Literature Review on Effective Sex- and Gender-Based Systems/Models of Care

January 30, 2007

Research Question 2: Reaching the Underserved

2. What models or approaches have been successful in engaging and retaining people in systems of healthcare, especially the underserved, the "difficult to reach," or low literacy populations? Are there sex/gender differences in the effectiveness of these approaches?

The question of how best to engage and retain the underserved in the U.S. healthcare system is a critical one. Such populations, by definition, are not frequent users of the healthcare system. They encounter numerous barriers to care, including lack of insurance, lack of financial resources, cultural and educational barriers (including a lack of knowledge on how to navigate the system to obtain care), and time constraints, among others. Our analysis of this literature is divided into three main topics. First, we identify and discuss the main approaches that have been used thus far to reach underserved populations. Second, we describe several approaches that have been successful in engaging or retaining underserved populations, including a description of the work CoEs have done in this regard. Finally, we provide data on the effectiveness of various approaches. To conclude the section, we discuss sex/gender differences in these approaches.

It is worth noting that approaches to engage or retain the underserved require an initial investment of time and resources, and this poses a barrier which must be overcome before change can occur. At the same time, many healthcare systems are realizing they must address these issues:

There are many cases when health care organizations see little or no short-term direct financial gain from improved communications with vulnerable populations. It can take considerable resources, in the short term, to address communication gaps. For instance, it can be expensive to implement interpreter services, which are rarely reimbursed to the level of their immediate costs. And some of the populations that are most at risk for communication gaps are poor and uninsured or underinsured. As a result, activities that attract these patients for care might seem to present an initial fiscal risk to a health care organization. On the other hand, most leaders know that ignoring vulnerable populations is not a realistic solution for the long-term. And there are significant costs associated with knowingly providing ineffective communication (American Medical Association, 2006).

Perhaps because of this initial financial barrier, paired with differences across organizations in their willingness to invest resources in this area, there is a wide degree of variability in how organizations are addressing this challenge. In this section, we discuss some of the innovators in this area.

There are numerous approaches to reaching and retaining underserved populations in the healthcare system. These approaches include respecting cultural values, using community health workers, reaching people at nontraditional or community-based sites to provide care, using appropriate language, modeling behavior, meeting other needs, and using follow-up reminders. We discuss each of these approaches in more detail in this section of the report.

One of the key approaches to designing healthcare systems that attract and retain underserved populations is to make these systems as culturally competent as possible. Cultural competency, at its core, simply means being aware of, respecting, and considering others' values. One technique that has been advocated to make care more culturally competent is for healthcare workers to inquire "into individuals' personal interpretations of their life's world experiences rather than relying on catalogs of cultural attributes or by adhering to popularly held opinions" (Kleiman, 2006). In particular, Kleiman (2006) highlights the need to ensure patients understand their treatment so that any objections or special needs can be addressed.

Cultural sensitivity creates a foundation for good relationships between healthcare providers and patients. If patients feel misunderstood, disrespected, or ignored, they are less likely to present for care. Cultural competency may be especially crucial for underserved populations (e.g., "lower-income respondents place more importance than counterparts on the doctor-patient relationship" (O'Malley & Forrest, 2002)), and, as America grows more diverse, cultural competency will continue to become more important (Strobino, Grason, & Minkovitz, 2002). Accordingly, cultural competency is increasingly being recognized as important by healthcare scholars and researchers (Fongwa, Evangelista, & Doering, 2006).

Studies repeatedly find that patients desire care that is culturally competent. For example, in a series of focus groups, "women expressed the importance of being in an all-inclusive, diverse, respectful, and nonviolent community, being treated as equal partners, being informed and skilled, continually learning and developing" (Kasle et al., 2002). A Canadian study of women's health needs reached a similar conclusion: "Both clinic staff and women drew attention to the importance of respectful and culturally appropriate interactions during clinical encounters" (Bottorff, Balneaves, Sent, Grewal, & Browne, 2001).

Studies of disadvantaged women also emphasize the need for care that is sensitive. For example, in a study of homeless women, their No. 1 complaint about the healthcare system was a perceived lack of respect from providers (Gelberg, Browner, Lejano, & Arangua, 2004). Lesbian women report similar problems. One set of authors has concluded "there is an absolute necessity for physician training programs ... [so that] lesbian women do not feel invisible, threatened, or estranged" (Bergeron & Senn, 2003). Another set of authors recommended seven steps for healthcare providers to make their settings more appropriate for lesbians, including not assuming that all patients are heterosexual (and changing routine forms to reflect that), creation of a safe environment where anti-gay/lesbian conversation is not tolerated, and assurances of confidentiality (Barbara & Quandt, 2001).

In addition to helping to attract and retain patients, cultural competency also may be related to a higher quality of care: "A recent review of published studies using an experimental or quasi-experimental design concluded that patients who received culturally competent care had significant improvement on multiple health outcomes, compared with those who did not" (Williams, 2005).

Another strategy to reach underserved populations is the use of community health workers. These lay health workers are called many things, including neighborhood workers, linkworkers, indigenous health workers, family health advocates, patient navigators, lay health advisers, consejeras, or promotoras. However, "a common definition of community health workers is that they are members of the community who work outside established health care locales to serve as connectors between populations that have been traditionally underserved and health care providers" (Brach & Fraserirector, 2000). As reflected in these many names, how these programs are implemented "on the ground" varies considerably.

To provide an example of how such a program might work, the "Woman-to-Woman Project" used family health advocates as a community-based intervention to reduce infant mortality rates. Trained women advocates from within the community met multiple times with young mothers and families to facilitate help-seeking and to create a social support network. Early results indicate that this approach is working (Baffour, Jones, & Contreras, 2006).

The study of such community health worker programs is becoming more common. For example, the National Cancer Institute recently awarded $25 million in grants to eight research institutions to fund patient navigator research programs. Each grant will focus on "cancer patients from racial/ethnic minority groups, patients with low socioeconomic status, and patients from medically underserved areas" (National Institutes of Health, 2005). Results from this research are not yet available.

The use of community health workers seems promising enough that at least one researcher has called for "the institutionalization of link workers, health advocates, or lay workers (promotoras) as part of the U.S. health care system" as a successful approach to correct some of the known deficits (Zambrana, 2001).

Another approach to reaching disadvantaged populations is to reach people where they are. For example, sex workers in Thailand were reached using a mobile bus that traveled to locations frequented by sex workers, where they were offered free and immediate screening for sexually transmitted diseases (Bush, Moss, & Wallis, 2006). Another "reach people where they are" approach that has been suggested is to screen new mothers for depression at well-child pediatric visits (Feinberg et al., 2006). Such approaches create opportunities to interact with otherwise hard-to-reach patients.

This approach is especially important as a means to reach people who may never go to a traditional healthcare location. For example, "seeking out women at popular gathering sites in the community, rather than waiting for them to present to a health care facility, is particularly appropriate for women affected by mental illness or homelessness" (Heyding, Cheung, Mocarski, Moineddin, & Hwang, 2005).

Places of religious worship are key sites for such interventions, especially for certain population segments. For example, studies have identified "community organizations, civic groups, and especially churches to be important channels of information to increase screening rates among African-American women" (Reid, Marshburn, & Siddharthan, 1999). Partnership with influential community organizations (such as faith-based groups) emphasizes the importance of health-related messages while providing an additional support structure for such messages. For example, "Project Joy, a faith-based initiative jointly funded by the Centers for Disease Control and the [NIH] Office of [Research on] Women's Health, showed improvement in body weight, waist circumference, systolic blood pressure, and healthful eating. ... An important component of this intervention was the involvement of the church community in its development" (Johnson & Fulp, 2002).

When trying to reach disadvantaged populations, the use of appropriate language (including the use of native or dominant spoken and written languages, and appropriate delivery, tone, and literacy level) is crucial. Jackson, Camacho et al. (2001) nicely summarize this literature:

Differences in spoken language present some of the greatest hurdles to both the delivery and receipt of appropriate healthcare. Whether the differences are in primary language (e.g., Spanish vs. English) or in jargon/terminology (e.g., "hypertension" vs. "high blood pressure"), the inability to communicate effectively severely limits all aspects of the care process. Even healthcare professionals perceive significant improvements in the efficacy of care provided when skilled interpreters are available. Unfortunately, most written documents and ancillary services are English-only, further complicating care delivery for non-English-speaking populations. Other cultural differences also can lead to difficulty in scheduling appointments, miscommunication between providers and patients, misdiagnoses, and poor compliance and poor follow-up on the patient's part.

Another approach that has been used to reach underserved populations is modeling of appropriate behaviors. For example, one study of African-American and Latina women found that such women did not see themselves as having been "brought up" knowing how to exercise:

Latinas indicated that young girls were not encouraged to be as physically active as boys and this had a negative effect on physical activity levels as the girls became adult women. African American women, in turn, indicated that their role models during their childhood were too busy with caregiving responsibilities to exercise or do any type of self-care. Without role models, it was difficult to adopt physical activity themselves (Eyler et al., 2002).

Thus, some patient populations may need role models to learn how to adopt specific behaviors. Community health workers may be able to serve in this function.

Even the best-designed programs will suffer if patient populations are distracted by other needs. Studies have found that barriers such as substance abuse, lack of housing, jobs, inadequate transportation, and childcare may prevent people from seeking care, using preventive services, or maintaining contact with the healthcare system (Biermann, Dunlop, Brady, Dubin, & Jr., 2006; Strobino et al., 2002). Thus, to reach disadvantaged populations, additional needs may also need to be addressed.

While initially reaching disadvantaged populations is a challenge, an additional challenge is ensuring that such populations continue to receive adequate follow-up care. Patients who are unsure about where to receive care are less likely to return for follow-up care (Kaplan, Crane, Stewart, & Juarez-Reyes, 2004). To increase use of follow-up care, telephone calls, mail reminders, and interventions from social workers may be helpful (Kaplan et al., 2004). Additionally, "mailing several reminders is even more effective" than mailing one reminder (Reid et al., 1999). Reminders are likely to be more effective if they are culturally competent (Weinrich, Weinrich, Weissbecker, Brent, & Seger, 2004).

To better understand how the challenge of reaching underserved populations can be overcome, we provide several detailed examples of existing programs to reach the underserved. In these cases, various approaches are used, including many of the methods described previously. We also describe the work being done by CoEs to meet the needs of underserved populations. CoEs have been leaders in offering such services to disadvantaged women.

Several key themes emerge in this discussion. First, to effectively reach underserved populations requires innovative approaches, as traditional approaches have largely failed in this regard. Second, effective programs invest the effort to know and understand the population they are targeting so that innovations can be as specific and motivating as possible. Finally, reaching underserved populations requires an investment of time, staff, and money, especially up-front.

The St. Agnes Nurses Center in West Chester, Penn., provides quality preventive health services to a vulnerable population of women and children. Its challenge is providing preventive health counseling, follow-up care, and health screenings. To better address these issues, the center implemented a structured preventive health screening form which was written into the patient intake materials.

In addition, the center has taken many steps to make its services more accessible to patients. It is located within the at-risk community and uses planned dinner discussions as a means to provide preventive health education. Center staff members work to be emotionally available to all patients, and emphasize patient communication. The Center also enhances physical availability through free cab rides, etc. The program attributes its success to

each professional becom[ing] fully committed to the provision of [preventive] services in his or her own practice. This may mean development of a standardized form to help improve screening rates among even the most forgetful of providers. Communication between all members of a given practice is paramount. Collaboration and discussion of patient needs are key factors in successful programs. Community access and trust are also important ingredients to successful and timely prevention campaigns (Kotarski, 2000).

New Leaf is an intervention program designed to help women quit smoking. It uses "behavior change theory to help counselors and patients remove obstacles to lifestyle modification (e.g., complexity, cost, lack of time, cultural irrelevance) by developing practical strategies to integrate more activity into participants' daily work and household and social activities" (Will, Farris, Sanders, Stockmyer, & Finkelstein, 2004). It was designed for a specific "Southern, multiethnic, low-literacy population" but has been adapted for other audiences (Will et al., 2004). Women who are interested in quitting smoking are referred to a state quitline, where up to six telephone contacts may occur (Will et al., 2004).

WISEWOMAN is a program sponsored by CDC to provide low-income, under- or uninsured women with the knowledge and skills to change their behavior related to cardiovascular disease and other chronic conditions. WISEWOMAN projects have discovered that many women entering the program are "unaware of their high blood pressure or their high cholesterol" and "nearly three quarters of the women who attended baseline screenings were overweight or obese" (Will et al., 2004). Each sponsored program has made efforts to be as culturally relevant as possible for the specific population it is serving: "We have learned that cultural adaptation involves more than simply translating interventions into a different language. It also requires careful formative research to understand dietary and physical activity practices, facilitators and barriers to behavioral change, and cultural norms" (Will et al., 2004).

To address structural barriers faced by women, the programs are "encouraging projects to develop multifaceted interventions that address intrapersonal, organizational, community, and policy influences on health and health behaviors. For example, to strengthen the family and peer support available to participants, some projects now invite family members and friends to attend the interventions" (Will et al., 2004). Other approaches being used include extended staff hours, hiring community health workers, making telephone calls to encourage attendance, and arranging transportation (Will et al., 2004).

Grady Memorial Hospital in Atlanta has created a care program for at-risk women who are in between pregnancies with the goal of helping women to appropriately space children and to avoid future births of very low birth weight infants. The program uses a Resource Mother "trained by the Fulton County Health Department" to provide home visits, and includes "24 months of integrated primary health care and dental services through enhanced nurse case management" (Biermann et al., 2006). All women delivering a very low birth weight infant at the hospital are given the opportunity to enroll in the program. There has been limited evaluation to date on this program, and drop-out rates have been high. However, among those who have stayed there have been no unplanned pregnancies within nine months after giving birth (Biermann et al., 2006). Pending funding, the program is hoping to expand to include services such as job skills training.

The Magnolia Project in Jacksonville, Fla. targets high-risk women to provide clinical services as well as "outreach, case management, risk reduction, support, well-woman prenatal care, health education, and community development" (Biermann et al., 2006). The program is staffed clinically by a nurse-midwife and other support staff, and uses a full-time health educator to provide "a brief counseling intervention on key issues (e.g., use of multivitamins, nutrition, douching, and safe sex) to every woman" (Biermann et al., 2006).

The program has been successful: "Participants receiving case management services from 2001 to 2003 successfully addressed two priority risks: 86% of participants with family planning issues were consistently using a method at closure; 74% of participants with repeated STDs had no recurrent STDs at closure" (Biermann et al., 2006). However, the success of the project has been limited by insufficient funding, siloed funding (e.g., funding focused specifically on STDs, primary care, or prenatal care, but not for an approach that addresses all these issues), and a lack of acceptance for a case management/risk assessment approach (Biermann et al., 2006).

Fitting in Fitness for Life! "takes a novel approach toward increasing physical activity levels among middle-aged women" (Segar, Jayaratne, Hanlon, & Richardson, 2002). Women participate in a series of "six moderated group sessions, [where] consciousness-raising methods are used, and ... participants discuss barriers to physical activity with particular attention to those that are specific to women" (Segar et al., 2002). The intervention "focuses on the importance of making time for self-care behavior, being active in ways that are pleasurable or enjoyable, and fitting convenient lifestyle physical activities into daily life" (Segar et al., 2002). The program has been successful, showing increased levels of physical activity among participants, and highlighting the importance of specifically tailoring interventions.

WomanKind was created in 1986 as part of the Fairview Health System in Minneapolis, Minn. Its mission is to provide "services to victims of domestic violence in combination with specialized education and training for health providers throughout the health care system" (Short, Hadley, & Bates, 2002). The program is "based on the assumption that health professionals fail to intervene because: they have little or no training to help them recognize the signs of domestic abuse; they are uncomfortable intervening with a victim of abuse; they don't see such intervention as their responsibility; [and] they don't have the time or the resources needed to assist the victim of abuse" (Short et al., 2002).

The program uses training and continuously on-call staff and volunteer advocates to address these needs. Results show that staff who have undergone the training are more comfortable initiating conversations about domestic violence, and that they provide more crisis-intervention and community referrals to patients (Short et al., 2002). One of the reasons the program has been successful is because of its emphasis on training: "Specific training on the dynamics of IPV [intimate partner violence], screening, identification, intervention, and documentation provide the knowledge and skills that enable health care providers to respond more effectively to IPV victims" (Short et al., 2002).

As noted, CoEs have been innovators in designing programs to reach underserved women with health services. Some efforts by CoEs include the following:

• To address cost barriers, the Boston University CoE "successfully networked with the Boston Medical Center, which serves as the safety net institution for the City of Boston. As a result of this linkage, the BU CoE is able to use resources from the uncompensated care pool provided by the State of Massachusetts, interpreter services in multiple languages, outreach programs to specific communities, and a network of referral services that accept patients regardless of ability to pay" (Jackson et al., 2001).
• Another CoE built on an existing program to provide additional services for ethnic minority patients. The program, Cultural Mediators, "consists of trained professionals drawn from the ethnic community who are then assigned to patients and are available for clinic and home visits. In this way, potential gaps between the healthcare providers and patients have been effectively bridged" (Milliken et al., 2001).
• Several of the CoEs have targeted efforts toward African-American women: "The Indiana University CoE, for example, sponsored the Indiana Black Expo Fair, which addressed such topics as domestic violence, sexually transmitted diseases (STDs), HIV education and screening, family planning, osteoporosis, smoking cessation, and exercise. Magee-Women's Hospital CoE supports the African American Womencare Program, which plans educational events for African American women in the community, such as the African American Women's Health Wellness Day, and publishes an African American Womancare Newsletter. The University of Illinois CoE launched the Roseland Project to increase physical activity among middle-to-older aged African American women in the Roseland community area" (Weitz, Freund, & Wright, 2001).
• The University of Pennsylvania CoE developed the Health Tip Card Project, a project for African-American women that earned it national recognition: "These easy-to-read cards with large, beautiful pictures cover such topics as cardiovascular disease, depression, cancer, and female aging issues. ... The Tip Cards emphasize the role women can take to ensure healthy lifestyles and include a list of community resources as well as a heart healthy recipe" (Weitz et al., 2001).
• The Puerto Rico CoE has been active in developing materials for the Hispanic population: "In addition to providing direct care, the Puerto Rico CoE disseminates educational materials and newsletters to partner organizations. It has developed a conference room on wheels, which can travel to off-site locations to provide educational programs to local communities" (Weitz et al., 2001).
• The CoEs also are developing programs to reach women with physical disabilities: "Several of the CoEs have fitted their clinical and mobile units to accommodate women with physical limitations" (Weitz et al., 2001). In addition, "researchers at the University of Pennsylvania CoE created an outreach program entitled 'Did You See What She Said? Creating Access to Healthcare with Deaf Women.' The goal of this program is to overcome healthcare barriers and optimize the use of visually accessible information pathways to empower deaf women as informed and effective consumers and advocates of healthcare services. The program seeks to provide training and support to deaf women, as well as to include deaf women in the training, advocacy, and technical assistance" (Weitz et al., 2001).

Several of these approaches to reach underserved populations are relatively new, and effectiveness information is still accumulating regarding what works and what does not. In this section of the report, we summarize available evidence. We divide these data into a discussion of specific projects and larger-scale analyses of what approaches are likely to be successful.

We found effectiveness data for two specific intervention studies:

• Rates of mammography screening were increased for inner-city women suffering from mental illness and/or homelessness "through a simple collaborative program involving the drop-in center and a nearby hospital, in which small groups of women were accompanied for mammography visits at a pre-arranged time" (Heyding et al., 2005).
• Another intervention used a "patient-navigator-like" approach to increase cancer screenings: "Women randomized to the intervention group received a series of phone calls from trained care managers who motivated them to get the required screening tests, answered questions about cancer screening, and offered assistance like making appointments or arranging transportation. Those randomized to usual care received one phone call advising them to get the tests they needed. All women also received a brochure with information on recommended screening tests. Over 18 months, screening rates for all 3 cancers went up significantly in the intervention group compared with the control group" (American Cancer Society, 2006). Each care manager received about seven hours of training, and managers were already health professionals (e.g., medical assistants) (American Cancer Society, 2006).

We also found several larger-scale attempts to summarize what is working in this area. The first such analysis looked at community health workers and concluded that

in the past several years, a number of studies using control group comparisons have supplied evidence that community health workers can improve, although sometimes modestly, access to and utilization of health care. These improvements include increases in breast screening practices, higher retention in patient education programs, increased follow-up, and better cervical cancer knowledge and/or screening practices (Brach & Fraserirector, 2000).

Another study concluded that there is "evidence to support the use of health care navigators-trained health professionals or lay community members who assist patients with specific conditions (such as an abnormal mammogram). Such navigators help patients maneuver their way through the health care system to obtain needed diagnostic or therapeutic procedures" (Betancourt, 2006). Thus, community health workers appear to be an effective technique to reach underserved populations.

Other reviews have looked at the role of interpreters and cultural competency to reach the underserved and to improve health outcomes. Many studies conclude that more evidence is needed for definitive results. However, findings include the following:

• Interpreters improve doctor-patient communication: "There is clear evidence that interpreter use can improve doctor-patient communication, patient satisfaction, patients' understanding of their conditions and follow-up instructions, and, by proxy, patient-centeredness" (Betancourt, 2006).
• Interpreters seem to improve patient outcomes, but the largest gains are associated with having language-concordant physicians: "After adjusting for socioeconomic characteristics and physician's discharge diagnosis, those clients who reported that an interpreter was needed but not used were more likely to be discharged without a follow-up appointment than clients with language-concordant physicians (OR=1.79, 95% confidence interval [CI]=1.00-3.23). Similarly, those clients who communicated through an interpreter were more likely to be discharged without a follow-up appointment than clients with language-concordant physicians" (Anderson, Scrimshaw, Fullilove, Fielding, & Normand, 2003).
• Multi-language signage likely improves outcomes: "Although no definitive studies exist, it is likely that multilingual hospital signage and written materials requiring low levels of health literacy (such as for the preparation regimen for a colonoscopy or informed consent) would improve patients' ability to take active roles in their care and thus improve quality" (Betancourt, 2006).
• Culturally competent care can improve disease outcomes: "There are several emerging models of 'culturally competent' disease management-disease management programs that also focus on sociocultural and linguistic barriers-that have proven successful in improving outcomes and addressing racial/ethnic health disparities" (Betancourt, 2006).
• Culturally competent approaches can overcome fear and resistance: "Several approaches have been found to be effective in overcoming resistance and increasing screening rates [among African-American and Latina women], including providing messages that emphasize the peace of mind that comes from screening and that cancer can be cured. Stories placed in newspapers, radio, and television publicizing role models, especially from minority communities have increased mammography screening rates" (Reid et al., 1999).

A comprehensive examination of cultural competency techniques was conducted by Brach and Fraserirector (2000). They divided the most frequent techniques into nine categories:

1. Interpreter services
2. Recruitment and retention of minority staff
3. Cultural competency training programs
4. Coordinating with traditional healers
5. Use of community health workers
6. Culturally competent health promotion
7. Including family and/or community members in healthcare decision-making, as appropriate
8. Staff worker immersion into another culture
9. Administrative and organizational accommodations, including selection of clinic locations, hours of operation, network membership, physical environments, and written materials

These nine techniques are hypothesized to improve communication and trust and expand understanding, leading to increased provision of appropriate services and better outcomes (Brach & Fraserirector, 2000). The authors conclude that "unfortunately, at this point there is little by way of rigorous research evaluating the impact of particular cultural competency techniques on any outcomes, including the reduction of racial and ethnic disparities. The only exception is that subset of techniques related to overcoming language barriers" (Brach & Fraserirector, 2000).

Another large study (Silow-Carroll, Alteras, & Stepnick, 2006) details the important components of providing patient-centered care to underserved populations. The movement toward patient centered care has aimed at making care more suitable, accessible, and effective for patients rather than having it organized in ways that historically worked well for providers. Patient-centered care deals with a similar set of issues to those involved in reaching the underserved:

The barriers that make it difficult for underserved populations to access care in general are the same ones that make it difficult to create a patient-centered environment. Language and other cultural differences among immigrants are major obstacles to both access to care and to developing positive relationships between patients and providers. Viewing medical professionals as "superior" and "authoritative" is very common in certain cultures and among those with low "health care literacy." This may impede patients' ability or willingness to take an active role in their own care. The alternative perspective, in which an immigrant patient does not trust or respect Western medicine, can also create a barrier to developing a strong provider-patient relationship. Conversely, if a provider does not understand that certain individuals and cultures place faith in folk remedies and alternative healing, he/she may not see the need to educate the patient about the importance of filling prescriptions and taking medications appropriately - perhaps along with folk remedies that will not harm the patient. Also, if a clinician does not trust that a patient will follow his/her instructions, that provider will be less likely to teach the patient and his or her family how to take on more responsibility for their own care (Silow-Carroll et al., 2006).

To create a patient-centered environment, and also to help recruit and retain underrepresented individuals in the health system, the authors recommend the following:

1. Welcoming environment: provide a physical space and an initial personal interaction that is 'welcoming,' familiar, and not intimidating;

2. Respect for patients' values and expressed needs: obtain information about patient's care preferences and priorities; inform and involve patient and family/caregivers in decision-making; tailor care to the individual; promote a mutually-respectful, consistent patient-provider relationship;
3. Patient empowerment or 'activation': educate and encourage patient to expand their role in decision-making, health-related behaviors, and self-management;
4. Socio-cultural competence: understand and consider culture, economic and educational status, health literacy level, family patterns/situation, and traditions (including alternative/folk remedies); communicate in a language and at a level that the patient understands;
5. Coordination and integration of care: assess need for formal and informal services that will have an impact on health or treatment, provide team-based care and care management, advocate for the patient and family, make appropriate referrals and ensure smooth transitions between different providers and phases of care;
6. Comfort and support: emphasize physical comfort, privacy, emotional support, and involvement of family and friends;
7. Access and navigation skills: provide what patients can consider a 'medical home,' keep waiting times to a minimum, provide convenient service hours, promote access and patient flow; help patients attain skills to better navigate the health care system;
8. Community outreach: make demonstrable, proactive efforts to understand and reach out to the local community (Silow-Carroll et al., 2006).

Silow-Caroll, Atleras, et al. (2006) identify feedback and measurement, patient/family involvement, employee training, organizational leadership, and structural support at the institutional level as important to achieving a patient-centered environment. They also report that even institutions that have successfully implemented patient-centered care struggle to recruit and maintain underrepresented minority physicians, deal with "boundary" problems as staff are overwhelmed by nonhealth-related patient issues, suffer from lack of finances, and encounter resistance to change. When a patient-centered system is successfully implemented however, it may lead to "better health outcomes as well as greater clinician satisfaction, reduced malpractice claims, and higher clinician loyalty" (Silow-Carroll et al., 2006).

In question 3, we discuss further how gender-based medicine can learn from and align with efforts such as those to create patient-centered care.

There are a variety of approaches being implemented to engage and retain the underserved in systems of healthcare. These approaches include community health workers, an emphasis on cultural competency, reaching people where they are, and providing information in the appropriate language or literacy level to facilitate understanding. Efforts to recruit populations into care focus on using community health workers and removing barriers to access (e.g., providing transportation or taking care to the people). Efforts to retain populations focus on ensuring that healthcare providers are aware of and responsive to cultural needs, including different traditions, expectations, values, and languages. Implementing such programs requires strong organizational leadership, adequate funding, and ongoing attention to overcome institutional barriers and resistance to change.

Limited efficacy data are available on the effectiveness of such programs, but available data suggest that such programs can be very effective in getting underserved populations into the system to receive care. In particular, efforts to work with community-based partners seem promising. Both men and women have been reached by efforts undertaken in partnership with community groups (e.g., religious organizations) that help promote knowledge of risk, screening, and positive health behaviors as well as the utilization of preventive and chronic care to improve health outcomes. Data are lacking, however, on the cost-effectiveness of such programs, and on whether there are gender differences in the effectiveness of these programs.

All of these programs include a focus on understanding the patient and patient values, and we would expect that patient needs and expectations would differ at least somewhat between male and female patients. To date, however, evaluations of such programs have not been sophisticated enough to make specific suggestions relating to how to engage or retain male vs. female patients.

Current as of March 2007