurisdictions across three states, authors were able to describe and disseminate information about COVID-19 case incidence and fatalities and identify acute and prolonged local outbreaks. Continuing to follow, interpret, and report accurate and timely COVID-19 case data in regions like this one is vital to residents, businesses, healthcare providers, and policymakers.

Transgender health education for medical students.

BACKGROUND: Transgender individuals face numerous health disparities and report negative experiences with health care providers related to their gender identity. Significant gaps in medical education regarding transgender health persist despite calls for increased sexual and gender minority content. The purpose of this student-led study was to assess the effectiveness of a half-day educational intervention on first- and second-year medical students' attitudes and knowledge of transgender health. METHODS: Students and faculty members collaborated to develop an educational session on transgender health. This content was presented to first- and second-year medical students at Integrated Grand Rounds, a pedagogical method in which basic science and clinical faculty members co-present didactic content interspersed between live patient interviews and student-led small group discussions. Student participants (n = 138) completed voluntary 9-item pre- and post-session surveys assessing comfort with and knowledge of transgender medicine. RESULTS: Students' comfort with and perceived knowledge about transgender patients increased significantly between pre- and post-test. Students' knowledge of transgender medicine standards of care also improved, though not all items reached significance. DISCUSSION: A half-day educational intervention improved many facets of medical students' attitudes and knowledge about transgender patients. The significant disparities in physical health, mental health and access to care currently experienced by transgender persons in the United States warrants the continued testing and refinement of educational interventions for future and practising providers. Students' comfort with transgender patients increased significantly between pre- and post-test.