Transgender-Competent Health Care: Lessons from the Community.

OBJECTIVES: Transgender (trans) individuals experience high discrimination levels when accessing medical and mental health care, resulting in poorer health outcomes compared with the general population and other minority populations. A community-based research design was used to elicit direct input from the trans community about critical trans-knowledgeable care components to address these disparities. The data collection included several focus groups with individuals recruited from the trans community. The information from this research guided the opening of the Gender Center, a centralized, multidisciplinary center of care for trans individuals within an urban safety-net hospital in Atlanta, Georgia. METHODS: The research team conducted five focus groups with 27 self-identified trans individuals between December 2016 and April 2017. Focus groups solicited the negative and positive experiences of trans individuals in the healthcare system and sought input about how best to serve this population. RESULTS: Analysis was done January through April 2020. Focus group participants identified financial difficulties, lack of insurance coverage, being underinsured, discrimination within the healthcare system and from providers, and a shortage of trans-competent providers as the most significant barriers to care. Participants emphasized the need to pay attention to creating a welcoming clinic environment, including trans-positive signage, and integrating trans staff members into the care team. CONCLUSIONS: This study demonstrates the importance of community-based research in addressing health disparities for trans people. It also offers insight into the unmet healthcare needs of the trans community, describes typical healthcare-related experiences of trans individuals, and identifies critical elements for providing high-quality trans-appropriate health care.

Care During Pregnancy, Childbirth, Postpartum, and Human Milk Feeding for Individuals Who Identify as LGBTQ.

The growing number of families that include members of sexual and/or gender minority (SGM) groups requires perinatal nurses to know how to provide respectful and affirming care to all people, including this population. Approximately 19% of adults who are members of SGM groups are raising 3 million children, with many hoping to become pregnant, foster, use surrogacy, or adopt in the future. Based on current literature, many nurses are not prepared to meet the clinical needs of patients who are members of SGM groups in the maternity setting. Likewise, patients and families of SGM groups often perceive that nurses are uncomfortable with providing care and are not always satisfied with their care. To meet these needs, it is important that nurses use strategies focused on promoting respectful, affirming care, reducing negative experiences, and eliminating marginalizing language and practices. Nurses must incorporate a holistic care focus for patients who are members of SGM minority groups that includes standardized strategic education; development of Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, or Plus (LGBTQ+) affirming and inclusive policies, practices, and language; flexibility, personal reflection of self-bias; and creating an environment of individualized compassionate care.

Barreras en mujeres indígenas para acceder a servicios obstétricos en el marco de redes integradas de servicios de salud / Barriers for indigenous women to access obstetric services within the framework of integrated health services networks

OBJETIVO: Analizar las barreras que enfrentan las mujeres indígenas para acceder a la red de servicios obstétricos en el marco de Redes Integradas de Servicios de Salud. MÉTODO: Se diseñó un estudio transversal descriptivo que integró métodos cuantitativos y cualitativos. La muestra fue intencionada, no probabilística. La recolección de datos se hizo en Oaxaca, México, durante 2017 y 2018. Se encuestó a 149 mujeres indígenas usuarias de servicios obstétricos para caracterizarlas sociodemográficamente y se seleccionaron 30 que tuvieron complicaciones durante el proceso de embarazo y parto para realizarles una entrevista semiestructurada. Se realizó observación no participante. RESULTADOS: La red de servicios obstétricos agrupa la atención de cuatro instituciones con diferentes modelos de atención, y por ello diversos tipos de establecimientos y recursos humanos para atender a las mujeres indígenas. Casi el 20% de las mujeres no iniciaron control prenatal en el primer trimestre del embarazo y el 27,2% tuvieron complicaciones durante el periodo gestacional. Las principales barreras fueron de disponibilidad (horarios de atención, aspectos geográficos), accesibilidad (carencia de recursos financieros), aceptabilidad (prácticas ancestrales vs. recomendaciones médicas) y continuidad del servicio (dificultades para ingresar al segundo nivel de atención y a especialidades médicas). CONCLUSIONES: El modelo de atención en redes posibilita el acceso a los servicios obstétricos, pero no garantiza la atención. Para ello, es necesario mejorar tanto la infraestructura de las instituciones prestadoras de servicios obstétricos como los procesos de atención. Hay que ampliar la visión del modelo considerando la perspectiva de derechos humanos y de equidad en salud

OBJECTIVE: To analyze the barriers that indigenous women face in access to the network of obstetric services in the context of the implementation of integrated healthcare networks (IHN). METHOD: We designed a cross-sectional descriptive study including quantitative and qualitative methods. Sampling was intentional, no probabilistic. Data collection was carried out in Oaxaca, Mexico, during 2017-2018. A total of 149 indigenous women who used obstetrical services were surveyed and sociodemographic characteristics were obtained. Later were selected 30 cases that had complications during pregnancy and childbirth for a semi-structured interview. Non-participant observation was conducted. RESULTS: The network of obstetric services comprises four institutions with different models of care and therefore different types of facilities and human resources to assist indigenous women. Nearly 20% of women did not start prenatal care in the first trimester of pregnancy and 27.2% had complications during the gestational period. The main barriers were availability (hours of operation, geographical aspects), accessibility (lack of financial resources), acceptability (ancestral practices vs. medical recommendations), and continuity of service (difficulties for admit patients in hospitals referred from first line of care). CONCLUSIONS: The networks model allows access to obstetric services but does not guarantee care. For this it is necessary to improve both: the infrastructure of the obstetric service providers, and the care processes. It is necessary to broaden the vision of the IHN management model considering the perspective of human rights and equity in health

Introducing cross-cultural education in palliative care: focus groups with experts on practical strategies.

BACKGROUND: The linguistic and cultural diversity found in European societies creates specific challenges to palliative care clinicians. Patients' heterogeneous habits, beliefs and social situations, and in many cases language barriers, add complexity to clinicians' work. Cross-cultural teaching helps palliative care specialists deal with issues that arise from such diversity. This study aimed to provide interested educators and decision makers with ideas for how to implement cross-cultural training in palliative care. METHODS: We conducted four focus groups in French- and Italian-speaking Switzerland. All groups consisted of a mix of experts in palliative care and/or cross-cultural teaching. The interdisciplinary research team submitted the data for thematic content analysis. RESULTS: Focus-group participants saw a clear need for courses addressing cross-cultural issues in end-of-life care, including in medical disciplines outside of palliative care (e.g. geriatrics, oncology, intensive care). We found that these courses should be embedded in existing training offerings and should appear at all stages of curricula for end-of-life specialists. Two trends emerged related to course content. One focuses on clinicians' acquisition of cultural expertise and tools allowing them to deal with complex situations on their own; the other stresses the importance of clinicians' reflections and learning to collaborate with other professionals in complex situations. These trends evoke recent debates in the literature: the quest for expertise and tools is related to traditional twentieth century work on cross-cultural competence, whereas reflection and collaboration are central to more recent research that promotes cultural sensitivity and humility in clinicians. CONCLUSION: This study offers new insights into cross-cultural courses in palliative and end-of-life care. Basic knowledge on culture in medicine, variable practices related to death and dying, communication techniques, self-reflection on cultural references and aptitude for interprofessional collaboration are central to preparing clinicians in end-of-life settings to work with linguistically and culturally diverse patients.

Validation and cultural adaptation of the Integrated Palliative care Outcome Scale (IPOS) for the Portuguese population.

BACKGROUND: To culturally adapt and validate the Integrated Palliative care Outcome Scale to European Portuguese. METHODS: Multi-centred observational study with 2 assessment points. Data were collected in nine centres using consecutive sampling. All patients were screened for eligibility. INCLUSION CRITERIA: ≥18 years, mentally fit to give consent, diagnosed with an incurable, potentially life-threatening illness, read, write and understand Portuguese. Translation and back translation with independent native speakers blind to the original measure created a Portuguese version, which was culturally adapted using cognitive interviews. For psychometric testing, the COSMIN checklist was followed. Reliability and content validity were assessed for patient and staff versions. Construct and criterion validity were tested for patient version. RESULTS: 1703 individuals were screened between July 1st 2015 and February 2016, 135 (7.9%) were included. Mean age was 66.8 years (SD 12.7), 58 (43%) were female. Most patients (109; 80.7%) had a cancer diagnosis. Cronbach's alpha showed good internal consistency, 0.657 for patient, 0.705 for staff versions. Intraclass correlation coefficient testing reproducibility revealed very good reliability, 0.794-0.950 for patient and 0.456-0.925 for staff versions. There was good content validity and significant results for construct validity. Physical symptoms were better detected by females. IPOS could discriminate: practical issues in different places of care, based on cancer diagnosis, physical and emotional symptoms based on life expectancy both for patient and professional dimensions, physical and emotional symptoms based on phase of illness, for professional dimensions, and physical symptoms from the patients' viewpoint. CONCLUSIONS: The Portuguese IPOS is a reliable and valid measure.

Salud intercultural y el modelo de salud propio indígena / Intercultural health and the indigenous health model

RESUMEN La población indígena tiene condiciones de vida inferiores al resto, reflejadas en mayor morbilidad y mortalidad a pesar de la cobertura del Sistema de Salud. Por ello, es importante conocer las causas de estas diferencias. Para esto, se hace uso de la interculturalidad como puente entre la cultura occidental y la cultura indígena. En este encuentro de saberes se identifica el modelo de salud indígena como respuesta cultural a la necesidad de mantener la salud y tratar la enfermedad, un modelo organizado jerárquicamente en el que la salud del individuo depende además de sus hábitos, de la armonía con la naturaleza, el espíritu, los dioses y su comunidad. Este modelo había sido menospreciado hasta hace poco tiempo por la comunidad científica; pero, gracias a los estudios en interculturalidad, se sabe que la salud también debe ser intercultural y que las políticas públicas deben incluirla para poder obtener los resultados esperados en la comunidad objetivo. Para hacer realidad estas políticas públicas debe haber voluntad y agenda política, una adecuada estructura en los servicios de salud y formación de los profesionales de la salud en interculturalidad desde sus estudios técnicos, tecnológicos, profesionales y de posgrado. Esas políticas públicas deben contener: capacitación, empleo de la lengua indígena local, alimentación y equipamiento con elementos tradicionales, diálogo respetuoso con los médicos tradicionales, atención humanizada, entre otros. Así se brinda una atención en salud de calidad que respeta las diferencias culturales de toda la población.(AU)

ABSTRACT The indigenous population has lower living conditions reflected in higher morbidity and mortality despite the coverage of the Health System, so it is important to know the causes of these differences. For this, Interculturality is used as a bridge between western culture and indigenous culture. In this meeting of knowledge, the indigenous health model is identified as a cultural response to the need to maintain health and treat disease, a hierarchically organized model in which the health of the individual also depends on their habits, on harmony with nature, the spirit, the gods and their community. Until recently, this model had been undervalued by the scientific community, but thanks to studies in Interculturality, it is known that health must also be intercultural and that public policies must include it in order to obtain the expected results in the target community. To make these public policies a reality, there must be a will and a political agenda, an adequate structure in the health services and training of health professionals in interculturality from their technical, technological, professional and postgraduate studies. These public policies must contain training, use of the local indigenous language, food and equipment with traditional elements, respectful dialogue with traditional doctors, humanized care, among others. This provides quality health care that is respectful of cultural differences to the entire population.(AU)

Culturally Sensitive Care in the Neonatal Setting to Infants Born to Parents From the Traveler Community: An Exploration of the Perspectives of Neonatal Staff.

Introduction: Culture and traditions influence people's health beliefs and these influence their actions and behaviors to prevent ill health and promote health and well-being. This qualitative study explored nurses'/midwives perspectives of culturally sensitive care in a neonatal setting to infants born to parents from the Traveler community. Method: A descriptive qualitative approach was used to interview 10 nurses/midwives from a neonatal unit in Ireland. Data were analyzed using Burnard's framework. Results: Themes identified were as follows: (a) barriers to breastfeeding for women from the Traveler community, (b) cultural issues affecting care provision to Traveler families in the neonatal unit, and (c) concerns of neonatal staff for infants born within the Traveler community. Discussion: The culture of the Traveler group was recognized as a major influence on decision making and interactions within the neonatal unit. Strategies are identified that could enhance the care of this group and the care of other ethnic groups.

The Future of Nursing Education: Multidisciplinary Community-Engaged Research for Undergraduate Nursing Students.

BACKGROUND: Undergraduate nursing students with research experience are more likely to pursue graduate education. Community-engaged research mentoring facilitates not only this process but also student engagement in topics such as cultural relevance and community partnerships. METHOD: Two cohorts of undergraduate students participated in a novel yearlong multidisciplinary mentored research experience based in a predominantly Black community. A qualitative, descriptive study using semistructured interviews was conducted with undergraduate students to describe effects of a multidisciplinary, community-engaged mentored research experience on cultural sensitivity, acquisition of research skills, and intent to pursue graduate study. RESULTS: Both cohorts of students demonstrated cultural sensitivity, acquired basic research skills, and had favorable attitudes toward or a definitive plan to pursue graduate education influenced by their participation in the mentored research experience. CONCLUSION: This approach may represent a viable strategy for increasing the number of graduate-prepared nurses and reducing health disparities via the provision of culturally competent care. [J Nurs Educ. 2020;59(6):341-344.].

Teaching health professionals how to tailor gender-affirming medicine protocols: A design thinking project.

BACKGROUND: Content knowledge surrounding transgender (trans) medicine is currently lacking in the formal medical education curricula. Evidence indicates that the main protocols used to assess and refer trans patients for gender-affirming medicine are misunderstood by health professionals, and require flexible adaptation to achieve health equity and patient-centred care. APPROACH: A free online educational tool for gender-affirming medicine, The Path to Patient-Centred Care, was developed to teach learners how to adapt assessment protocols. Resource creation was supported by a knowledge translation grant that endorsed design thinking, a human-centred and solutions-focused framework recommended for use in curriculum development. EVALUATION: The Path to Patient-Centred Care provides learners with information related to key principles of patient-centred care in gender-affirming medicine, including a guide on how to adapt the main assessment protocols to achieve equitable care. The curriculum also includes narratives from trans patients and health professionals that focus on health equity, and a clinical vignette about a complex case, designed to foster critical thinking on medical ethics. Project future directions involve an implementation and evaluation pilot study with a diverse group of continuing professional development medical learners using a mixed-methods program evaluation design. REFLECTION: The use of design thinking to develop this resource exemplifies a novel approach to curriculum development. By using pedagogical strategies that foster critical reflection, this innovative online education tool strives to teach self-directed learners how to provide care that emphasizes trans people's self-determination and autonomy in medical decision-making.

Decolonizing and Indigenizing pharmacy education in Canada.

BACKGROUND: An emphasis on equity, diversity, and inclusion is growing within the field of education, including health professions education. In particular, no published literature exists regarding decolonizing and Indigenizing pharmacy education. Post-secondary pharmacy programs in Canada have a unique opportunity to learn from the decolonizing and Indigenizing practices observed in the educational programs of other health professions and post-secondary institutions and become international leaders in this area. METHODS: Literature searches on PubMed, MEDLINE, ERIC (Ovid), iPortal, and PsycINFO were performed, revealing zero articles on decolonizing and/or Indigenizing pharmacy education. Search terms were expanded to include all health professions education programs with published literature on decolonizing and Indigenizing practices. All publications that included either or both terms (decolonizing and/or Indigenizing) and within any realm of health professions education (e.g., curriculum, assessment, evaluation, instructional design) were reviewed. RESULTS: Literature on decolonizing and Indigenizing health professions education in health disciplines, such as nursing and speech pathology, were reviewed. In conjunction with literature on decolonization and Indigenization of education, with a focus on post-secondary institutions, a number of strategies are proposed to decolonize and Indigenize pharmacy education. IMPLICATIONS: Findings from this review will better inform post-secondary pharmacy education programs to engage in decolonization and Indigenization practices. Engaging in decolonization and Indigenization of pharmacy education is expected to not only improve the educational experience of Indigenous students in pharmacy programs, but also improve the care received by Indigenous patients from all graduates of pharmacy.

A Theory of Cultural Humility.

Introduction: Leaders are realizing the importance of recognizing diversity and applying cultural humility for successful outcomes. When a difference in perspective is misunderstood or not adequately considered, the resulting conflict interferes with the accomplishment of goals and relationships. With the intent to advance mutual understanding and improve human interactions, a theory to guide nurses and other professions on how to appreciate diversity and apply cultural humility is presented. Method: Guided by Walker and Avant's strategies, the theory was developed from a synthesis of key concepts and constructs from research and scholarly works. Results: The theory of cultural humility is presented. Discussion: To foster a better understanding of the multiple considerations involved in being culturally humble, this theory provides clarity of the related concepts, influences, and outcomes. This theory may help learners recognize the multiple factors that lead to discordant perspectives and exude flexibility to foster positive outcomes.

State Regulations to Support Children's Cultural and Religious Food Preferences in Early Care and Education.

OBJECTIVE: In July 2018 the Academy of Nutrition and Dietetics released a benchmark encouraging early care and education (ECE) programs, including child care centers and family child care homes, to incorporate cultural and religious food preferences of children into meals. We examined the extent to which states were already doing so through their ECE licensing and administrative regulations prior to the release of the benchmark. This review may serve as a baseline to assess future updates, if more states incorporate the benchmark into their regulations. METHODS: For this cross-sectional study, we reviewed ECE regulations for all 50 states and the District of Columbia (hereafter states) through June 2018. We assessed consistency with the benchmark for centers and homes. We conducted Spearman correlations to estimate associations between the year the regulations were updated and consistency with the benchmark. RESULTS: Among centers, eight states fully met the benchmark, 11 partially met the benchmark, and 32 did not meet the benchmark. Similarly for homes, four states fully met the benchmark, 13 partially met the benchmark, and 34 did not meet the benchmark. Meeting the benchmark was not correlated with the year of last update for centers (P = 0.54) or homes (P = 0.31). CONCLUSIONS: Most states lacked regulations consistent with the benchmark. Health professionals can help encourage ECE programs to consider cultural and religious food preferences of children in meal planning. And, if feasible, states may consider additional regulations supporting cultural and religious preferences of children in future updates to regulations.

Race and Blackness: A Thematic Review of Communication Challenges Confronting the Black Community Within the U.S. Health Care System.

Effective communication is integral to the patient-provider relationship. Yet, as a result of structural factors that ignore the unique health care needs of different populations of patients who identify as Black-both African American and African immigrants-are confronted with communication challenges during health care seeking encounters. Using cultural safety as a framework, in this article, we thematically review communication challenges specifically experienced by patients of African descent in the U.S. health care system. In our review, we focus on complications that might arise from discrimination, mistrust, health literacy, and impacts of culture and language barriers on health literacy. In conclusion, we offer recommendations for improving the health care experiences and potential health outcomes for this population, through nursing care and health care delivery.

Intended and Unintended Consequence in the Digital Age of Psychiatry: The Interface of Culture and Technology in Psychiatric Treatments.

Culture plays a critical role in shaping the structure, content, and process of psychiatric treatment and influences the use of technology. Mental health providers and health care systems should account for the impact of the interface of technology and culture on clinical processes. Psychiatrists need to assess and monitor the impact of this interface on therapeutic processes. Health care systems should attend to these issues as they develop, adapt, and deploy technologies. As a field, psychiatry needs to develop frameworks for formally evaluating the use of existing and innovating technologies for use in mental health treatment.

Nurses- puerperal mothers interaction: searching for cultural care.

OBJECTIVE: To identify the importance of the cultural care dimension in the nurse-puerperal mother interaction. METHOD: Qualitative study based on content analysis. To collect data, 36 semi structured interviews were applied (21 nurses and 15 women who had recently given birth). The participants' free and informed consent was ensured and all ethical requirements were respected. Data analysis was supported by NVivo 10 software. RESULTS: The following categories were considered the most relevant: (i) nurses' attitudes that puerperal mothers consider crucial in health care provision; (ii) nurses' cultural competence; (iii) language resources used by nurses in their interaction with people from other cultures; (iv) the limitations that were observed during nurses-new mothers interactions. CONCLUSION: Evidence shows that, generally speaking, nurses claim to provide personalized health care assistance. However data revealed that the kind of interaction observed between nurses and women who had just given birth has not always been the most effective and that the former often show they lacked the appropriate cultural competence to deal with the latter's expectations and needs.

Nurses- puerperal mothers interaction: searching for cultural care / Interacción enfermeras y madres: en la búsqueda de un cuidado cultural / Interação enfermeiros e puérperas: na procura de um cuidado cultural

ABSTRACT Objective: To identify the importance of the cultural care dimension in the nurse-puerperal mother interaction. Method: Qualitative study based on content analysis. To collect data, 36 semi structured interviews were applied (21 nurses and 15 women who had recently given birth). The participants' free and informed consent was ensured and all ethical requirements were respected. Data analysis was supported by NVivo 10 software. Results: The following categories were considered the most relevant: (i) nurses' attitudes that puerperal mothers consider crucial in health care provision; (ii) nurses' cultural competence; (iii) language resources used by nurses in their interaction with people from other cultures; (iv) the limitations that were observed during nurses-new mothers interactions. Conclusion: Evidence shows that, generally speaking, nurses claim to provide personalized health care assistance. However data revealed that the kind of interaction observed between nurses and women who had just given birth has not always been the most effective and that the former often show they lacked the appropriate cultural competence to deal with the latter's expectations and needs.

RESUMEN Objetivo: identificar la dimensión de la competencia cultural en la interacción entre enfermeras y mujeres que hayan dado a luz recientemente. Método: estudio cualitativo basado en el análisis de contenidos. En la recopilación de datos se utilizó la entrevista semiestructurada. Han participado 21 enfermeras y 15 madres en un total de 36 entrevistas. Se aseguró el consentimiento previo, libre e informado de todos los participantes y todos los requisitos éticos fueron respetados. El análisis de datos fue apoyado por el programa NVivo 10. Resultados: las siguientes categorías fueron destacadas: (i) actitudes de las enfermeras que las madres creen ser indispensables en el proceso de cuidar; ii) el ejercicio de la competencia cultural; iii) los recursos lingüísticos utilizados por las enfermeras en la interacción con personas de otras culturas; iv) restricciones y problemas observados en las interacciones entre enfermeras y madres. Conclusión: se concluye que, en general, las enfermeras afirman que cuidan de sus pacientes de manera personalizada. Todavía, los datos revelaron que las interacciones entre enfermeras y madres son a menudo poco eficaces y a las enfermeras les resulta difícil demostrar su competencia cultural.

RESUMO Objetivo: Identificar a dimensão do cuidado cultural na interação entre enfermeiras e puérperas. Método: Estudo qualitativo assente na análise de conteúdo. Na colheita de dados se utilizou a entrevista semiestruturada, a 21 enfermeiras e 15 puérperas num total de 36 entrevistadas. Se assegurou o consentimento livre e esclarecido bem como respeitaram-se todos os requisitos éticos. A análise de dados foi suportada pelo NVivo 10. Resultados: Destacaram-se as categorias: (i) Atitudes das enfermeiras que as puérperas reconhecem imprescindíveis no processo de cuidar; (ii) Exercitar a competência cultural; (iii) Recursos linguísticos utilizados pelas enfermeiras na interação com pessoas de outras culturas; (iv) Constrangimentos manifestados nas interações enfermeiras e puérperas. Conclusão: Conclui-se que apesar das enfermeiras, ao nível discursivo, afirmarem que cuidam de forma personalizada, os dados revelaram que nem sempre as enfermeiras foram eficazes nas interações com as puérperas, de forma a demonstrarem a competência cultural, num estadio considerado culturalmente consciente.

A Culture-Based Family-Centered Health Navigation Intervention for Chronic Disease Management in Native Hawaiians.

Greater medical and psychological concerns coupled with disparities in income and education and experiences with cultural distress have created an unprecedented demand for health and mental health services for Native Hawaiians. With 75% of the healthcare system moving to a value-based system within the next 2 years, a low-cost workforce that brings added value will be in high demand. The addition of community health navigators to an existing integrated patient-centered medical home may result in a culturally congruent, preventive, and responsive model of wellness that promotes health equity. The purpose of this paper is to discuss the culturally-based navigation framework we used to implement a pilot program in an integrated primary care setting, describe the intervention that was used, and examine the lessons learned throughout the process. Outcomes will be provided at a later date. We believe that our model will not only redesign an existing clinical practice but also will provide a reproducible model that can be translated into other settings to increase the health care utilization among Native Hawaiians and lead to improved outcomes.