Trauma Amid Roe v. Wade Despair 

Amid my concern of the massive societal impact from overturning Roe v. Wade, lies the intersection of this decision’s havoc with every iteration of trauma.

Roe v. Wade has been overturned, and like many, I’m devastated. There will be mass impact of this decision across systems and sectors for generations to come. As I pondered a unique way to approach this blog post, one chronic theme came to mind. Amid my concern for all populations, lies the intersection of this decision’s havoc with every iteration of trauma.

Here are the facts: There is Pervasive Trauma

  • Vulnerable and marginalized populations live with rampant access to care obstacles; historical, experiential, and medical trauma are embedded within in the DNA of each person. 
  • The Turnaway Study released last Spring revealed stark facts of trauma’s wrath for women denied an abortion.
    • They are 4X as likely to end up living in poverty, stay with abusive partners, suffer from poor physical and mental health, plus have decreased aspirations. 
  • Collective Occupational Trauma for practitioners will further escalate as they reconcile:

There Will be More Trauma to Come

We can also expect:

  • Thousands of unplanned births and the potential for increased maternal morbidity and mortalityThere will be trauma.
  • Increased mental health challenges for persons dealing with unwanted pregnancies; There will be trauma.
  • High rates of suicidal ideation, gestures, and action for victims of rape, sexual assault, and interpersonal violence who are forced to carry a pregnancy to full-term; There will be trauma.
  • A ripple effect for college-aged students facing an unwanted pregnancy, and forced to raise children on college campuses, delay, or give up hopes of earning a degree; There will be trauma.
  • Persons with chronic conditions, medical, psychiatric, and intellectual disabilities often face often life-threatening conditions when forced to maintain a pregnancy. “Abortion restrictions do not only endanger people who don’t wish to be pregnant. Many people who want biological children have conditions that put them at higher risk of adverse outcomes and miscarriages…this poses clear psychological risks, as well as physical ones”; There will be trauma
  • A rise in adverse childhood experiences scores for children born of unintended pregnancies, and for persons exposed to adverse life experiencesThere will be trauma.
  • Threats to other rights and freedoms of ALL vulnerable and marginalized populations across the diversity, equity and cultural inclusion landscape; There will be trauma.

Moving Forward

Many associations and entities have already published position statements opposing the overturning of Roe V. Wade. This list of resources will fuel your advocacy energies:

ACLU

Center for Reproductive Rights

Center for Trauma-informed Policy and Practice

Guttmacher Institute

Human Rights Campaign

International Partners for Reproductive Justice (Ipas)

Keep Our Clinics

NARAL Pro-Choice America

National Abortion Federation

National Black Women’s Reproductive Agenda

National Latina Institute for Reproductive Justice

National Network of Abortion Funds

PACEs Connection

Planned Parenthood

Rape, Abuse, Incest National Network (RAINN)

Women Have Options

There are other countless other resources, and I invite all to add resources to this list. In the meantime, seek support by reaching out to each other: family, friends, colleagues, and counseling. Stay fierce, advocate, and ensure appropriate care for those in need. There will be ongoing emotions to reconcile as society contends with the new reality. We must be ready to ensure necessary health and mental health intervention, and for every person. After all, There will be trauma.

New Annual Report Highlights Economic, Educational, and Racial Disparities

The economic, employment, and racial disparities detailed in County Health Rankings and Roadmaps’ 2022 Annual Report have a ripple effect across all social determinants of health. Access to all basic human needs is at issue and must be addressed.

County Health Rankings and Roadmaps (CHR&R) released their 2022 annual report this week, and what a read it is! Those in the health equity space unfamiliar with this resource need to get familiar quickly! The site provides current data and outcomes on societal disparities for every county in the United States. CHR & R was created by the University of Wisconsin Population Health Institute with funding from the Robert Wood Johnson Foundation. The site is among my favorite “go to” sites for health disparities data, along with CMS’s Mapping US Medicare Disparities and the Health Equity Tracker courtesy of the Satcher Health Leadership Institute and Morehouse School of Medicine). But, back to those CHR & R the interesting results!

What the Data Reveals

Much has been written during the pandemic about economic shifts and their impact on the population. The results of the CHR & R report are glaring, and have strong potential to impact wholistic health equity across physical, behavioral, and psychosocial health:

  • Many US residents do not earn a living wage: $35.80 an hour for households with one adult and two children:
    • In nearly all US counties, the typical wage is less than the living wage for the area. Among these counties, a more than 73% increase in wages is necessary to meet the living wage; some counties require a 229% increase.
  • The gender disparity gap is only eclipsed by that for racial disparities:
    • Women earn 81 cents on the dollar relative to White Men
    • Women of all races and ethnicities must work more time to earn the $61,807 average annual salary of a White man.
      • Asian Women: 34 days more (approximately 1 month)
      • White Women: 103 days more (> 3.5 months)
      • Black Women: 223 days more (> 7 months)
      • American Indian/Alaskan Native: 266 days (>8.5 months)
      • Hispanic Women: 299 days more (approximately 10 months)
    • The largest pay gaps exist in the South and Western Plains States, often related to prevailing systemic racism
  • Childcare costs negate the ability of many parents to work, and is considered unaffordable when it exceeds 7% of the household’s income:
    • No counties have the childcare cost for two children at or below the 7% benchmark
    • On average, a family with two children spends 25% of its household income on childcare 
    • Childcare cost burden is highest in urban metro regions and rural counties: 27% and 25% respectively
    • For a person earning the federal minimum wage of $7.25-an-hour, the average childcare costs for two children is >90% of their annual income.
  • Vast educational disparities appear across rural, suburban and urban schools:
    • 50% of all counties in the US have a public school funding deficit, needing to spend >$3,000 more per student, annually 
    • 70% of counties with deficits of > -$4,500 per student, annually, are rural
    • Counties with higher proportions of Black, Hispanic, and American Indian & Alaska Native populations have funding deficits higher than most US counties; deficits are especially high in certain areas, such as the Southern Black Belt region (systemic racism hits again).
    • Large school funding deficits (-$4,500 per student, annually) correlate with students performing below their grade level for reading and math.

Ripples Effects and Recommendations

The economic, employment, and racial disparities detailed in the report have a ripple effect across all social determinants of health. Access to all basic human needs is at issue, and must be addressed. The report includes a series of data maps, resources, and successful programming to mitigate the issues. Recommendations encompass, but are not limited to:

A table with additional measures and data sources are appears at end of the report, which reaffirms the product’s value to the industry. The report is accessible from the embedded URL above, or through the County Ranking and Roadmaps site, www.countyhealthrankings.org

Feel free to add your comments about this blog post below, or other valuable resources. 

The Impact of Trauma and Systemic Racism on Wholistic Health Equity

Abundant data on wholistic health disparities mandates intentional, sustainable quality improvement action. Will the next generation of metrics account for this reality?

There is an industry priority to right the societal wrongs associated with historical trauma and systematic racism. These long-standing realities are key drivers of wholistic health disparities: physical, behavioral, and psychosocial health.. A fluid stream of outcomes mandate concordant approaches to racial, ethnic, and other cultural contexts of treatment (e.g., disability, familial choice, gender orientation, regional influences). Yet, despite research to validate data wholistic health outcomes, reflective quality metrics have not been developed.

What Are We Talking About?

            Abundant data assesses the impact of historical, racial, and other types of trauma on health and behavioral health outcomes. Increased healthcare utilization has been identified for survivors of physical and sexual trauma, primarily minority women. Campbell et al. (2002) studied 2,355 females, 21-25 years old, enrolled in a large health maintenance organization (HMO). Patients who experienced intimate partner violence had a far higher prevalence (>50%-70%) of gynecological and central nervous system complaints (e.g., back and pelvic pain, fainting, headaches, seizures), plus other stress-related health issues (e.g., hypertension, insomnia, susceptibility to viral/bacterial infections). Purkey et al. (2020)identified trauma survivors as frequent users of primary, urgent, and emergency care for acute and chronic symptoms. Clarke et al., (2019) discussed the presence of vague somatic complaints by patients who endured traumatic experiences (e.g., ACEs, bulling, pressures to excel in school and career). Costly emergency department visits and ambulatory diagnostic tests are frequently used to identify etiology for chronic and diffuse pain, digestive problems, headaches accompanied chronic illness exacerbation, yet to no avail.    

Another vital dyad for attention involves chronic pain management and stigma experienced by patients from marginalized communities. Wallace et al. (2021) completed a recent study; participants were trauma survivors (e.g., historical, racial, sexual) and members of indigenous, LGBTQIA+, or refugee communities. The results were telling. When physical and emotional pain were expressed to providers, they was minimized or dismissed. If acknowledged by providers, short-term prescriptions were given versus referrals to behavioral health and other specialists.

What Does it Imply?

Data mandates the need for intentional, sustainable quality improvement in this arena. Will the next generation of metrics account for this reality? Racism remains a major factor to drive racial and ethnic inequities in health and mental health, though fails to be addressed in healthcare’s quality proposition. Of the articles reviewed for this blog post, trauma-informed quality analysis of care remained elusive. 2021 saw a fresh generation of industry health equity measures, yet few addressed integrated care, let alone assesses wholistic health equity. Existing metrics continue to silo health or behavioral health. Insufficient focus has been on industry-vetted quality models addressing population-focused, concordant, trauma and equity-focused interventions. 

Where Will Health Equity’s Quality Compass Point?

This author is developing a Quintile Aim for consideration, which adds the pivotal domain of Wholistic Health Equity to the industry’s seminal quality compass. NCQA continues to push this agenda in evolving new metrics. Public comment is open (until 3/11/22) for new HEDIS measures targeting the SDoH. Wyatt et al. (2016) posed a 5-step quality model for organizations to advance health equity delivery to the communities they served, addressed in Figure 1. 

Figure 1: A Framework for Healthcare Organizations to Achieve Health Equity (Wyatt et al., 2016) 

Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J (2016). Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper: Institute for Healthcare Improvement 

The model was well-intended though had limited substance or strategic action to leverage the intent. This effort was reminiscent of the Quadruple Aim; little data drove the model and obstructed full industry acceptance. By contrast, Dover and Belon’s (2019) Health Equity Measurement Framework (HEMF) is worthy of exploration. Based on the World Health Organization’s Social Determinants of Health model, HEMF vast evaluation areas to measure health equity at macro, meso, and micro levels, as shown in Figure 2. 

Figure 2: HEMF Framework Elements (Dover & Belon, 2019)

Dover, D.C. and Belon, A.P.  (2019. The health equity measurement framework: a comprehensive model to measure social inequities in health. Int J Equity Health 18,36 https://doi.org/10.1186/s12939-019-0935-0

The HEMF model is worthy of a test drive to gauge its true merit. Use of the wide-scope of theoretical and evidence-based industry elements is an asset. Population diversity and complexity are accounted for through power-related and disparity measures. Health beliefs, behaviors, and values are acknowledged with stress factored in; the traumatic-response across circumstances is embedded. My desire to keep this post brief limits further elaboration on the HEMF model. However, know it poses strong value as a robust quality model to address health, behavioral, and racial health disparities across populations exposed to trauma’s diverse lens.  

Have other integrated care quality models that account for wholistic health equity? Add your considerations and comments below!

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