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Db 4
Health Disparities in the United States
Instructions:
Read the articles/webpages listed under lectures (There are multiple – please read each of them)
Respond to each of the following prompts: 5 points for each
What impacted you the most in these readings? How did you feel the impact(s)? What thoughts do you have around this? Include two or more citations to illustrate your topics.
How does this information influence your thoughts around our discussions about helping others, holding space for your patient, patient advocacy, continuing education and other items?
After reviewing the causes of death, what surprised you in the data? How does this data contribute to or is impacted by Social Determinants of Health? What connections can you make? Include two or more citations to illustrate your topics.
Compare and contrast the ideas of equity and equality in healthcare. What factors are at play? How does this impact the Social Determinants of Health? Include two or more citations to illustrate your topics.
Health equity vs. health equality: What distinguishes each? (stkate.edu
Disparities in Health and Health Care: 5 Key Questions and Answers | KFF
Minority Health | CDC
Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review – PMC (nih.gov)
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US veterans and their unique issues: enhancing
health care professional awareness
This article was published in the following Dove Press journal:
Advances in Medical Education and Practice
1 December 2015
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Maria Olenick 1
Monica Flowers 1
Valerie J Diaz 1,2
Nicole Wertheim College of
Nursing and Health Science, Florida
International University, Miami, FL,
USA; 2Operational Health Support
Unit Jacksonville, United States Navy
Nurse Corps, Jacksonville, FL, USA
1
Abstract: United States veterans are a multifaceted population with a distinct culture that
includes, but is not limited to, values, customs, ethos, selfless duty, codes of conduct, implicit
patterns of communication, and obedience to command. Veterans experience mental health
disorders, substance use disorders, post-traumatic stress, and traumatic brain injury at disproportionate rates compared to their civilian counterparts. Eighteen to 22 American veterans commit
suicide daily and young veterans aged 18–44 are most at risk. Health care professionals must
be aware of patients’ military history and be able to recognize suicide-risk factors, regardless of
age. Advancement in medical technology has allowed servicemen to survive their injuries but,
for many, at the cost of a traumatic limb amputation and associated mental scarring. Health care
professionals must be able to address physical safety concerns, as well as, emotional health of
veterans. Approximately 49,933 American veterans are homeless and face the same difficulties
as non-veterans in addition to service-related matters. Separation from military service and
issues related to complex multiple deployments are among specifically identified veteran issues.
Successful veteran reintegration into civilian life rests upon providing veterans with training
that builds on their military knowledge and skill, employment post-separation from service,
homelessness prevention, and mental health programs that promote civilian transition. Preparing
health care providers to meet the complex needs of a vast veteran population can be facilitated
by implementing veteran content into curricula that includes veteran patient simulations and
case studies, and utilizes veteran clinical faculty.
Keywords: veterans, veteran health care, veteran health issues, veteran content
Introduction
Correspondence: Maria Olenick
Nicole Wertheim College of Nursing
and Health Sciences, Florida international
University, 11200 8th Street,
AHC3 – 329, Miami, FL 33199, USA
Tel +1 305 348 7757
Fax +1 305 348 7765
Email [email protected]
United States veterans are multifaceted and may be considered a population, a culture,
and a subculture. Military culture includes, but is not limited to, the values, customs,
traditions, philosophical principles, ethos, standards of behavior, standards of discipline, teamwork, loyalty, selfless duty, rank, identity, hierarchy, ceremony and etiquette,
cohesion, order and procedure, codes of conduct, implicit patterns of communication,
and obedience to command (LD Purnell, University of Delaware and Florida International University, personal communication, January, 2015).1
The American veteran population is a unique population. Varying military service
branches and varying military experiences among the veteran population is unique.
Varying wartime eras and health-specific issues associated with those eras are unique
among the veteran population. From a comparison of veterans from the Vietnam, Persian
Gulf, and Iraq/Afghanistan (Operation Iraqi Freedom [OIF]/Operation Enduring
Freedom [OEF]) war eras, Fontana and Rosenheck2 noted distinct differences. OIF/OEF
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License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on
how to request permission may be found at: http://www.dovepress.com/permissions.php
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Olenick et al
veterans include fewer African-Americans, more Latinos,
and more females than other eras. In addition, this group is
younger, less likely to be married, less likely to have been
incarcerated, and more likely to be gainfully employed.2 It
was also observed that OIF/OEF veterans appear to be more
socially integrated, less often diagnosed with substance abuse
disorders, and required less Veterans Affairs (VA) disability
compensation for post-traumatic stress disorders (PTSDs)
when compared to their Persian Gulf and Vietnam veteran
counterparts.2
US veteran-specific health issues
Mental health or behavioral adjustment
disorders
Medical records of veterans reveal “that one in three patients
was diagnosed with at least one mental health disorder – 41%
were diagnosed with either a mental health or a behavioral
adjustment disorder”.3 In compensation or in combination
with military-related diseases, many veterans develop substance use disorders (SUDs) and a large number ultimately
commit suicide. LeardMann et al4 found that male veterans
diagnosed with “depression, manic-depressive disorder,
heavy or binge drinking, and alcohol-related problems” were
significantly associated with an increased risk of suicide.
Thus, identifying and treating mental health illness has the
greatest potential to mitigate suicide risk. Unfortunately,
reluctance to seek help or treatment makes diagnosing and
treating mental illness difficult in this population.
SUDs
The stressors of military service increase the risk of veterans
having problems with alcohol, tobacco, or drugs (or a
combination). Johnson et al5 found that cigarette smoking
and alcohol consumption is higher among veterans than
non-military personnel. For some veterans, treatment of a comorbid condition (eg, PTSD, depression, pain, insomnia) may
resolve the problem. For others, long-term care is required.
Thus, multiple clinical practice guidelines have been developed
“and evidence-based screening tools to help clinicians identify
veterans with SUDs and improve outcomes”.5
PTSD
Also known as “shell shock” or “combat fatigue”, PTSD
results from witnessing or experiencing (directly or indirectly)
a traumatic event.6 The disease is not limited to veterans,
however, military personnel experience PTSD almost four
fold (8% of non-military men versus 36% of male veterans).5 PTSD is an amalgam of symptoms, severity, and
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d uration. According to the American Psychiatric Association,6
diagnosis is based upon four symptom categories: intrusive
symptoms (flashbacks), avoidance of reminders (isolation),
negative thoughts and feelings (“no one can be trusted”),
and arousal and reactivity symptoms (exaggerated startle
response). PTSD is often associated with “traumatic brain
injury (TBI), military sexual trauma (MST), sleep problems,
substance use, pain, and other psychiatric disorders, and
requires comprehensive assessment”.5 Treatment is aimed at
therapy (psychotherapy, prolonged exposure therapy, family/
group therapy, and others), social support, and/or medication
such as antidepressants. Screening tools and evidence-based
guidelines have been developed to accurately and expeditiously assess and treat veterans.
TBI
TBI is “a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external
force”.5 TBI can be classified as mild, moderate, or severe
depending on the length of unconsciousness, memory loss/
disorientation, and responsiveness of the individual following the event (ie, are they able to follow commands). While
mild TBI (or concussion) is the most common, diagnosis
is difficult since symptoms include “headaches, dizziness/
problems walking, fatigue, irritability, memory problems and
problems paying attention”.5,7
Depression
Among the available data from the National Alliance on
Mental Illness (NAMI),2 depression ranks among the most
common mental health disorders. The diagnosis rate for
veteran depression is 14% (although NAMI believes depression is under diagnosed). Notably, NAMI2 found that individuals with PTSD were less likely to commit suicide versus those
with depression probably due to the increased awareness and
acceptance of PTSD. Despite its devastating effects, major
depression is a treatable illness with 80%–90% success rate
using medication, psychotherapy, and/or electroconvulsive
therapy.2 Models of care, such as Translating Initiatives for
Depression into Effective Solutions, show eight out of ten
veterans are effectively treated.8
Suicide
With 18 to 22 veterans committing suicide on a daily basis,
risk assessment and intervention are paramount.9 Private
and public health care professionals must be aware of
patients’ military history (since not all veterans seek care
in VA clinics)5 and be able to recognize suicide-risk factors,
Advances in Medical Education and Practice 2015:6
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regardless of age. Young veterans aged 18–44 years are most
at risk of suicide; yet, Kemp and Bossarte9 found that even
older veterans, aged 50 years and older, were still almost
twice as likely to commit suicide versus non-veterans (69%
and 37%, respectively). Additionally, “11% of veterans who
survive a first suicide attempt will reattempt within 9 months,
and 6% of those will die”.5 Kemp and Bossarte9 found evidence supporting the efficacy of VA health care systems in
lowering veterans’ non-fatal suicide attempt rate, thus referral
to a VA facility is recommended for appropriate counseling
and health services.
Chronic pain
With 82% of OEF and OIF veterans reporting chronic pain,
diagnosis and treatment are essential.5 A comprehensive
assessment of pain is crucial, but also identifying associated
physiological/biological and psychological factors since
“chronic physical pain is often associated with co-morbid
conditions, including TBI and PTSD, that may complicate
treatment”. 5,7 Treatment should focus on concurrently
addressing all conditions, with extreme cautionary use of opioids due to the heightened risk of veterans developing SUDs.
Amputations
Advancement in medical technology and bodily protection
allow soldiers to survive injuries at a higher rate than in previous wars. Yet, the scars from a traumatic amputation are deep
and many soldiers develop mental health injuries related to
the event and “in cases involving multiple limb amputations
or disfigurement, body image issues may create multiple
social and employment barriers”.5 According to military
casualty statistics, 1,573 veterans have suffered major loss
of limb amputations from battle injuries since 2010.10
Health care professionals must be able to address the
physical safety concerns, as well as, the emotional health of
the veteran. Sensory aids, prosthesis, and medical rehabilitation require an interdisciplinary-team approach in healing
wounded soldiers.
Rehabilitation care
Many veterans have a hard time reacclimating into society after deployment due to military skills that are not
transferrable to civilian life, bodily trauma that rendered that
individual handicapped, and/or war-related mental disease.
Rehabilitation care is aimed at a balance of vocational,
physical, social, and mental therapies to prepare veterans
for re-entry into civilian life. Vocational programs help
job-seeking veterans develop skills and knowledge required
Advances in Medical Education and Practice 2015:6
Veteran unique health issues
for a particular job. Physical rehabilitation focuses on
improving veterans’ quality of life and independence. Social
rehabilitation assists veterans to assimilate to non-military
life and establish new ways of life post-deployment. Mental
rehabilitation teaches veterans with mental health illness the
living skills of community functioning and ability to deal
with their new environment.
Hazardous exposures
Veterans’ past exposure to chemicals (Agent Orange, contaminated water), radiation (nuclear weapons, X-rays), air
pollutants (burn pit smoke, dust), occupational hazards
(asbestos, lead), warfare agents (chemical and biological
weapons), noise, and vibration increase their risk of health
problems even years after the initial assault.11 For example,
long-term health problems have been implicated in association
with Agent Orange exposure in Vietnam veterans.12 For those
who served in Iraq and Afghanistan, there is insufficient data
to identify long-term health effects of hazardous exposure
to pollutants, such as “burn pits” and infectious agents such
as rabies, despite the immediate side-effects experienced by
most veterans.5 Obtaining an accurate medical and deployment history is essential in providing accurate diagnosis and
appropriate treatment.
Homelessness
It is estimated that approximately 49,933 veterans are homeless (~12% of homeless adult population).13 Homeless veterans
face the same difficulties as non-veterans such as substance
use, unemployment, and mental illness; yet plagued with the
additional burdens of military-related factors, “such as PTSD,
TBI, a history of multiple deployments, and military skills that
might not be transferable to the civilian work environment”.5
National Coalition for Homeless Veterans13 found that 51% of
homeless veterans have disabilities, 50% suffer from a serious mental illness, and 70% have SUDs. National Coalition
for Homeless Veterans13 believes housing and employment
opportunities are a top priority for homeless veterans.
Complex deployment and
reintegration needs
Veteran issues related to separation from military service
and other issues related to complex deployment needs are
among specifically identified veteran issues. Veterans’
successful reintegration into civilian life outcomes and
interprofessional solutions stem from community involvement, access to resources, and support from peers. Reflection
on best practices related particularly to employability
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Olenick et al
and training builds on knowledge and skills gained in the
military (ie, university accelerated programs for veterans
where military medics and corpsmen transition through an
accelerated program into nursing earning credit for military
education and training [such as the Veterans Bachelor of
Science in Nursing which is a Health Resources and Services Administration funded program]; Military Police to
Criminal Justice, Navigational Experience and Knowledge to
Geology and/or Geography, etc), employment post-military
separation, reintegration into society, veteran demographics,
homelessness prevention and other mental health and SUD
programs that facilitate veterans’ successful transition into
urban civilian and family life. Successful reintegration after
military separation is an essential focus for holistic and
effective veteran care.
Rationale for integrating veterancentric content into curricula
The veteran population is growing. In 2014, over 20 million
veterans resided in the USA per the US Department of
Veteran Affairs, 2015.14 Veterans are seeking health care
services in the Veteran Health Administration as well as
civilian treatment facilities. In order to understand and
address health care needs of this vast and growing population,
incorporating veteran-specific content into curricula is of
primary importance. Veteran content specifically illuminates
the unique yet complex health issues, mental and behavioral
adjustment disorders, veteran wartime era, and civilian
reintegration obstacles that, in combination, magnify their
physical condition. Transparent presentation of the veteran
circumstance can facilitate an interdisciplinary approach to
care incorporating nursing, occupational therapy, physical
therapy, mental health, pain management, nutrition, psychosocial, and social support services to ensure positive
health care outcomes for this population. Several innovative
strategies address these unique issues.
Professional curricula
Ideas for strategies to begin integration of veteran content
into health care professional curricula include but are not
limited to the following:
1. Provide presentations and seminars on veteran content
delivered by well-known and distinguished speakers and/
or experts on particular veteran content.
2. Embed veteran content into courses (undergraduate and
graduate) and identify specific courses to curriculum map
where veteran content occurs.
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3. Recruit and hire faculty that come from veteran and
military backgrounds and experiences.
4. Provide faculty development opportunities to expand and
improve their knowledge on veteran issues.
5. Identify veterans in clinical areas and provide clinical
experiences for students with veteran patients of different
war eras, branches of service, and military experience
backgrounds.
6. Provide veteran simulations and case studies as part of
undergraduate and graduate curriculum.
7. Provide students the opportunity to develop individualized
patient plans and Subjective, Objective, Assessment, Plan
(SOAP) notes that reflect needs of veteran patient.
The American Association of Colleges of Nursing 15
offers a “Joining Forces: Enhancing Veterans’ Care Tool
Kit” (http://www.aacn.nche.edu/downloads/joining-forcestool-kit/educational-resources) with a variety of educational
resources on many veteran issues, references to articles on
particular veteran issues, case studies, a veteran assessment
tool, curricular examples including slides and syllabi for
veteran-specific courses. This site is an excellent resource.
Discussion
Currently, there are approximately 22 million US veterans.14
Preparing future health care providers to meet the needs of
this extraordinary number of veterans is essential. Providing
faculty development in the area of veteran-specific health
issues and how to integrate veteran content into curricula
will contribute to improving veteran outcomes and providing
excellent care to those who served this country.
Total enrollees of veterans who utilize the VA health care
system (8.9 million in 2013)16 is less than half the current total
veteran population. Furthermore, approximately 61% of all
separated OEF/OIF veterans have used VA health care since
October, 2001.17 This means that veterans are largely using
civilian medical care facilities further stressing the need for
health care providers to be well versed in veteran-specific
health issues, war eras, and reintegration issues veterans face;
in order to provide excellent veteran care and outcomes.
Conclusion
Promotion and implementation of veteran health issues into
curricula, and other veteran content relevant to enhancing veteran care and outcomes, is essential in health care
provider education and vital to the holistic care of veterans
across the lifespan and across the country. Programs targeted
at enhancing veteran-specific knowledge for faculty and
Advances in Medical Education and Practice 2015:6
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students will serve to improve care for diverse veteran
populations.
Acknowledgments
This project was supported by funds from the Division of
Nursing and Public Health, Bureau of Health Workforce,
Health Resources and Services Administration, Department
of Health and Human Services Grant UF1HP26980, Veterans’
Bachelor of Science Degree in Nursing Program (VBSN).
Disclosure
The authors have disclosed no conflicts of interest, financial
or otherwise in this work.
References
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educational-resources. Accessed August 20, 2015.
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vetdata/Utilization.asp. Accessed August 20, 2015.
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Health Care Utilization by recent veterans. US Department of Veteran
Affairs. Available from: http://www.publichealth.va.gov/epidemiology/
reports/oefoifond/health-care-utilization/. Accessed August 20, 2015.
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639
TRAINING IN SEXUAL AND GENDER MINORITY HEALTH
PERSPECTIVE
ly ambivalent. Nevertheless, some
trainees or clinicians may seek to
opt out of the SGM health educa
tion that their training programs
or employers attempt to mandate.
The legal protections outlined in
2018 by the new HHS Conscience
and Religious Freedom Division
refer to the right to refuse par
ticipation in certain medical pro
cedures5; whether people may suc
cessfully invoke these protections
to avoid general education on
SGM health care remains to be
seen. If clinicians and trainees do
begin opting out of such educa
tion, publicly designating compe
tency in SGM health may become
more important.
Inclusion of SGM health topics
in licensing and certification ex
aminations could also help en
sure that trainees learn important
information about these popula
tions. SGM health education could
be incorporated into a broader
conceptual framework of health
disparities so that clinicians un
derstand how patients’ SGM iden
tities intersect with other core
aspects of their identity, such as
race or ethnicity, to contribute to
their health-related experiences.
The history of medicine has
demonstrated that as new evi
dence emerges, clinicians update
their knowledge and skills to bet
ter serve all patients. We are op
timistic that the same will be true
for SGM health.
Disclosure forms provided by the authors
are available at NEJM.org.
From the National LGBT Health Education
Center, the Fenway Institute (K.L.A., A.S.K.),
and the Division of Infectious Diseases
(K.L.A.) and Department of Psychiatry
(ASK), Massachusetts General Hospital
— all in Boston.
1. Sexual & Gender Minority Research Of-
Pe Sons of Non • ma Gender
and ealt ‘isparities
—
fice. Annual report, fiscal year 2017. Bethesda,
MD: National Institutes of Health (https://
dpcpsi.nih.govisitesldefaultlfileslFY2Ol7
_SGMRO.AnnualReport._RP5O8FINAL
.508.pdf).
2. Obedin-Maliver J, Goldsmith ES, Stew
artL, etal. Lesbian, gay, bisexual, and trans
gender-related content in undergraduate
medical education. JAMA 2011;306:971-7.
3. James SE, Herman JL, Rankin S, Keis
ling M, Mottet L, AnafI M. The report of the
2015 U.S. Transgender Survey. Washington,
DC: National Center for Transgender Equal
ity, December 2016 (https:/Itransequality.orgl
sites!defàultlfilesldocslustslUSTS-Full-Report
-Decl7.pdf).
4. Hollenbach AD, Eckstrand KL, Dreger
A, eds. Implementing curricular and institu
tional climate changes to improve health
care for individuals who are WET, gender
nonconforming, or born with DSD: a resource
for medical educators. Washington, DC: As
sociation ofAmerican Medical Colleges, 2014
(https:Ilwww.aamc.orgldownloadl4l4l72/
datallgbt.pdf).
5. Conscience and religious freedom.
Washington, DC: Department of Health and
Human Services, Office for Civil Rights,
2018 (https:Ilwww.hhs.govlconscience/index
.html).
DOl: 10.1056/NEJMp1810522
Copyright © 2018 Massachusetts Medical Society.
wareness, Vi ibility,
Walter Liszewski, M.D.,J. Klint Peebles, M.D., Howa Yeung, M.D., arid Sarah Arron, M.D., Ph.D.
wo-spirit, agender, gender flu
id, genderqueer, gender-non
conforming, third sex: whatever
the terminology, in many cultures
throughout history, some people
have identified as neither male
nor female, or as “nonbinary.” As
our society’s concept of gender
evolves, so does the visibility of
contemporary nonbinary people.
Yet many members of the medi
cal community may not know
how to interact with nonbinary
patients respectfully or recognize
their unique needs and barriers
to care.
Nonbinary people’s gender
identity lies outside the boundaries
of a strict male—female dichotomy.
As a gender identity, it is indepen
dent of biologic sex (male, female,
or intersex) and sexual orientation
(heterosexual, homosexual, bisex
ual, or pansexual). Nonbinary and
transgender persons are consid
ered gender minorities, but there
may be differences between the
two (see Glossary).
Nonbinary people are becom
ing more visible in popular cul
ture and social media, and several
U.S. states and cities currently or
will soon allow a gender-neutral
designation on driver’s licenses
(Arkansas, the District of Co
lumbia, California, Maine, Minne
sota, and Oregon) or birth cer
tificates (California, New Jersey,
Oregon, Washington State, and
New York City).
Current data on health dispar
ities affecting gender minorities
come from two large surveys: the
2011 National Transgender Dis
N ENGLJ MED 379;25 NEJMORG
crimination Survey (6450 partici
pants, 33% of whom did not
identify as exclusively male or
female and 14% of whom identi
fied as gender-nonconforming)
(transequality.org)3 and the 2015
U.S. Transgender Survey (27,715
participants, 3l01o of whom identi
fled as nonbinary) (transequality
.org).2 As compared with the gen
eral public in other studies, genderminority persons are more likely
to live in poverty (29% vs. 12°Io),
be unemployed (15% vs. 5%), be
uninsured (14% vs. 11°Io), be the
victim of intimate-partner violence
(24% vs. 18%), have attempted
suicide (40% vs. 4.6%), have ex
perienced severe psychological
stress in the past month (3901o vs.
5%), and have I-IIV (1.4% vs.
0.3%). Thirty percent have been
DECEMBER 20, 2018
2391
PERSONS OF NONBINARY GENDER
PERSPECTIVE
Glossary of Gender and Sex Terms.~
Cisgender: Having a gender identity that is aligned with one’s sex assigned at birth — for exam
ple, identifying as a woman and having been born with female genitalia.
Gender expression: Presentation of one’s gender identity through actions and appearance.’
Gender identity: One’s internal sense of one’s gender and how it fits into societal categories, such
as woman, man, or nonbinary person.’ A person’s gender identity may change over time.
Gender minority: Persons and groups not identifying as cisgender. Gender minorities may iden
tify as rionbinary, transgender, or both. Although some identify exclusively as nonbinary or
transgender, given that some identify as both, without specific demographic data it is diffi
cult to discuss the health care needs of one group without including the other.
Intersex: A biologic sex that does not fit typical definitions of female or male; it is also known as
“differences of sex development.” Intersex persons may have any gender identity (male, female,
or nonbinary) and sexual orientation.
Nonbinary: Identifying as neither male nor female, having a gender other than male or female,
having multiple genders, or not having a gender. Other common terms used to describe
people who reject the binary gender model include gender-nonconforming, genderqueer,
agender, third gender or third sex, and gender-fluid.2 Whereas cisgender people and some
transgender people may clearly delineate their gender identity within the conventional gen
der binary (for example, exclusively identifying as female), nonbinary persons often maintain
a more expansive concept of gender.
Sex: The reproductive phenotype, categorized as male, female, or intersex. Sex is typically assigned
at birth on the basis of the appearance of external genitalia and, if necessary, by assessment of
chromosomes and gonads.’
Sexual orientation: One’s sexual identity in terms of the gender of people to whom one is at
tracted, such as heterosexual (straight), homosexual (gay or lesbian), bisexual, and others.
Sexual orientation is a separate and distinct concept from gender.’
Transgender Having a gender identity that does not exclusively match one’s sex assigned at
birth.’ Some transgender persons identify exclusively with the sex “opposite” to the one they
were assigned at birth. For example, a transgender woman is someone who was assigned as
male at birth but
