Nanlesta A. Pilgrim

Race/Ethnicity and Workplace Discrimination: Results of a National Survey of Physicians

ABSTRACTBACKGROUNDPromoting racial/ethnic diversity within the physician workforce is a national priority. However, the extent of racial/ethnic discrimination reported by physicians from diverse backgrounds in today’s health-care workplace is unknown.OBJECTIVETo determine the prevalence of physician experiences of perceived racial/ethnic discrimination at work and to explore physician views about race and discussions regarding race/ethnicity in the workplace.DESIGNCross-sectional, national survey conducted in 2006–2007.PARTICIPANTSPracticing physicians (total n = 529) from diverse racial/ethnic backgrounds in the United States.MEASUREMENTS AND MAIN RESULTSWe examined physicians’ experience of racial/ethnic discrimination over their career course, their experience of discrimination in their current work setting, and their views about race/ethnicity and discrimination at work. The proportion of physicians who reported that they had experienced racial/ethnic discrimination “sometimes, often, or very often” during their medical career was substantial among non-majority physicians (71% of black physicians, 45% of Asian physicians, 63% of “other” race physicians, and 27% of Hispanic/Latino(a) physicians, compared with 7% of white physicians, all p < 0.05). Similarly, the proportion of non-majority physicians who reported that they experienced discrimination in their current work setting was substantial (59% of black, 39% of Asian, 35% of “other” race, 24% of Hispanic/Latino(a) physicians, and 21% of white physicians). Physician views about the role of race/ethnicity at work varied significantly by respondent race/ethnicity.CONCLUSIONSMany non-majority physicians report experiencing racial/ethnic discrimination in the workplace. Opportunities exist for health-care organizations and diverse physicians to work together to improve the climate of perceived discrimination where they work.

Protective and Risk Factors Associated with Adolescent Sexual and Reproductive Health in the English-speaking Caribbean: A Literature Review

PURPOSE To identify risk and protective factors associated with adolescent sexual and reproductive health (ASRH) in the English-speaking Caribbean through a structured literature review. METHODS Peer-reviewed articles published between January 1998 and December 2009 focused on the sexual and reproductive health of adolescents, aged 10-19 years, were included in this review. Articles were organized according to Bronfenbrenners ecological systems theory. Research gaps were also identified. RESULTS A total of 30 studies assessed ASRH. At the individual level, gender, psychosocial well-being, and mental health were key factors associated with ASRH. Within the microsystem, the quality of the parent-adolescent relationship, the presence of violence, substance abuse or mental health problems in the family, and peer relationships were important determinants of ASRH. Within the macrosystem, cultural attitudes had an effect on youths sexual behavior and generally, safer sex practices appear to be increasing. Within the chronosystem, a history of physical and sexual abuse was associated with several ASRH outcomes. CONCLUSION A research agenda that incorporates a multisystem approach and advocates for the inclusion of socially marginalized youth is needed to fully understand and adequately address ASRH in the Caribbean.

Health care workplace discrimination and physician turnover.

OBJECTIVE To examine the association between physician race/ ethnicity, workplace discrimination, and physician job turnover. METHODS Cross-sectional, national survey conducted in 2006-2007 of practicing physicians (n = 529) randomly identified via the American Medical Association Masterfile and the National Medical Association membership roster. We assessed the relationships between career racial/ethnic discrimination at work and several career-related dependent variables, including 2 measures of physician turnover, career satisfaction, and contemplation of career change. We used standard frequency analyses, odds ratios and chi2 statistics, and multivariate logistic regression modeling to evaluate these associations. RESULTS Physicians who self-identified as nonmajority were significantly more likely to have left at least 1 job because of workplace discrimination (black, 29%; Asian, 24%; other race, 21%; Hispanic/Latino, 20%; white, 9%). In multivariate models, having experienced racial/ethnic discrimination at work was associated with high job turnover (adjusted odds ratio, 2.7; 95% CI, 1.4-4.9). Among physicians who experienced workplace discrimination, only 45% of physicians were satisfied with their careers (vs 88% among those who had not experienced workplace discrimination, p value < .01), and 40% were contemplating a career change (vs 10% among those who had not experienced workplace discrimination, p value < .001). CONCLUSION Workplace discrimination is associated with physician job turnover, career dissatisfaction, and contemplation of career change. These findings underscore the importance of monitoring for workplace discrimination and responding when opportunities for intervention and retention still exist.

Reaching Mothers and Babies with Early Postnatal Home Visits: The Implementation Realities of Achieving High Coverage in Large-Scale Programs

Background Nearly half of births in low-income countries occur without a skilled attendant, and even fewer mothers and babies have postnatal contact with providers who can deliver preventive or curative services that save lives. Community-based maternal and newborn care programs with postnatal home visits have been tested in Bangladesh, Malawi, and Nepal. This paper examines coverage and content of home visits in pilot areas and factors associated with receipt of postnatal visits. Methods Using data from cross-sectional surveys of women with live births (Bangladesh 398, Malawi: 900, Nepal: 615), generalized linear models were used to assess the strength of association between three factors - receipt of home visits during pregnancy, birth place, birth notification - and receipt of home visits within three days after birth. Meta-analytic techniques were used to generate pooled relative risks for each factor adjusting for other independent variables, maternal age, and education. Findings The proportion of mothers and newborns receiving home visits within three days after birth was 57% in Bangladesh, 11% in Malawi, and 50% in Nepal. Mothers and newborns were more likely to receive a postnatal home visit within three days if the mother received at least one home visit during pregnancy (OR2.18, CI1.46–3.25), the birth occurred outside a facility (OR1.48, CI1.28–1.73), and the mother reported a CHW was notified of the birth (OR2.66, CI1.40–5.08). Checking the cord was the most frequently reported action; most mothers reported at least one action for newborns. Conclusions Reaching mothers and babies with home visits during pregnancy and within three days after birth is achievable using existing community health systems if workers are available; linked to communities; and receive training, supplies, and supervision. In all settings, programs must evaluate what community delivery systems can handle and how to best utilize them to improve postnatal care access.

Sexual Coercion Among Adolescent Women in Rakai, Uganda Does Family Structure Matter?

Studies on adolescent girls’ vulnerability to sexual coercion in Sub-Saharan Africa have focused mainly on individual and partner risk factors, rarely investigating the role the family might play in their vulnerability. This study examined whether household family structure and parental vital status were associated with adolescent girls’ risk of sexual coercion in Rakai, Uganda. Modified Poisson regression was used to estimate relative risk of sexual coercion in the prior 12 months among 1,985 unmarried and married adolescent girls aged 15 to 19 who were participants in the Rakai Community Cohort Study between 2001 and 2008. Among sexually active girls, 11% reported coercion in a given past year. Unexpectedly, living with a single mother was protective against experiencing coercion. As much as 4.1% of never-married girls living with single mothers reported coercion, compared to 7.8% of girls living with biological fathers (adj. relative risk [RR] = 2.24, 95% confidence interval [CI]: 0.98-5.08) and 20% of girls living in stepfather households (adj. RR = 4.73, 95% CI: 1.78-12.53). Ever-married girls whose mothers alone were deceased were more likely to report coercion than those with both parents alive (adj. RR = 1.56, 95% CI: 1.08-2.30). Protecting adolescent girls from sexual coercion requires prevention approaches that incorporate the family, with particular emphasis on including the men (e.g. fathers) who might play an influential role in young girls’ sexual development. Understanding the family dynamics underlying the risk and protective effects of a given household structure might highlight new ways in which to prevent sexual coercion.

Adolescent mental and physical health in the English-speaking Caribbean

OBJECTIVE Bronfenbrenners ecological systems theory, a multisystem framework, was used to identify risk and protective factors associated with adolescent mental and physical health (AMPH) in the English-speaking Caribbean. METHODS A structured literature review, using the online databases of Medline, PsychInfo, and Scopus, was conducted to identify peer-reviewed studies published between January 1998 and July 2011 focused on adolescents ages 10-19 years. RESULTS Sixty-eight articles were examined: 40 on adolescent mental health (AMH), 27 on adolescent physical health (APH), and 1 on both topics. Key individual factors included gender and age. Religiosity and engagement in other risk behaviors were associated with AMH, while the presence of other chronic illnesses affected APH. Significant determinants of AMH in the microsystem included family and school connectedness, family structure, and socioeconomic status. Maternal obesity, parental education, and school environment influenced APH. Studies that investigated macrosystem factors reported few consistent findings related to AMPH. A history of family mental health problems and physical and sexual abuse was significantly associated with AMH in the chronosystem, while a family history of diabetes and low birth weight were associated with APH. Studies did not examine the exosystem or the mesosystem. CONCLUSIONS AMPH in the English-speaking Caribbean is affected by a variety factors in developing adolescents and their surroundings. Gender, family, and early exposure to negative environments are salient factors influencing AMPH and present potential avenues for prevention and intervention. A fuller understanding of AMPH in this region, however, requires scientifically rigorous studies that incorporate a multisystem approach.

Clients’ Perceptions of Service Quality and Satisfaction at Their Initial Title X Family Planning Visit

Family planning service quality and clients’ satisfaction with services are important determinants of clients’ contraceptive use and continuation. We examine women’s experiences at family planning clinics on a range of dimensions, including patient-centered communication (PCC), and identify experiences associated with higher ratings of service quality and satisfaction. New female clients (n = 748), ages 18–35 years, from clinics in three major metropolitan areas completed computer-administered interviews between 2008 and 2009. Factors associated with primary outcomes of service quality and satisfaction were assessed using multinomial and ordinary logistic regression, respectively. Higher scores on a Clinician–Client Centeredness Scale, measuring whether clinicians were respectful, listened, and provided thoughtful explanations, were associated with perceptions of good quality care and being very satisfied. Higher scores on a Clinic Discomfort Scale, measuring staff and waiting-room experiences, were associated with reduced satisfaction. Clients’ interactions with clinicians, especially PCC, influence their perceptions of service quality, whereas their satisfaction with services is also influenced by the facility environment. These measures are adaptable for agencies to identify the factors contributing to their own clients’ satisfaction–dissatisfaction with care and perceptions of service quality.

Family structure effects on early sexual debut among adolescent girls in Rakai, Uganda

This study assessed the association between household family structure and early sexual debut among adolescent girls, ages 15–19, in rural Rakai District, Uganda. Early sexual debut is associated with detrimental physical, emotional, and social outcomes, including increased risk of HIV. However, research on the family’s role on adolescents’ sexual risk behaviors in sub-Saharan Africa has been minimal and rarely takes into account the varying family structures within which African adolescents develop. Using six rounds of survey data (2001–2008) from the Rakai Community Cohort Study, unmarried adolescent girls (n = 1940) aged 15–17 at their baseline survey, were followed until age 19. Parametric survival models showed that compared to adolescent girls living with both biological parents, girls who headed their own household and girls living with stepfathers, grandparents, siblings, or other relatives had significantly higher hazards of early sexual debut before age 16. Adolescent girls were significantly more likely to debut sexually if neither parent resided in the household, either due to death or other reasons. In addition, the absence of the living biological father from the home was associated with a higher risk of sexual debut, regardless of the biological mother’s presence in the home. Our study’s findings suggest that family structure is important to adolescent girls’ sexual behavior. There is need for research to understand the underlying processes, interactions, and dynamics of both low and high-risk family structures in order to devise and strategically target interventions for specific types of family structures.

Sexual and Reproductive Health Care Receipt Among Young Males Aged 15–24

PURPOSE This study aimed to describe young mens sexual and reproductive health care (SRHC) receipt by sexual behavior and factors associated with greater SRHC receipt. METHODS There were 427 male patients aged 15-24 who were recruited from 3 primary care and 2 sexually transmitted disease (STD) clinics in 1 urban city. Immediately after the visit, the survey assessed receipt of 18 recommended SRHC services across four domains: screening history (sexual health, STD/HIV test, family planning); laboratories (STDs/HIV); condom products (condoms/lubrication); and counseling (STD/HIV risk reduction, family planning, condoms); in addition, demographic, sexual behavior, and visit characteristics were examined. Multivariable Poisson regressions examined factors associated with each SRHC subdomain adjusting for participant clustering within clinics. RESULTS Of the participants, 90% were non-Hispanic black, 61% were aged 20-24, 90% were sexually active, 71% had female partners (FPs), and 20% had male or male and female partners (M/MFPs). Among sexually active males, 1 in 10 received all services. Half or more were asked about sexual health and STD/HIV tests, tested for STDs/HIV, and were counseled on STD/HIV risk reduction and correct condom use. Fewer were asked about family planning (23%), were provided condom products (32%), and were counseled about family planning (35%). Overall and for each subdomain, never sexually active males reported fewer services than sexually active males. Factors consistently associated with greater SRHC receipt across subdomains included having M/MFPs versus FPs, routine versus non-STD-acute visit, time alone with provider without parent, and seen at STD versus primary care clinic. Males having FPs versus M/MFPs reported greater family planning counseling. CONCLUSIONS Findings have implications for improving young mens SRHC delivery beyond the narrow scope of STD/HIV care.

Multiple sexual partnerships among female adolescents in rural Uganda: The effects of family structure and school attendance.

Abstract Background: A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents. Methods: The sample consisted of 2337 unmarried adolescent girls, aged 15–19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001–2008 available for each girl was used. Analyses were stratified by age (15–17 year olds and 18–19 year olds) and school status. Multinomial logistic and poisson regressions were used. Results: Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents. Conclusion: The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.