Dismantling Barriers to Health Equity

September 2020Milenko Martinovich

The obstacles that stand between our most vulnerable populations and effective health care are multi-layered and complex, but researchers at the UCSF School of Nursing are working to eradicate barriers to health equity. 

From bettering the lives of San Francisco Bay Area transit workers, to improving diversity in precision medicine research, to facilitating a safe health care environment for LGBTQ+ individuals, the School’s faculty and doctoral students are committed to advancing equal access to health care and opportunities for optimum health. 

Healthy Public Transit System = Healthy Community

Keeping public transit systems running smoothly 24 hours a day requires a fleet of workers, both on the front lines and behind the scenes. But what toll does that take on workers, mentally and physically? And how does the workers’ stress impact their work?

Brianna Singleton, a PhD student in the School of Nursing, is examining occupational burnout among Bay Area Rapid Transit (BART) workers, with the goal of improving the relationships between organizations and their workers to co-create a workplace culture that supports employees’ well-being. Her work aims to illuminate the unique mental health experience of transit industrial workers — specifically mechanics and electricians — who are often underrepresented in health research. 

Historically, BART, and the transit industry as a whole, represent the rich racial, ethnic and cultural diversity of the communities they serve. Similarly, transit workers experience many of the same work stressors as transit users — long commutes to work, navigating relationships with supervisors and co-workers, and balancing personal and professional obligations.

However, there are occupational hazards specific to the transit industrial industry, Singleton said. Singleton is conducting comprehensive interviews with these workers to explore the connections between worker identity and perceptions of health, wellness and occupational burnout. 

And their health can have a tangible community impact. If a bus mechanic is depressed and cannot go to work one day, a replacement must be found. If not, that bus may not be operational or arrive late, impacting thousands of people trying to get to work. 

These things add up, Singleton said. If buses and trains continue to be late, more people will decide to drive, causing more environmental damage. Because housing and businesses are usually built near transit hubs, communities may lose those elements if public transit becomes unreliable and fewer people utilize it. 

“We need a healthy public transit system to have a healthy community,” she said. “To achieve that, we need healthy workers – mentally and physically.”

What Does Diversity Mean in Precision Medicine Research?

In recent decades, researchers have made a concerted effort to increase diversity among participants in precision medicine research (PMR).  Even with these efforts, less than 4 percent of all participants in genome-wide association studies (GWAS) were of African and Hispanic/Latin American ancestry. 

What constitutes diversity and who gets to decide? Professor Janet Shim, along with graduate students Nicole Foti and Mel Jeske, are exploring these questions. 

Janet Shim Shim and her team, with collaborators at Columbia University, Stanford University and the University of Washington, are following ongoing studies involved in several national PMR consortia, interviewing the studies’ researchers and learning how diversity and inclusion are being defined and implemented, from recruitment to data collection to measurement and analysis. What questions are the researchers asking participants? How are similarities and differences among individuals and groups being described, defined, measured and compared? Who gets to decide and how are those decisions made? 

The team aims to mine the range of strategies used, and develop guidance for the research community on the consequences of different ways to infuse diversity and inclusion throughout these research projects. 

“There are always going to be choices,” Shim said. “Trying to systematically offer a view of what some of the big tradeoffs might be in terms of how diversity is defined and operationalized, and ideas and strategies around inclusion, that’s our end game.” 

The UCSF team has collected data for the past two years and will continue to do so for the next two years. Sandra Soo-Jin Lee, a professor at Columbia University, serves as the principal investigator on this NIH-funded study along with Shim as co-principal investigator. 

“At the end of the day, it’s about having researchers think more proactively about some of these decisions and have diversity and inclusion not just be words or good PR, but a commitment to specific practices all throughout the lifecourse of their studies,” Shim said. 

Removing Breastfeeding Disparities for Black Women

Across the nation, due to systemic barriers such as racism, Black infants are less likely to be breastfed or receive donor human milk than other babies. A Centers for Disease Control study found the breastfeeding rate for Black babies at 3 months of age was 58 percent, while the rate for white infants was 73 percent.

Ifeyinwa Asiodu, an assistant professor in the School of Nursing, is working to examine the barriers that lead to breastfeeding disparities and perpetuate health inequities in Black Ifeyinwa Asiodu communities. Asiodu’s research and outreach aims to increase Black women’s access to resources and services necessary to nourish healthy babies. She hopes her current two-year NIH-funded project, “Contraception, Human Milk, and Research Mechanisms (CHARM) Study,” will lead to the development and testing of culturally appropriate interventions that center both breastfeeding and contraception and improve health care services and education received by Black women, infants and families.

During the COVID-19 pandemic, access to quality perinatal resources and support has been more restricted, and Black mothers have been particularly affected during this time.

Asiodu has partnered with the California Black Infant Health Program and the California Breastfeeding Coalition to launch and lead the COVID-19 Birth Worker Relief Fund. The fund provides one-time grants to Black, Indigenous, People of Color (BIPOC) birth workers - lactation support persons, doulas, midwives, and BIPOC-led public health and community-based organizations serving pregnant and postpartum BIPOC communities during the pandemic. 

About 141 BIPOC individuals and organizations have been selected to receive relief funding as of Sept. 3. The fund has received financial support from the Tara Health Foundation, W.K. Kellogg Foundation, Yellow Chair Foundation,  Every Mother Counts, Pritzker Family Foundation, Medela, the Foundation for the Advancement of Midwifery, Coeffective and private donors, bringing its total to more than $330,000. 

Overcoming Barriers for Gender Minority Individuals in Health Care Settings

LGBTQ+ individuals often avoid seeking health care because of the stress they experience from interacting with providers. They have reported being rejected for care and providers lacking awareness of their health needs — such as screening transgender men on whether they need pap smears. These unmet needs can lead to harmful outcomes.

Kristen Clark To support the health of the LGBTQ+ community, Kristen Clark, a PhD student in the School of Nursing, is examining stressors that gender minority individuals encounter in health care settings and how those stressors affect their physical and mental health. 

“There are a lot of provider knowledge gaps and that makes it challenging to get care,” she said. “Knowing you’ll have to explain that you’re trans is a stressful experience to anticipate. And when you’re discouraged from seeking care, you may seek resources from places that are not safe.” 

By minimizing or removing these stressors, Clark believes LGBTQ+ individuals would be more likely to seek preventative care and treatment. 

In her NIH-funded project, Clark is analyzing data from the 2015 United States Transgender Survey to help identify factors that are causing stressors in health care settings. Her study concludes in 2021, but results thus far indicate “an association between health care discrimination and emotional and physical symptoms” for transgender individuals. 

Having providers who are more knowledgeable and understanding of transgender individuals could help minimize these negative experiences, she said.

“Making sure providers are competent to care for people who are vulnerable and are just seeking what they need to live in a peaceful way is really important,” Clark said.