A systematic review of psychosocial and sex-based contributors to gender disparities in the United States across the steps towards kidney transplantation.

INTRODUCTION: Persistent findings suggest women and patients identified as "female" are less likely to receive a kidney transplant. Furthermore, the limited research on transplantation among transgender and gender diverse people suggests this population is susceptible to many of the same psychosocial and systemic barriers. OBJECTIVE: This review sought to 1) highlight terminology used to elucidate gender disparities, 2) identify barriers present along the steps to transplantation, and 3) summarize contributors to gender disparities across the steps to transplantation. METHODS: A systematic review of gender and sex disparities in the steps towards kidney transplantation was conducted in accordance with PRISMA guidelines across four social science and public health databases from 2005 to 23. RESULTS: The search yielded 1696 initial results, 33 of which met inclusion criteria. A majority of studies followed a retrospective cohort design (n = 22, 66.7%), inconsistently used gender and sex related terminology (n = 21, 63.6%), and reported significant findings for gender and sex disparities within the steps towards transplantation (n = 28, 84.8%). Gender disparities among the earlier steps were characterized by patient-provider communication and perception of medical suitability whereas disparities in the later steps were characterized by differential outcomes based on older age, an above average BMI, and Black racial identity. Findings for transgender patients pointed to issues computing eGFR and the need for culturally tailored care. DISCUSSION: Providers should be encouraged to critically examine the diagnostic criteria used to determine transplant eligibility and adopt practices that can be culturally tailored to meet the needs of patients.

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality.

Patients from minoritized backgrounds based on race/ethnicity, gender, sexuality, and other social identities are more likely to experience inequities in access in kidney transplantation. Although these inequities have been reported over the decades, limited research focuses on the experiences of patients with intersecting minoritized social statuses and the mechanisms that contribute to their reduced access to transplantation. Intersectionality, a framework for understanding the ways in which multiple social identities represent interacting systems of oppression and privilege, offers a nuanced approach for understanding the experiences of patients diagnosed with end-stage organ disease with intersecting social identities. This article outlines complex systems that perpetuate inequities by highlighting the value of intersectionality in studying disparate outcomes to transplant and providing recommendations for the transplant community. This article aligns with the ESOT call for action to promote equity in transplantation worldwide.

A Nominal Group Technique Study of Patients Who Identify as Black or African American and Access to Renal Transplantation.

Introduction: Completion of the renal transplant evaluation has been associated with several barriers for patients who identify as Black or African American. This study sought to prioritize barriers to and motivators of completing the renal transplant evaluation. Methods/Approach: Semi-structured interviews and focus groups with a nominal group technique were used to generate priority scores. Transplant professionals (N = 23) were recruited from 9 transplant centers in the Mid-Atlantic, Mid-Western, and Southeastern parts of the United States. Black or African American identifying renal patients (N = 30) diagnosed with end-stage kidney disease were recruited from 1 transplant center in the Mid-Atlantic region. Findings: Priority scores were created to assess the quantitative data of participant rankings of top barriers and motivators. The most significant barriers identified by both patients and transplant professionals comprised financial constraints, insurance issues, difficulty navigating the healthcare system, transportation difficulties, and multiple health problems. Facilitators consisted of family/social support, transplant education, patient navigators, comprehensive insurance, and physician repertoire and investment. A qualitative description of the ranked factors resulted in themes classified as intrapersonal, health, socioeconomic, transplant-specific healthcare, and general healthcare. Conclusion: These findings provided vital information to transplant centers nationwide about assessing the influences of renal transplant evaluation completion. Achieving equity in access to transplantation for Black or African American renal patients requires multilayered approaches.

Impact of Alexithymia on Organ Transplant Candidates' Quality of Life: The Mediating Role of Depressive Symptoms.

Solid organ transplant candidates who display alexithymia tend to report psychological distress with some displaying symptoms associated with depression which in turn has a negative impact on their quality of life. This study sought to examine the mediating role of depression on the relationship between alexithymia and physical and psychological quality of life. The sample comprised 707 patients who were under consideration for solid organ transplantation. Mediation models were used to examine the proposed hypotheses, specifically that alexithymia would predict quality of life, and that depression would mediate the relationship between alexithymia and physical and psychological quality of life. Findings revealed that alexithymia predicted both physical and psychological quality of life. Depression scores partially mediated the relationship between alexithymia and both physical and psychological quality of life. Transplant candidates with higher levels of alexithymia who report poor physical and psychological quality of life may be at increased risk for depression. Results highlight the need to assess alexithymia within this unique patient population, who may understate symptoms of depression due to attempts at positive impression management.

Pre-transplant evaluation completion for Black/African American renal patients: Two theoretical frameworks.

OBJECTIVE: Black/African Americans (B/AA) are less likely to complete the pre-transplant evaluation for kidney transplantation despite higher prevalence rates of end-stage renal disease (ESRD). To better understand the barriers and motivators to completing the evaluation process, two qualitative studies were conducted to categorize and elucidate the relationships between these factors. METHODS: In Phase I, semi-structured interviews were conducted with a stratified purposeful sample of transplant professionals (N = 23). Focus groups were conducted during Phase II with a purposeful sample of B/AA patients (N = 30). RESULTS: Thematic analyses assessed using grounded theory revealed a multitude of factors at individual and systemic levels, including health and informational/educational-related factors. Two comprehensive theoretical frameworks, a socio-ecological model of barriers and a model of motivators are presented. Medical mistrust is an example of a community factor identified as impeding completion rates. Systemic motivators included compressed time for testing and fewer intervals between doctor's appointments. CONCLUSIONS: This study offers a structure for understanding impediments to and facilitators of pre-transplant evaluation completion as seen through the eyes of both B/AA ESRD patients seeking transplant and the providers who work with them. PRACTICE IMPLICATIONS: Recommendations for intervention and systemic changes to narrow health disparities are discussed.

Development of the Collectivist-Sensitive Trait Forgivingness Scale.

Mounting evidence suggests that experiences of forgiveness vary across cultures. However, culturally sensitive conceptualizations of forgiveness lack empirical support, in part because psychometrically sound instruments designed to capture unique aspects of forgiveness in non-Western cultures are rare. For this reason, we developed the Collectivist-Sensitive Trait Forgivingness Scale (TFS-CS), which is designed to measure trait forgivingness within societies characterized by a blend of individualistic and collectivistic worldviews. In Study 1 (N = 597), exploratory factor analysis revealed a 16-item three-factor structure of third-party forgiveness, collectivistic forgiveness, and interpersonal resentment among South Africans. In Study 2 (N = 897), the three-factor model replicated in an independent South African sample. Findings also offered preliminary evidence supporting the construct validity of the TFS-CS. Overall, these studies support a conceptualization of trait forgivingness with similarities and differences relative to Western models and highlight the importance of appreciating the influence of culture when measuring forgiveness.

Communicating About Choices in Transplantation (COACH).

INTRODUCTION: Previous research highlights the difficulties patients with end-stage renal disease awaiting kidney transplant experience while attempting to manage both the logistical and the content-related aspects of discussions about transplantation. This article presents pilot results of the behavioral communication intervention program, Communicating about Choices in Transplantation (COACH), designed to improve transplant candidates' communication about transplantation. RESEARCH QUESTIONS: As compared to matched controls, increases in knowledge of deceased and living donor transplantation, communication self-efficacy, intentions to hold conversations about transplantation, and self-reported discussion were expected for pilot participants from pre- and postassessment; decreases in conversational difficulties were also posited. DESIGN: Using a nonrandomized quasi-experimental design, we compared transplant knowledge and communication between patients completing a 2-hour COACH session (pilot sample) to a sample of matched controls (n = 10). Data were collected via semi-structured telephone interviews upon enrollment and 1 month after enrollment or attendance at a COACH program session. RESULTS: The results revealed significant differences in knowledge from pre- to postassessment between the pilot and control samples ( P = .02). Although no other statistically significant between-group differences were found, paired-sample t tests revealed significant pre-post increases in transplant knowledge (7.6 [standard deviation, SD = 2.0] to 9.5 [SD =1.8]; P = .05) and communication self-efficacy (1255.8 [SD = 239.7] to 1513.8 [SD = 114.3]; P = .009) for pilot participants. Decreases in perceived conversational difficulties were also observed ( P = .53). DISCUSSION: Results provide preliminary support for the program's impact. Moreover, participant evaluations of the COACH were overwhelmingly positive. A more definitive program evaluation with a larger, more diverse sample is currently underway.

Living Kidney Donors' Information Needs and Preferences.

INTRODUCTION: Past research suggests the information exchanged from transplant centers to potential living kidney donors is, in many cases, suboptimal. The purpose of this study was to assess donors' perceptions of the information provided while considering living donation. METHODS: Semistructured telephone interviews conducted with 81 past living donors seen at 1 mid-Atlantic transplant center assessed the extent to which living kidney donors deemed Centers for Medicare and Medicaid Services (CMS)-mandated information useful to making a decision about donation and to which more information was or would have been desired before donating. Understanding of and satisfaction with the information was also assessed. RESULTS: Participants were primarily white (67.9%), females (67.9%), with an average age of 57.8 years. Perceived usefulness ranged from a mean of 3.1 for the confidentiality of the transplant center's communication to 4.1 for postoperative care and short-term medical risks of donation. Donors of minority descent as well as those with more education and less income found the information provided most useful. Few donors desired additional information about the right to opt out of (8.6%) or decline (13.6%) donation; however, most wanted more information regarding the risk of being refused health, disability and/or life insurance after donating (77.8%), and insurance coverage for future health problems (66.7%). DISCUSSION: This study revealed limited usefulness of certain CMS-mandated topics and a desire for additional information about donation. Efforts to standardize the informed consent process should incorporate donors' perspectives as to the specific topics, quantity of information, and the mode of communication found most useful when considering living donation.

Disparities in the completion of steps to kidney transplantation: protocol for a systematic review.

INTRODUCTION: Disparities in access to transplantation have been well documented. The extant literature, however, focuses largely on disparities and related barriers for African-American patients and none has used the steps to transplantation as a guiding framework. This review will catalogue disparities in the steps to transplantation as well as the barriers and facilitators to completion of each step identified in the extant literature. The results of the review will be used to generate recommendations for future research to improve equity in access to kidney transplantation. METHODS AND ANALYSIS: Standard procedures will be used in the conduct of the review. Searches will be performed using the following electronic databases: PubMed/Medline, PsycINFO, CINHAL, EMBASE, Cochrane library and Web of Science. Reports of original research will be eligible for inclusion if they are published from 2005 to present, written or available in English language, performed in the USA, enrol adult participants (18 years of age or more), and employ descriptive or observational designs. Two authors will independently screen retrieved articles for inclusion. MaxQDA will be used for data analysis and management. All included reports will be coded for article characteristics; disparities identified; barriers and motivators of completion of steps to transplantation; and proposed solutions to disparities and barriers. Each report will be coded independently by two authors and discrepancies resolved by discussion among the full team. A qualitative approach to data analysis is planned. Risk of bias will be assessed using standard procedures. ETHICS AND DISSEMINATION: The findings will provide crucial information on the current status of disparities in access to transplantation. PRISMA guidelines will be followed in reporting the results of the review. It is anticipated that these results will inform research which seeks to increase parity in access to transplantation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014015027.

The influence of TBI impairments on family caregiver mental health in Mexico.

PURPOSE: This study examined the influence of five types of impairments in individuals with traumatic brain injury (TBI)-and caregiver stress due to these impairments-on the mental health of family caregivers in Guadalajara, Mexico. METHOD: Ninety caregivers completed measures of TBI impairments and of their own mental health. The majority were female (92.20%) with a mean age of 47.12 years (SD = 12.67). Caregivers dedicated a median of 50 hours weekly to caregiving and had spent a median of 11 months providing care. RESULTS: Two canonical correlation analyses suggested that these two sets of variables were broadly related, such that more severe impairments in individuals with TBI and more caregiver stress due to those impairments were associated with lower caregiver mental health. Across both analyses, social impairments were most associated with increased caregiver burden. Follow-up analyses also uncovered that caregiver stress due to cognitive impairments was uniquely associated with caregiver burden and anxiety. CONCLUSIONS: These results are the first to provide evidence that social and cognitive impairments in individuals with TBI from Latin America are the impairments most associated with caregiver mental health and highlight the need for interventions that target social and cognitive functioning.