Approaching Trans Healthcare Competency: The Implementation of Trans Health Education for Medical Providers in Appalachia

Barriers to competent and safe healthcare disproportionately impact people who are marginalized because of their race, ethnicity, gender, or socioeconomic status. It is well documented that transgender patients in particular experience barriers to both accessing care and receiving high quality, non-discriminatory care (Hatzenbuehler & Pachankis, 2016; James et al., 2016; Rahman et al., 2019; Safer et al., 2016). This lack of access to culturally competent healthcare services contributes to health disparities that disproportionately impact the trans community. Literature on barriers to competent care for trans patients indicates that providers experience discomfort related to their ability to provide competent care (Safer et al., 2016). Many providers endorse a median of only five hours of trans healthcare training across their entire medical school curriculum (Hughto et al., 2015), and in some cases, as little as 45 minutes per year (Sawning et al., 2017). Primary care clinics should be the place in which general health and wellbeing are addressed for trans patients, as has been true for cisgender people. Primary care providers should be competent in assessing eligibility for Hormone Replacement Therapy (HRT) and surgery (Wylie et al., 2016), as well as providing necessary preventative care. Thus, this makes primary care the ideal setting for the proposed medical education implementation project. The current study aimed to develop and implement a training program for medical residents in primary care in rural South Central Appalachia. A six-stage development and implementation study is described. The intervention was evaluated for pedagogical outcomes including sustainability for future use, usefulness to residents, and accessibility. Evaluation of effectiveness included analyses of changes in providers’ self-reported competency, awareness of discriminatory experiences, and attitudes towards treating trans patients. There were no significant differences in pre-post competency scores (r=22, M=33.29[SD=5.96]; r=31, M=37.33[SD=1.02], SD=8.00) or in pre-post attitudes scores (r=15, M=32.76[SE=0.8], SD=4.69; r=13, M=34.7273[SE=1.00], SD=4.692). Accessibility and sustainability were measured qualitatively and included data such as resident attendance and ease of use of material for future behavioral health provider trainers. These outcomes were found to be satisfactory based on stakeholder feedback. Usefulness included three data points (satisfaction, helpfulness, value of training)

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

Hemophagocytic Macrophages Harbor Salmonella enterica during Persistent Infection

Salmonella enterica subspecies can establish persistent, systemic infections in mammals, including human typhoid fever. Persistent S. enterica disease is characterized by an initial acute infection that develops into an asymptomatic chronic infection. During both the acute and persistent stages, the bacteria generally reside within professional phagocytes, usually macrophages. It is unclear how salmonellae can survive within macrophages, cells that evolved, in part, to destroy pathogens. Evidence is presented that during the establishment of persistent murine infection, macrophages that contain S. enterica serotype Typhimurium are hemophagocytic. Hemophagocytic macrophages are characterized by the ingestion of non-apoptotic cells of the hematopoietic lineage and are a clinical marker of typhoid fever as well as certain other infectious and genetic diseases. Cell culture assays were developed to evaluate bacterial survival in hemophagocytic macrophages. S. Typhimurium preferentially replicated in macrophages that pre-phagocytosed viable cells, but the bacteria were killed in macrophages that pre-phagocytosed beads or dead cells. These data suggest that during persistent infection hemophagocytic macrophages may provide S. Typhimurium with a survival niche

Medical Mistrust Mediates the Relationship Between Sexual Victimization and Medical Non-Adherence

Sexual victimization has been associated with significant negative health outcomes as well as increased healthcare utilization (e.g., Breiding et al., 2013; Sickel et al., 2002). However, due to fear, embarrassment, or confidentiality concerns (Logan et al., 2004; Nasta et al., 2005), women may mistrust medical advice and not adhere to treatment recommendations, exacerbating development of negative health outcomes. Some research (Meade et al., 2009) has identified sexual victimization as a predictor of medical nonadherence, but to our knowledge no research has examined the role of medical mistrust in this relationship. A sample of 857 women was recruited via social media. Regression analyses in R Markdown revealed that sexual trauma was a significant predictor of both medical nonadherence (b = 0.4, SE = .08, p \u3c .0001) and medical mistrust (b = 1.36, SE = .027 p \u3c .0001), and further that medical mistrust predicted medical nonadherence (b = 0.06 SE = .01, p \u3c .0001). Additionally, medical mistrust was found to significantly mediate the relationship between sexual trauma and medical nonadherence (b = .09, SD = .03, 95% CI =.04, .14). Results emphasize the importance of trauma-informed care and patient-provider rapport in bolstering resiliency and strengthening survivors’ adherence to medical recommendations. Suggestions for further application and intervention will be discussed

Medical Mistrust Mediates the Relationship Between Sexual Victimization and Physical Health Complaints.

Abstract available in the Annals of Behavioral Medicine

Exploration of Risk and Resiliency Factors for the Relationship Between Infertility and Sexual Functioning.

Abstract available in the Annals of Behavioral Medicine

Prenatal Care and Breastfeeding Intentions in Rural Pregnant Women

Abstract available in the Annals of Behavioral Medicine

Anxiety Mediates the Relationship between Sexual Trauma Stigma and Somatic Health Complaints

Existing research demonstrates that sexual trauma victims experience increased risk of adverse health outcomes including cardiovascular disorders, increased risk of chronic pain, and somatic health complaints. Similarly, sexual trauma is correlated with increased risk of adverse psychological effects including PTSD, depression, and anxiety. Perceived stigmatization as a result of sexual trauma has been hypothesized to be a mechanism through which sexual trauma affects health. Sexual trauma stigma (STS) has been found to mediate the relationship between sexual trauma and psychological distress. The experience of stigmatization has also been linked to somatization and is associated with increased anxiety. Similarly, among a sample of participants with a trauma history, adversity and resultant discrimination predicted somatic health complaints with post-traumatic stress symptoms (PTSS) partially mediating this relationship. However, the experience of STS specifically and its effect on somatic health complaints and anxiety has not yet been examined. As anxiety is associated with somatic symptoms, and is often comorbid with PTSS, it may be a mechanism through which STS effects somatic health complaints. Therefore, the current study seeks to examine the relationship between STS and somatic health complaints as well as the potential mediating effect of anxiety. It was hypothesized that STS would predict somatic health complaints, and that anxiety would mediate this relationship. An international sample of 528 women with a sexual trauma history was recruited via social media (Reddit) and mediation results were found using the “psych” package for RMarkdown (Version 5.2.2) with bootstrapping (5000 samples). Overall, the model was significant R2 = .19, (F(2,1230) = 148.53, p \u3c .01). Regression analyses revealed that sexual trauma stigma was a significant predictor of both anxiety (b = .21, SE = .01, p \u3c .01) and somatic health symptoms (b = .13, SE =.01, p \u3c .01), and that anxiety also predicted somatic symptoms (b = .39, SE = .03, p \u3c .01). Anxiety was found to significantly mediate the relationship between sexual trauma and somatic health symptoms, b = .08, SE = .01, 95% CI [0.06, 0 .11]. Current findings confirm the relationship between sexual trauma stigma and somatic health complaints and identify anxiety as an important mediator of this relationship. Providers should be aware that experiences of sexual victimization are related to feelings of stigmatization and may increase anxiety, impacting somatic health complaints. These findings indicate future clinical implications for trauma informed care within medical settings to better serve women who may experience stigma related to sexual trauma and highlights anxiety as a key target for interventions to reduce somatic symptoms

Infertility’s Impact on Relationship Satisfaction: The Role of Sexual Dysfunction and Infertility Stigma

Abstract available in the Annals of Behavioral Medicine

Association Between Time Trying to Conceive and Self-Perceptions of Female Infertility

Female infertility is a prevalent global health concern. Social class has been examined in relation to interpretations of formal infertility diagnoses. However, this study sought to investigate subjective self-definitions of infertility experiences. This study compared reported length of time trying to conceive and self-perceptions of infertility status, which created four groups: women who met the medical definition of infertility and considered themselves to be experiencing infertility, women who met the medical definition and did not consider themselves to be experiencing infertility, women who did not meet the medical definition but did consider themselves to be experiencing infertility, and women who did not meet the medical definition of infertility and did not consider themselves to be experiencing infertility. We were interested in examining subjective socioeconomic status as a predictor of group membership, operating on the idea that women who perceive themselves as lower SES might be less likely to acknowledge a subjective infertility status due to more limited resources for treatment. Female participants (N = 1233) were recruited from the social networking site Reddit to complete online self-report surveys created via the REDCap survey platform. A subset of female participants (n = 548) who reported they were currently trying to conceive was utilized for this study’s sample. A chi-square test of independence was conducted to examine the relationship between reported length of time trying to conceive and self-perceptions of infertility status. Results indicated a significant association between these variables, χ2 (1, N = 594) = 239.08, p \u3c .001, indicating that women’s self-perception of whether or not they were experiencing infertility was largely in line with the medical definition of infertility. We intended to conduct logistic regression analysis to examine subjective socioeconomic status as a predictor of group membership, specifically for women who met the medical definition of infertility but did not perceive themselves as experiencing infertility. However, logistic regression was not performed due to a lack of statistical power for this group (n = 14). Future research should expand upon this rationale to inclusively investigate factors contributing to self-identification of infertility experiences. Understanding the role of psychosocial factors involved in infertility status perceptions could facilitate specific interventions to promote infertility treatment-seeking behaviors